Cancer-related fatigue: ESMO Clinical Practice Guidelines for diagnosis and treatment

Controlled register‐based study of road traffic accidents in 12,651 Finnish cancer patients during 2013–2019

BACKGROUND

Little controlled evidence exists on road traffic accident (RTA) risk among patients diagnosed with cancer, while clinicians are often requested to comment their ability to drive. The aim of this study was to evaluate RTA risk in a population-based cohort of cancer patients living in Southwest Finland.

PATIENTS

All adult patients diagnosed with cancer in 2013-2019 were included. Acute appendectomy/cholecystectomy and actinic keratosis patients without cancer were selected from the same region as the control cohort. Participants were cross-referenced to a national driving licence database, yielding 12,651 cancer and 6334 control patients with a valid licence. Due to marked differences in their clinical presentation, the cancer cohort was divided into nine cancers of interest (breast, prostate, colorectal, lung, melanoma, head & neck, primary brain tumours, gynaecological and haematological malignancies). The nationwide law-regulated motor liability insurance registry was searched for all RTAs leading to injury with claims paid to not- or at-fault participants. At-fault drivers were verified based on sex and birth year.

RESULTS

During a median follow-up of 34 months, 167 persons were at-fault drivers in RTAs leading to injury. Among the nine cancers of interest, RTA risk did not differ from the control cohort. Among cancer patients, multivariable regression suggested male sex and opioid use, but not advanced cancer stage or given systemic therapy, as the most influential risk factors for RTA.

CONCLUSIONS

Cancer diagnosis itself was not associated with increased RTA risk, but other associated symptoms, medications, comorbidities or specific cancer subgroups may.

The cancer patients' perspective on feasibility of using a fatigue diary and the benefits on self-management: results from a longitudinal study

PURPOSE

To evaluate the patients' perspective on feasibility of using a fatigue diary and its benefits on self-management.

METHODS

This longitudinal study enrolled 50 cancer patients in routine care. Following baseline (t0) assessment, patients were asked to complete a 7-day fatigue diary and subsequently obtained written diary evaluation. Feasibility, benefits, and fatigue-related attitudes were assessed via self-report 1 (t1) and 4 months (t2) after distributing the diary. Data were analyzed descriptively and using Wilcoxon signed-rank tests.

RESULTS

Most patients (94%) completed the diary for 7 days and rated feasibility as high. After diary completion and receiving the evaluation, fewer patients felt helpless in the face of fatigue (t1: 21% vs. t0: 53%). Additionally, more patients addressed fatigue with their general practitioner (t2: 49% vs. t0: 36%) and pro-actively searched for information and help (t2: 59% vs. t0: 38%). The diary enabled a majority of patients to be aware of their fatigue patterns, to plan daily routines accordingly and to take adequate actions against fatigue.

CONCLUSION

The study showed that symptom monitoring via a fatigue diary was considered feasible and enhanced self-management in cancer patients. Thus, fatigue diaries might be a useful measure contributing to an improved fatigue management. The results reinforce guideline recommendations for routine application of fatigue diaries in clinical care. Healthcare professionals should encourage patients to fatigue diary use and provide individually tailored counseling based on diary entries.

Predictors of functional outcomes in adults with brain tumor undergoing rehabilitation treatment: a systematic review

INTRODUCTION

The number of diagnosed brain tumors (BT) has increased in recent years. The results of treatment of patients with surgery, chemotherapy and radiotherapy are also improving and their survival rate has increased significantly. Symptoms of the disease and side effects of oncological treatment may reduce the functional performance of patients. It is so important to conduct rehabilitation in this group of patients. The aim of this systematic review is to identify predictors of effective rehabilitation in aspects of physical functioning of BT patients. The study was registered with health and social care, welfare, public health, education, crime, justice and international development departments, where there is a health-related interest outcome PROSPERO. We have received registration number is: CRD42021269398.

EVIDENCE ACQUISITION

To find relevant publications, the algorithm of keywords ("brain tumor") AND (rehabilitation OR "physical activity" OR exercise OR "physical therapy") was used. The search was conducted in PubMed, Web of Science, PEDro, ClinicalTrials.gov and Cochrane Library. Information was extracted using the PICO format (i.e., participants, intervention, comparison, outcomes).

EVIDENCE SYNTHESIS

the initial search identified a total of 1122 results, and 21 articles met the criteria and were selected for analysis.

CONCLUSIONS

The results present that rehabilitation is an important and safe cancer encouraging therapy, brings functional benefits. The type of rehabilitation program, especially in BT patients, depends on many factors such as time and type of oncological treatment, general conditions which is strongly related to the general functioning of the patient. It still is a need for clinical research into the safety and effectiveness of rehabilitation interventions already during radio or chemotherapy in this group of cancer patients.

Effectiveness of a phone-based nurse monitoring assessment and intervention for chemotherapy-related toxicity: A randomized multicenter trial

Purpose

Anticancer treatment-related toxicities can impact morbidity and mortality, hamper the administration of treatment, worsen the quality of life and increase the burden on the healthcare system. Therefore, their prompt identification is crucial. NICSO (Italian Network for Supportive Care in Cancer) conducted a nationwide randomized trial to evaluate the role of a planned, weekly phone-based nurse monitoring intervention to prevent and treat chemotherapy, targeted therapy- and immunotherapy-related toxicities. Here, we report the results from the chemotherapy arm.

Methods

This was a nationwide, randomized, open-label trial conducted among 29 Italian centers (NCT04726020) involving adult patients with breast, colon, or lung cancer and a life expectancy ≥6 months receiving adjuvant chemotherapy. Patients received either a weekly nurse monitoring phone call and an educational leaflet reporting practical advice about prevention and treatment of toxicities (experimental group) or the educational leaflet only (control group).

Results

The addition of a nurse monitoring intervention may help reduce time spent with severe toxicities (grade ≥3), particularly those less frequently reported in clinical practice, such as fatigue. When considering grade 1–2 AEs, times with mild/moderate diarrhea, mucositis, fatigue and pain were shorter in the experimental arm. Time spent without AEs was significantly longer in the experimental arms for all the toxicities. The requirement for special medical attention was comparable between groups.

Conclusion

This study suggests the need for implementing a better system of toxicity assessment and management for patients treated with adjuvant chemotherapy to promote effective preventive and/or therapeutic intervention against these events.

Effect of melatonin on quality of life and symptoms in patients with cancer: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

This study systematically reviewed the effect of melatonin (MLT) on quality of life (QoL) and symptoms among patients with cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Library, PubMed, Embase, Web of Science, Medline, CINAHL, Scopus, ClinicalTrials.gov, China Biology Medicine (CBM), ProQuest and Open Grey were searched from inception to November 2021.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of MLT on QoL, sleep quality, fatigue, depression, pain, stomatitis rate and stomatitis severity in adult patients with cancer, without language restrictions. Studies that reported the effects of MLT along with other interventions and had incomplete or absent outcome data were excluded.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data, and another two reviewers assessed the risk of bias. The risk of bias for each eligible study was assessed using the Cochrane assessment tool. The mean difference or standard mean difference (SMD) with 95% CIs was used in the computation of continuous variables to synthesise data. The relative risk was used for dichotomous outcomes. Heterogeneity was assessed and quantified (I² statistic).

RESULTS

A total of 19 qualified studies that included 2101 patients with cancer (MLT: 1078, control: 1023) were included in the meta-analysis. The results indicated that MLT had no significant effect on QoL (SMD=-0.01, 95% CI (-0.14 to 0.11), p=0.83), sleep quality (SMD=-0.18, 95% CI (-0.62 to 0.26), p=0.42), fatigue (SMD=-0.34, 95% CI (-0.73 to 0.06), p=0.10), pain (SMD=-0.34, 95% CI (-0.7 to 0.02), p=0.06) or stomatitis severity (RR=0.78, 95% CI (0.47 to 1.30), p=0.35). MLT reduced stomatitis rate among patients with cancer (RR=0.47, 95% CI (0.26 to 0.88), p=0.02), except those with head and neck cancer (RR=1.09, 95% CI (0.92 to 1.29), p=0.35). MLT eased depression in patients who received administration for more than 14 days (SMD=-0.14, 95% CI (-0.27 to -0.01), p=0.03) and those who underwent surgery (SMD=-0.17, 95% CI (-0.32 to -0.03), p=0.02).

CONCLUSION

The findings showed that MLT did not improve the QoL, sleep quality, fatigue, pain or stomatitis severity among patients with cancer. It had a limited effect on decreasing the stomatitis rate and easing depression. Different treatments, durations and cancer types were the main sources of heterogeneity. Further large-scale RCTs are urgently needed. In addition, the effects of different combinations of MLT dosage and duration, administration types and joint measures are worthy of further study.

PROSPERO REGISTRATION NUMBER

CRD42021292855.

Acupuncture for Managing Cancer-Related Fatigue in Breast Cancer Patients: A Systematic Review and Meta-Analysis

Breast cancer (BC) is the most common cancer in women and is a serious threat to women's health. Cancer-related fatigue (CRF) is a distressing symptom in BC patients during and after chemotherapy or radiation therapy that severely affects quality of life (QoL). AT is widely used for fatigue management. However, the effect of AT on CRF is still uncertain. This study aimed to evaluate the efficacy and safety of AT in the management of CRF in patients with BC. Eleven databases were searched through June 2022. Two researchers independently performed the database search, study selection, data extraction, and risk of bias assessment. Study selection was performed based on predefined Participants, Intervention, Comparators, Outcomes, Study design (PICOS) criteria, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed when reporting the results. A meta-analysis was performed according to the Cochrane systematic review method using RevMan 5.3. A total of 12 studies including a total of 1084 participants were included. The results showed that AT had a beneficial effect compared with sham AT (n = 256, SMD = -0.26, 95% CI [-0.51, -0.01], p = 0.04, I² = 0%) and a long-term effect on fatigue score (n = 209, MD = -0.32, 95% CI [-0.59, -0.04], p = 0.02, I² = 0%). Meta-analysis showed that AT had a beneficial effect compared with usual care (UC) on fatigue scores (n = 238, SMD = -0.39, 95% CI [-0.66 to -0.12], p = 0.005, I² = 0%). Of the 12 articles, 3 articles were judged as having a low risk of bias in all domains and hence were of high quality. No serious adverse effects were identified. AT is an effective and safe treatment for CRF, and AT is more effective than sham AT or UC or wait-list control (WLC). Nevertheless, the methodological quality of most of these studies was low, and the included studies/sample sizes were small, so the ability to derive decisive implications was limited. Further research is needed to confirm these findings.

Management of Immune-Related Adverse Events from Immune-Checkpoint Inhibitors in Advanced or Metastatic Renal Cell Carcinoma

Immune checkpoint inhibitors (ICI) are now, among other cancers, routinely used for the treatment of advanced or metastatic renal cell carcinoma (mRCC). In mRCC various combinations of ICIs and inhibitors of the vascular epidermal growth factor receptor tyrosine kinase (VEGFR-TKIs) as well as dual checkpoint inhibition (nivolumab + ipilimumab), the latter for patients with intermediate and poor risk according to IMDC only (international metastatic renal cell carcinoma database consortium), are now standard of care in the first line setting. Therefore, a profound understanding of immune-related adverse events (irAE) and the differential diagnosis of adverse reactions caused by other therapeutic agents in combination therapies is of paramount importance. Here we describe prevention, early diagnosis and clinical management of the most relevant irAE derived from ICI treatment focusing on the new VEGFR-TKI/ICI combinations.

Which Type of Exercise During Radiation Therapy Is Optimal to Improve Fatigue and Quality of Life in Men with Prostate Cancer? A Bayesian Network Analysis

Context

Physical exercise in men with prostate cancer (CaP) has shown benefits in improving cancer-related fatigue (CRF) and quality of life (QoL) during radiation therapy. However, types of exercises that are more effective are not well understood.

Evidence acquisition

We searched PubMed, Web of Science, and ClinicalTrials.gov up to November 2021 to identify potentially relevant studies. Randomized controlled trials (RCTs) testing the effects of exercise training on CRF, QoL, and treatment-related toxicities in patients with CaP undergoing radiation therapy were included. The quality of individual studies was evaluated using the Tool for the assEssment of Study qualiTy and reporting in Exercise (TESTEX) scale. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. A meta-regression analysis was conducted to test the study-level covariates. A random-effect network meta-analysis was conducted based on a Bayesian model.

Evidence synthesis

Eight RCTs with 466 participants were included. Exercise achieved significant improvements in CRF (standardized mean difference [SMD] = 1.24, 95% confidence interval or CI [0.43, 2.06], I2 = 93%) and QoL (SMD = 1.40, 95% CI [0.05, 2.75], I2 = 95%). Based on the meta-regression and Bayesian model, combined moderate-intensity continuous training aerobic exercise and resistance exercise (MICT/RES) showed the highest probability of ranking first in terms of CRF and QoL improvement, but the results of QoL were unstable. Exercise training also had a positive effect on urinary toxicities (SMD = -0.53, 95% CI [-0.79, -0.27], I2 = 0%). A subgroup analysis indicated that MICT/RES might be the most promising exercise modality for reducing intestinal toxicities (SMD = -1.76, 95% CI [-2.32, -1.20]).

Conclusions

MICT/RES might be superior to any other types of exercise at reducing CRF. MICT/RES was more effective on significantly mitigating urinary and intestinal toxicities.

Patient summary

In prostate cancer (CaP) survivors during radiation therapy, exercise training is an effective and safe intervention to reduce cancer-related fatigue (CRF) and improve quality of life (QoL), and should be prescribed as a rehabilitation option for clinical management. As for the types of exercises, moderate-intensity continuous training aerobic exercise and resistance exercise seem to be the most effective interventions to reduce CRF, improve QoL, and mitigate treatment-related symptoms.

Optimizing treatment management of trastuzumab deruxtecan in clinical practice of breast cancer

INTRODUCTION

The antibody-drug conjugate trastuzumab deruxtecan (T-DXd) targets human epidermal growth factor receptor 2 (HER2) and has been evaluated in patients with HER2-positive unresectable/metastatic breast cancer in the phase II DESTINY-Breast01 trial (NCT03248492; DS8201-A-U201) and the randomized phase III DESTINY-Breast03 trial (NCT03529110; DS8201-A-U302). Approximately 20 additional studies are ongoing in breast cancer, including HER2-low breast cancer, and other solid tumor types within the DESTINY trial program. T-DXd has demonstrated a generally manageable safety profile, with low-grade hematologic and gastrointestinal adverse events (AEs) among the most common; interstitial lung disease (ILD)/pneumonitis has been observed in patients receiving T-DXd and can be severe. This review discusses the management of common AEs and AEs of special interest in patients with HER2-positive unresectable/metastatic breast cancer, including nausea and vomiting, neutropenia, infusion-related reactions, alopecia, fatigue, ILD/pneumonitis, and left ventricular dysfunction.

METHODS

Expert opinions, institutional protocols, and strategies to help optimize AE management and maximize the potential benefits of T-DXd in patients with breast cancer from five oncologists treating patients with T-DXd in North America and Europe are discussed.

RESULTS

Prophylaxis for nausea and vomiting and proactive management of ILD/pneumonitis are especially important in treating patients with T-DXd. Management strategies for other T-DXd-related AEs of interest (e.g. neutropenia, infusion-related reactions, alopecia, fatigue, and left ventricular dysfunction) are also discussed.

CONCLUSIONS

This review provides context for understanding the usage, monitoring, and management practices of other health care providers and institutions with experience using T-DXd to help with safe and effective management of T-DXd-related AEs, particularly since the duration of T-DXd treatment may be quite long. Proper management of T-DXd-related AEs will allow optimal exposure and benefit from T-DXd and will help avoid premature discontinuation or improper dose reductions.

Cancer-related fatigue in patients treated with mistletoe extracts: a systematic review and meta-analysis

PURPOSE

Cancer-related fatigue remains one of the most prevalent and distressing symptoms experienced by cancer patients. Effective treatments for cancer-related fatigue are needed. The objective of this meta-analysis is to determine the impact of mistletoe extracts as a pharmacological treatment for the management of cancer-related fatigue.

METHODS

We included randomized clinical trials (RCTs) and non-randomized studies of interventions (NRSIs) in cancer patients. Inclusion criteria were cancer-related fatigue severity or prevalence as an outcome and testing of mistletoe extracts compared to control groups. We searched Medline (EuropePMC), Embase, the Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, and opengrey.org through October 2020. We assessed the risk of bias using the Cochrane risk of bias tools for RCTs and NRSIs and conducted a meta-analysis.

RESULTS

We performed one meta-analysis with 12 RCTs, including 1494 participants, and one meta-analysis with seven retrospective NRSIs, including 2668 participants. Heterogeneity between the studies was high in both meta-analyses. Most studies had a high risk of bias. A random-effects model showed for RCTs a standardized mean difference of -0.48 (95% confidence interval -0.82 to -0.14; p = 0.006) and for NRSIs an odds ratio of 0.36 (95% confidence interval 0.20 to 0.66; p = 0.0008).

CONCLUSION

Treatment with mistletoe extracts shows a moderate effect on cancer-related fatigue of similar size to physical activity. These results need to be confirmed by more placebo-controlled trials. Future trials should investigate different treatment durations and their effect on cancer-related fatigue in post-treatment cancer survivors.

TRIAL REGISTRATION

This meta-analysis has been registered under the PROSPERO registration number CRD42020191967 on October 7, 2020.

Reducing severe fatigue in patients with diffuse glioma: a study protocol for an RCT on the effect of blended cognitive behavioural therapy

Background

Fatigue is the most frequent and burdensome symptom of patients with diffuse glioma. It is closely linked to decreased health-related quality of life and symptoms such as depression and sleep disturbances. Currently, there is no evidence-based treatment that targets severe fatigue in patients with brain tumours. Cognitive behavioural therapy is aimed at fatigue-maintaining beliefs and behaviour. This therapy has been proven effective in reducing severe fatigue in cancer survivors and patients with multiple sclerosis. A blended therapy program combines sessions with a therapist with therapist-guided web-based therapy modules. The aim of this randomized controlled trial is to determine the efficacy of blended cognitive behavioural therapy in treating severe fatigue in patients with diffuse glioma.

Methods

We will include a maximum of 100 patients with diffuse glioma with clinically and radiologically stable disease and severe fatigue (i.e. Checklist Individual Strength, subscale fatigue severity ≥ 35). Patients will be randomized to blended cognitive behavioural therapy or a waiting list condition. The 12-week intervention GRIP on fatigue consists of five patient-therapist sessions and five to eight individualized web-based therapy modules supported by email contact. The primary outcome measure is fatigue severity. Secondary outcome measures include sleep quality, health-related quality of life, depression, anxiety, functional impairment and subjective and objective cognitive functioning. Primary and secondary outcome measures will be assessed at baseline and after 14 and 24 weeks. Magnetoencephalography and MRI will be used to evaluate potential biomarkers for intervention success. This trial has a Bayesian design: we will conduct multiple interim analyses to test for efficacy or futility of the trial. This is the first trial within the GRIP trial platform: a platform developing four to five different interventions for the most common symptoms in patients with diffuse glioma.

Discussion

The results of the GRIP on fatigue trial will provide information about the efficacy of this intervention on fatigue in patients with diffuse glioma. Multiple other outcomes and possible predictors of treatment success will also be explored.

Trial registration

Netherlands Trial Register NL8711. Registered on 14 June 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06485-5.

Nutritional screening in a cancer prehabilitation programme: A cohort study

BACKGROUND

Cancer patients are often malnourished pre-operatively. Study aims were to establish if current screening was appropriate for use in prehabilitation and investigate any association between nutritional risk, functionality and quality of life (QoL).

METHODS

This cohort study used routinely collected data from September 2020 to August 2021 from patients in a Prehab4cancer programme. Included patients were aged >18 years, had colorectal, lung or oesophago-gastric cancer and were scheduled for surgery. Nutritional assessment included patient generated subjective global assessment (PG-SGA) short-form and QoL with a sit-to-stand test. Association between nutritional risk and outcomes were analysed using adjusted logistic regression.

RESULTS

From 928 patients referred to Prehab4Cancer service over 12-months, data on nutritional risk were collected from 526 patients. Pre-operatively, 233 out of 526 (44%) patients were at nutritional risk (score ≥2). During prehabilitation, 31% of patients improved their PG-SGA and 74% of patients maintained or improved their weight. Odds ratios (OR) with confidence intervals (CI) showed that patients with better QoL using EuroQol-5 Dimensions (OR 0.05, 95% CI 0.01, 0.45, P=0.01), EuroQol Visual Analogue Scale (OR 0.96, 95% CI 0.93, 1.00, p=0.04) or sit-to-stand (OR 0.96, 95% 0.93, 1.00, p=0.04) were less likely to be nutritional at risk.

CONCLUSION

Nearly half of patients in Prehab4Cancer programme assessed using PG-SGA were at risk of malnutrition. However, almost half of the sample did not have their risk assessed. Patients at risk of malnutrition were more likely to have a poorer QoL and sit-to-stand test than those who were not at risk. This article is protected by copyright. All rights reserved.

Efficacy and safety of oral Chinese medicine on cancer-related fatigue for lung cancer patients after chemotherapy: Protocol for systematic review and meta-analysis

Introduction

Lung cancer has the highest mortality rate of about 18.0% among malignant tumors worldwide, and chemotherapy is the main treatment. 80% of patients receiving chemotherapy suffers from cancer-related fatigue, which is the most severe symptom, with a large effect on quality of life as well as prognosis. Oral Chinese medicine, a kind of complementary and alternative medicine, has been proved to benefit lung cancer patients. However, no studies have reviewed whether it can reduce fatigue in lung cancer patients after chemotherapy, which is the purpose of our study.

Methods

Two reviewers will systematically and independently retrieve papers, select studies for inclusion, extract data, and assess risk of bias. The following nine databases will be searched: China National Knowledge Infrastructure, Wan Fang database, Chinese Scientific Journals Database, Chinese biomedical literature service system, PubMed, Web of Science, OVID, Scopus, and EMBASE from inception to February, 2022. Included studies will only be randomized controlled trials. Primary outcome is cancer-related fatigue. Secondary outcomes are quality of life, immunologic function, and the incidence of adverse events. We will use RoB 2 tool to assess the risk of bias and RevMan to analyze data. Risk ratios will be calculated for dichotomous data and mean differences for continuous data. Random-effect model will be used to integrate statistical effects. Meta-regression, subgroup and sensitivity analyses will be carried out. We will evaluate the strength and overall quality of evidence with four levels: very low, low, moderate, and high.

Results

The review of current evidence of oral Chinese medicine on cancer-related fatigue for lung cancer patients after chemotherapy will be narratively summarized and quantitatively analyzed.

Conclusion

The definitive conclusion will help physicians to determine whether oral Chinese medicine is an effective treatment for reducing fatigue in lung cancer patients after chemotherapy in clinical settings.

Systematic review registration

PROSPERO CRD42021292576.

Late effects, long-term problems and unmet needs of cancer survivors

Great efforts are being made in cancer treatment, with impressive improvement in survival. The situation concerning research and care for long-term problems and late effects in the growing population of cancer survivors, however, is unsatisfactory. Therefore, in the FiX survey 1,348 disease-free survivors about 4 years after diagnosis of different cancer types were asked to rate existing burdens and support received for them along a list of 36 potential problems. Health-related quality of life (HRQoL) was assessed with the EORTC QLQ-C30. Determinants of burdens were explored using logistic regression analysis. While cancer survivors' global HRQoL, physical and role function ratings were comparable or better than age- and sex-matched reference values of the general population, emotional and cognitive function was worse, especially among women (p<.01). Most frequently reported problems with at least moderate burden were loss of physical performance (36.3%), fatigue (35.1%), sexual problems (34.7%), sleep problems (34,1%), arthralgia (33.8%), anxiety (28.0%), neuropathy (25.6%), memory problems (23.0%) and concentration problems (21.9%). Burdened survivors often rated received support as poor, especially regarding support for problems that physicians might consider medically non-threatening, or for which no effective pharmacologic or medical treatment is known. Determinants for burden included higher age, female gender, having ever received chemotherapy and overweight/obesity. In conclusion, a significant number of cancer survivors suffer from long-term or late effects and have unmet care needs. Awareness of health care professionals should be increased for these issues. The results of our study can contribute to the development of targeted survivorship plans. This article is protected by copyright. All rights reserved.

Incidence of fatigue associated with immune checkpoint inhibitors in patients with cancer: a meta-analysis

Background

Fatigue is one of the most common adverse effects associated with cancer immunotherapy using checkpoint inhibitors (CPIs). Because treatment-related fatigue also frequently occurs in patients treated with non-immunological therapies, our study aimed to compare the incidence of fatigue in CPI-treated patients with that associated with non-immune therapies in randomised trials.

Methods

PubMed and ClinicalTrials.gov were searched for phase III studies using a CPI alone or in combination with chemotherapy or non-immunologic targeted therapy in the experimental arm and control arm using inactive therapies such as placebo or observation, chemotherapy, or non-immunologic targeted therapy. Adverse events listed in the full texts as well as those available from clinicaltrials.gov were reviewed for all identified studies.

Results

A total of 60 studies involving 41 435 patients were included in the analysis. All-grade fatigue was reported in 30.4% of patients [95% confidence interval (CI) 29.9% to 31.0%] in the immunotherapy arms of the analysed studies. Using anti-programmed cell death protein 1 agents as reference, the odds ratio (OR) for fatigue was significantly higher both for anti-cytotoxic T lymphocyte-associated antigen 4 agents (OR 1.46, 95% CI 1.04-2.04) and the combination of anti-cytotoxic T lymphocyte-associated antigen 4 and anti-programmed cell death protein agents (OR 1.43, 95% CI 1.12-1.83). Fatigue was significantly less likely to occur in patients treated with CPI compared with patients receiving chemotherapy (OR 0.79, 95% CI 0.73-0.85), but significantly was more common in patients receiving the combination of CPI/chemotherapy compared with patients receiving chemotherapy alone (OR 1.12, 95% CI 1.03-1.22).

Conclusions

Although immunotherapy using CPIs was associated with treatment-related fatigue, the occurrence of all-grade fatigue was significantly higher in patients treated with chemotherapy compared with patients receiving CPIs. The risk of fatigue was higher for CPI/chemotherapy combinations than for chemotherapy alone. These results suggest that although the effects of CPIs and chemotherapy are additive, chemotherapy was the dominant cause of treatment-related fatigue in the analysed trials.

•

Fatigue is a common adverse event associated with cancer immunotherapy but also with other therapies and with cancer itself.

•

This meta-analysis analysed the incidence of fatigue reported in phase III trials of checkpoint inhibitors.

•

Fatigue was more common in patients treated with chemotherapy compared with patients receiving checkpoint inhibitors.

•

Chemotherapy was the dominant cause of fatigue in combinations of chemotherapy and checkpoint inhibitors.

Impact on fatigue of different types of physical exercise during adjuvant chemotherapy and radiotherapy in breast cancer: systematic review and meta-analysis

BACKGROUND

Physical exercise in women with breast cancer has shown benefits in reducing fatigue levels during adjuvant radiotherapy and chemotherapy. However, it is not well understood which type of exercise is more effective.

OBJECTIVE

Assess the impact of different types of physical exercises on fatigue and which is the most effective in reducing this adverse effect during adjuvant treatment in breast cancer.

METHODS

The inclusion criteria were randomized clinical trials of physical exercise in women diagnosed with breast cancer in stages I to IV, above 18 years, evaluating fatigue using validated questionnaires. The meta-analysis pooled results by standardized mean difference (SMD).

RESULTS

A total of 20 randomized clinical trials involving 1793 participants revealed that the practice of physical exercise was statistically effective in reducing fatigue (SMD =  - 0.46; 95% CI: - 0.66, - 0.27). Our analysis of subgroups suggests that the supervised combination of resistance training (RT) with aerobic training (AT) is the most effective physical exercise to reduce fatigue (SMD =  - 1.13; 95% CI: - 2.09, - 0.17). The supervised RT was more effective (SMD =  - 0.30; 95% CI: - 0.46, - 0.15) than supervised AT or mind-body techniques. It was observed that only during chemotherapy, women with breast cancer in the intervention groups showed a significant reduction in fatigue (SMD =  - 0.38; 95% CI: - 0.55 to - 0.20).

CONCLUSION

Physical exercise during adjuvant chemotherapy and/or radiotherapy in women with breast cancer can be considered beneficial in reducing fatigue, especially for women undergoing chemotherapy and for supervised training of resistance or combined RT and AT.

Integrating supportive care into the multidisciplinary management of lung cancer: we can't wait any longer

INTRODUCTION

Due to important achievements in terms of diagnostic and therapeutic tools and the complexity of the disease itself, lung cancer management needs a multidisciplinary approach. To date, the classical multidisciplinary team involves different healthcare providers mainly dedicated to lung cancer diagnosis and treatments. Nevertheless, the underlying disease and related treatments significantly impact on patient function and psychological well-being. In this sense, supportive care may offer the best approach to relieve and manage patient symptoms and treatment-related adverse events.

AREAS COVERED

Evidence report that exercise, nutrition, smoking cessation and psychological well-being bring many benefits in patients with lung cancer, from both a physical and socio-psychological points of view, and potentially improving their survival. Nevertheless, supportive care is rarely offered to patients, and even less frequently these needs are discussed within the multidisciplinary meeting.

EXPERT OPINION

Integrating supportive care as part of the standard multidisciplinary approach for lung cancer involves a series of challenges, the first one represented by the daily necessity of specialists, such as kinesiologists, dietitians, psycho-oncologists, able to deliver a personalized approach. In the era of precision medicine this is an essential step forward to guarantee comprehensive and patient-centered care for all patients with lung cancer.

Side Effects of Endocrine Therapy Are Associated With Depression and Anxiety in Breast Cancer Patients Accepting Endocrine Therapy: A Cross-Sectional Study in China

Objective

Hormone positive breast cancer patients bear side effects of endocrine therapy and that may be related to depression and anxiety. We sought to find an association between mental health and side effects of endocrine therapy.

Methods

A total of 398 patients participated. Sociodemographic, disease profile, and side effects questionnaires were administered. We screened for depressive and anxiety disorders by using the SDS (Self-Rating Depression Scale) and SAS (Self-Rating Anxiety Scale).

Results

The prevalence of depression and anxiety in our study were 33.4% (133) and 13.3% (53), respectively. Depression was linked to education level (≤8 years, OR = 3.59, 95% CI: 2.22–5.78), night sweats (yes, OR = 1.90, 95% CI: 1.17–3.09), vaginal dryness (yes, OR = 2.22, 95% CI: 1.19–4.16), and fatigue (yes, OR = 1.94, 95% CI: 1.21–3.11); anxiety was associated with education level (≤8 years, OR = 3.13, 95% CI: 1.62–6.08), time to diagnosis (≤ 3 years, OR = 2.14, 95% CI: 1.13–4.07), osteopenia (yes, OR = 2.43, 95% CI: 1.26–4.70), loss of hair (yes, OR = 2.80, 95% CI: 1.10–7.15), and fatigue (yes, OR = 2.89, 95% CI: 1.54–5.43). A stratified analysis according to age (≤45 years and > 45 years) was performed as an exploratory. None of factor-age interactions was statistically significant.

Conclusion

Side effects of endocrine therapy were significantly associated with anxiety and depression. Side effects deserve greater emphasis and clinical interventions are needed to reduce anxiety and depression in breast cancer patients accepting ET.

Geriatric functional assessment for decision-making on adjuvant chemotherapy in older colon cancer patients

BACKGROUND/AIMS

Despite the increasing need for geriatric assessment prior to chemotherapy, the method for this assessment remains inadequate for older cancer patients. We aimed to propose a simple assessment method to predict the performance of adjuvant chemotherapy in older patients after colon cancer surgery.

METHODS

This prospective study included patients over 65 years of age who were scheduled for adjuvant chemotherapy after colon cancer surgery. Before initiating chemotherapy, their functional status was assessed on the basis of activities of daily living (ADL)/instrumental activities of daily living (IADL). These parameters were analyzed with clinical characteristics and the patterns of adjuvant chemotherapy. The focus was on the completion rate of adjuvant chemotherapy.

RESULTS

A total of 89 patients with a median age of 72 years were analyzed. Among them, 54 (61%) were non-impaired and 35 (39%) were impaired regarding their ADL/IADL classification. Low body mass index and impairment of ADL/IADLs were significantly associated with chemotherapy interruption. Among toxicities, fatigue and hand-foot syndrome were independent prognostic factors for chemotherapy interruption. Impairments of ADL/IADL were significantly associated with fatigue regardless of age. Based on age and ADL/IADL stratification, younger patients (≤ 72 years) and/or those who were ADL/IADL non-impaired were significantly more likely to complete adjuvant chemotherapy than older patients (> 72 years) and ADL/IADL impaired patients (p = 0.038). This was regardless of the chemotherapy regimen.

CONCLUSION

Functional assessment using ADL/IADL is a convenient method to predict chemotherapy toxicity and performance. These results suggested that routine screening for ADL/IADLs could guide appropriate patient selection for the completion of adjuvant chemotherapy and predict expected outcomes.

Meta-Analysis of Randomized Controlled Trials on Yoga, Psychosocial, and Mindfulness-Based Interventions for Cancer-Related Fatigue: What Intervention Characteristics Are Related to Higher Efficacy?

Simple Summary

Many individuals with cancer suffer from persistent exhaustion due to cancer therapy, known as cancer-related fatigue (CRF). Yoga, psychosocial, and mindfulness-based interventions are recommended to reduce CRF. However, it is not clear yet how interventions need to be designed to maximize their efficacy. This meta-analysis aimed to identify intervention characteristics associated with greater reductions in CRF. A total of 70 interventions with 6387 participants were included in the analysis. Our results found a positive effect of yoga, psychosocial, and mindfulness-based interventions, while all invention types revealed large differences in intervention effects. In psychosocial interventions, using a group setting and working on cognition was related to higher efficacy. Regarding yoga and mindfulness-based interventions, no specific intervention characteristics emerged as more favorable than others. Overall, this meta-analysis suggests opportunities to optimize psychosocial interventions for CRF, whereas the design of yoga and mindfulness-based interventions seems to allow for variation.

Abstract

Cancer-related fatigue (CRF) is a burdensome sequela of cancer treatments. Besides exercise, recommended therapies for CRF include yoga, psychosocial, and mindfulness-based interventions. However, interventions conducted vary widely, and not all show a significant effect. This meta-analysis aimed to explore intervention characteristics related to greater reductions in CRF. We included randomized controlled trials published before October 2021. Standardized mean differences were used to assess intervention efficacy for CRF and multimodel inference to explore intervention characteristics associated with higher efficacy. For the meta-analysis, we included 70 interventions (24 yoga interventions, 31 psychosocial interventions, and 15 mindfulness-based interventions) with 6387 participants. The results showed a significant effect of yoga, psychosocial, and mindfulness-based interventions on CRF but with high heterogeneity between studies. For yoga and mindfulness-based interventions, no particular intervention characteristic was identified to be advantageous for reducing CRF. Regarding psychosocial interventions, a group setting and work on cognition were related to higher intervention effects on CRF. The results of this meta-analysis suggest options to maximize the intervention effects of psychosocial interventions for CRF. The effects of yoga and mindfulness-based interventions for CRF appear to be independent of their design, although the limited number of studies points to the need for further research.

Body Mass Index-Adjusted Weight Loss Grading System and Cancer-Related Fatigue in Survivors 1 Year After Esophageal Cancer Surgery

BACKGROUND

The association between pre- and postoperative weight loss and cancer-related fatigue after esophageal cancer surgery is unclear. This nationwide, prospective, longitudinal cohort study aimed to assess the influence of weight loss on cancer-related fatigue among esophageal cancer survivors.

METHODS

Patients who underwent esophagectomy for cancer between 2013 and 2019 in Sweden were enrolled in this study. Exposure was measured by the body mass index-adjusted weight loss grading system (WLGS). Cancer-related fatigue was assessed using the fatigue scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the EORTC QLQ-Fatigue 12 (QLQ-FA12) questionnaire measuring overall fatigue and physical, emotional, and cognitive fatigue. Growth mixture models were used to identify unobserved trajectories of cancer-related fatigue. Multivariable linear and logistic regression models were fitted to assess the associations between WLGS and cancer-related fatigue, adjusting for potential confounders.

RESULTS

Three trajectories were identified-low, moderate, and severe persistent fatigue. Cancer-related fatigue remained stable in each trajectory between 1 and 3 years after esophagectomy. Among the 356 enrolled patients, 4.5-22.6% were categorized into the severe persistent fatigue trajectory in terms of QLQ-C30 (19.9%), FA12 overall (10.5%), physical (22.6%), emotional (15.9%), and cognitive fatigue (4.5%). No association between pre- or postoperative WLGS and cancer-related fatigue was found between 1 and 3 years after esophageal cancer surgery.

CONCLUSIONS

Weight loss did not seem to influence cancer-related fatigue after esophageal cancer surgery.

Post-Corona-Fatigue – das bekannte Bild in neuem Gewand?

Hintergrund

Die myalgische Enzephalitis oder das „chronic fatigue syndrome“ (ME/CFS) ist als Folge von COVID(Corona Virus Disease)-19 erneut in den Fokus gerückt. Grundsätzlich problematisch ist die Tatsache, dass ME/CFS als eigenständige Entität gilt, aber extreme Fatigue auch ein häufiges Symptom einer zugrunde liegenden Erkrankung ist. Ziel des Beitrags ist es, die Akzeptanz für ME/CFS und extreme Fatigue bei nicht vollumfänglich verstandener Symptomatologie zu erhöhen und den Bedarf an Forschung, Orientierung für niedergelassene Ärzte sowie an Beratungsangeboten für Patienten hervorzuheben

Material und Methoden

Orientierende Recherchen in Form einer fokussierten Informationsbeschaffung.

Ergebnisse

In verschiedenen Forschungsprojekten konnte die Hypothese von postinfektiöser ME/CFS als Autoimmunerkrankung bestätigt werden. Generell erschweren sowohl die Heterogenität der diagnostischen Kriterien als auch die Vielfalt von Formulierungen zur Beschreibung der Symptomatik sowie verschiedene Codierungsmöglichkeiten eine klare Zuordnung der Symptome zu einem Krankheitsbild. Belastungsintoleranz wurde als schwerwiegendes Symptom einer Post-COVID-19-Erkrankung identifiziert. Aus diesem Grund werden aktuell die Empfehlungen in internationalen Leitlinien insbesondere hinsichtlich von Pacing überarbeitet. Die Auswirkungen auf Empfehlungen bei tumorbedingter Fatigue oder bei MS sind unklar.

Schlussfolgerung

Vor dem Hintergrund eines abnehmenden „burden of disease“ durch steigende Impfraten sollte die Forschung zu Fatigue nicht nur viral bedingte Erkrankungen umfassen.

Cancer-related fatigue and depression: a monocentric, prospective, cross-sectional study in advanced solid tumors

Background

Cancer-related fatigue (CRF) is common in patients with advanced solid tumors and several risk factors are described. The possible role of depression is reported by clinicians despite the association with CRF being unclear.

Material and methods

In this monocentric, cross-sectional, prospective study we recruited patients with advanced solid tumors who were hospitalized at Fondazione IRCCS Istituto Nazionale dei Tumori of Milan. The primary objective was to assess the correlation between CRF and depression. Secondary objectives were the estimation of CRF and depression prevalence and the identification of associated clinical risk factors. CRF and depression were evaluated through the Functional Assessment of Cancer Therapy-Fatigue subscale and the Zung Self Depression Scale (ZSDS) questionnaires. The Cochran-Armitage trend test was used to demonstrate the primary hypothesis. Univariate and multivariate logistic regression models were used to investigate the impact of clinical variables.

Results

A total of 136 patients were enrolled. The primary analysis found a linear correlation (P < 0.0001) between CRF and depression. The prevalence of CRF and of moderate to severe depressive symptoms was 43.5% and 29.2%, respectively. In univariate analysis, patients with poor Eastern Cooperative Oncology Group performance status (ECOG PS), anemia, distress, pain, and receiving oncological treatment were at a significantly higher risk for CRF, whereas poor ECOG PS, pain, and distress were risk factors for depression. In multivariate analysis, high levels of ZSDS were confirmed to be correlated to CRF: odds ratio of 3.86 [95% confidence interval (CI) 0.98-15.20) and 11.20 (95% CI 2.35-53.36) for ZSDS of 50-59 and 60-100, respectively (P value for trend 0.002). Moreover, the ECOG PS score was confirmed to be significantly associated with CRF (OR 7.20; 95% CI 1.73-29.96; P = 0.007).

Conclusions

Our data suggest a strong correlation between CRF and depression in patients with advanced solid tumors. Further investigations are needed to better understand this relationship and if depressive disorder therapeutic strategies could also impact on CRF.

•

Validated patient-reported outcome measures were used for screening CRF and depression in advanced cancer patients.

•

A direct strong correlation between CRF and depression was found in these patients, often unconsidered by clinicians.

•

Other different clinical risk factors for the onset and worsening of CRF were identified.

•

A comprehensive evaluation of cancer patients, that should also consider mood disorders, could improve CRF management.

Knowledge regarding cancer-related fatigue: a survey of physical therapists and individuals diagnosed with cancer

BACKGROUND

Cancer-related fatigue (CRF) is a common side effect and remains under-diagnosed. Screening of CRF by physical therapists (PTs) and patient perspectives of their experiences has not been comprehensively examined.

PURPOSE

To survey PTs to understand the frequency of CRF screening, and to assess the knowledge and experiences of survivors as it relates to CRF.

METHODS

Two separate electronic surveys developed by the authors were distributed. One targeted oncology PTs, the other for adult survivors of cancer.

RESULTS

Of the 199 PT respondents, 36% reported screening for CRF at every encounter. Screening included interviews (46%) and/or standardized questionnaires (37%). The most common barriers to receiving treatment for CRF was lack of physician referrals and time constraints. Of patient responses (n = 61), 84% reported CRF as an important ongoing issue; 77% reported that they initiated the discussion about CRF with their provider, and 23% reported being told there were treatment options for CRF.

CONCLUSION

CRF is common among cancer survivors. However, consistent screening by PTs is lacking. Patients with CRF frequently initiated the conversation with their providers because of symptoms and many patients were not told of treatment options. These findings represent a substantial gap in clinical practice regarding CRF screening and management.

Molecular biomarkers in cardio-oncology: Where we stand and where we are heading

Until recently, cardiotoxicity in the setting of a malignant disease was attributed solely to the detrimental effects of chemo- and/or radio-therapy to the heart. On this account, the focus was on the evaluation of well-established cardiac biomarkers for the early detection of myocardial damage. Currently, this view has been revised. Cardiotoxicity is not restricted to a single organ but instead affects the endothelium as a whole. Indeed, it has come into light that not only cancer therapy but also malignant cells per se can impair the cardiovascular system, through a paracrine and endocrine mode of action. Even more intriguingly, a clear interplay between molecular pathways involved in cancer and cardiovascular disease has become prevalent, suggesting a common nominator that governs the pathophysiology of these two entities. Taken together, our strategy in the quest of novel biomarkers in the emerging field of cardio-oncology should be critically reshaped.

Relationships between daily physical activity combinations and psychophysical health status of Italian breast cancer survivors

In breast cancer survivors (BCS), the contemporaneous increase of sedentary time and reduction of physical activity (PA) requires early attention because it has negative consequences for their health. Aims of the study were to investigate: a) the correlations between PA, sedentarism, and health-related measures; b) the association between different patterns of daily activity and health-related outcomes. Two hundred and nineteen BCS (50.98 ± 6.28) were selected for this study. Psychological, anthropometric, endocrine, sleeping, and both daily sedentary time and PA variables were considered. Sedentarism and PA have opposite correlations with anthropometric variables, anxiety, depression, morning salivary cortisol, and sleeping characteristics. The first favors pathological values and the latter favors normal values. Regression tree analysis showed the impact of different daily sedentary time and PA combinations on the investigated variables and allowed the individualization of their optimal combination for health. Our results could be useful to healthcare providers and BCS.

Sexual Health Dysfunction After Radiotherapy for Gynecological Cancer: Role of Physical Rehabilitation Including Pelvic Floor Muscle Training

Introduction

The present study aims to describe: 1. How the side effects of radiotherapy (RT) could impact sexual health in women; 2. The effectiveness of physical rehabilitation including pelvic floor muscle training (PFMT) in the management of sexual dysfunction after RT.

Materials and Methods

Search keys on PubMed, Web of Science, Scopus, PEDro, and Cochrane were used to identify studies on women treated with radical or adjuvant RT and/or brachytherapy for gynecological cancers with an emphasis on vulvo-vaginal toxicities and PFMT studies on sexual dysfunction for this group of women.

Results

Regarding the first key question, we analyzed 19 studies including a total of 2,739 women who reported vaginal dryness, stenosis, and pain as the most common side effects. Reports of dosimetric risk factors and dose-effect data for vaginal and vulvar post-RT toxicities are scant. Only five studies, including three randomized controlled trials (RCTs), were found to report the effect of PFMT alone or in combination with other treatments. The results showed some evidence for the effect of training modalities including PFMT, but to date, there is insufficient evidence from high-quality studies to draw any conclusion of a possible effect.

Conclusions

Gynecological toxicities after RT are common, and their management is challenging. The few data available for a rehabilitative approach on post-actinic vulvo-vaginal side effects are encouraging. Large and well-designed RCTs with the long-term follow-up that investigate the effect of PFMT on vulvo-vaginal tissues and pelvic floor muscle function are needed to provide further guidance for clinical management.

Effectiveness of exercise training on cancer-related fatigue in colorectal cancer survivors: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

To investigate the effects of exercise training on cancer-related fatigue (CRF) in colorectal cancer survivors.

METHODS

Randomized controlled trials published between 1 January 2010 and 19 October 2020, selected through online search conducted in PubMed, Scopus, Web of Science, SPORTDiscus and PEDro databases, were included. Eligible trials compared the effect of exercise training interventions, versus non-exercise controls on CRF, in colorectal cancer survivors, during or after treatment. The methodological quality of individual studies was analysed using the Physiotherapy Evidence Database (PEDro) scale. Standardized mean differences (SMD) that were pooled using random-effects models were included as the effect size. In addition, 95% prediction intervals (PI) were calculated.

RESULTS

Six trials involving 330 colorectal cancer patients met the inclusion criteria and presented reasonable to good methodological quality. An overall small-to-moderate effect of exercise training on CRF was found (SMD =  - 0.29: 95% CI: [- 0.53; - 0.06]; p = 0.01; PI: [- 0.63; 0.04]; low-quality evidence). Subgroup analysis revealed moderate effects of exercise interventions performed during chemotherapy (SMD =  - 0.63; 95% CI: [- 1.06; - 0.21]; p = 0.003) and small, non-significant effects, when exercise training was performed after cancer treatment (SMD =  - 0.14; 95% CI: [- 0.43; 0.14]; p = 0.32). Steady improvements were achieved when a combination of aerobic plus resistance exercise was used, in interventions lasting 12 to 24 weeks.

CONCLUSION

Exercise training could be regarded as a supportive therapy for the clinical management of CRF in colorectal cancer patients undergoing chemotherapy, but further studies are necessary to clarify the effects of exercise interventions on CRF after cancer treatment.

Financial Burden of Drugs Prescribed for Cancer-Associated Symptoms

PURPOSE

The financial toxicity of anticancer drugs is well-documented, but little is known about the costs of drugs used to manage cancer-associated symptoms.

METHODS

We reviewed relevant guidelines and compiled drugs used to manage seven cancer-associated symptoms (anorexia and cachexia, chemotherapy-induced peripheral neuropathy, constipation, diarrhea, exocrine pancreatic insufficiency, cancer-associated fatigue, and chemotherapy-induced nausea and vomiting). Using GoodRx website, we identified the retail price (cash price at retail pharmacies) and lowest price (discounted, best-case scenario of out-of-pocket costs) for patients without insurance for each drug or formulation for a typical fill. We describe lowest prices here.

RESULTS

For anorexia and cachexia, costs ranged from $5 US dollars (USD; generic olanzapine or mirtazapine tablets) to $1,156 USD (brand-name dronabinol solution) and varied widely by formulation of the same drug or dosage: for olanzapine 5 mg, $5 USD (generic tablet) to $239 USD (brand-name orally disintegrating tablet). For chemotherapy-induced peripheral neuropathy, costs of duloxetine varied from $12 USD (generic) to $529 USD (brand-name). For constipation, the cost of sennosides or polyethylene glycol was <$15 USD, whereas newer agents such as methylnaltrexone were expensive ($1,001 USD). For diarrhea, the cost of generic loperamide or diphenoxylate-atropine tablets was <$15 USD. For exocrine pancreatic insufficiency, only brand-name formulations were available, range of cost, $1,072 USD-$1,514 USD. For cancer-associated fatigue, the cost of generic dexamethasone or dexmethylphenidate was <$15 USD, whereas brand-name modafinil was more costly ($1,284 USD). For a 4-drug nausea and vomiting prophylaxis regimen, costs ranged from $181 USD to $1,430 USD.

CONCLUSION

We highlight the high costs of many symptom control drugs and the wide variation in the costs of these drugs. These findings can guide patient-clinician discussions about cost-effectively managing symptoms, while promoting the use of less expensive formulations when possible.

The Mediating Effect of Perceived Injustice and Pain Catastrophizing in the Relationship of Pain on Fatigue and Sleep in Breast Cancer Survivors: A Cross-Sectional Study

OBJECTIVE

Multidimensional aspects of pain have raised awareness about cognitive appraisals, such as perceived injustice (PI) and pain catastrophizing (PC). It has been demonstrated that they play an important role in patients' pain experience. However, the mediating effect of these appraisals has not been investigated in breast cancer survivors (BCS), nor have they been related to fatigue and sleep.

METHODS

Cross-sectional data from 128 BCS were analysed by structural path analysis with the aim to examine the mediating effect of PI and PC in the relationship of pain on fatigue and sleep.

RESULTS

The indirect mediating effects of PI on fatigue (CSI*PI = 0.21; P < 0.01 and VAS*PI = 1.19; P < 0.01) and sleep (CSI*PI = 0.31; P < 0.01 and VAS*PI = 1.74; P < 0.01) were found significant for both pain measures (Central Sensitization Inventory (CSI) and Visual Analogue Scale (VAS)). PC, on the other hand, only mediated the relationship between pain measured by VAS and fatigue (VAS*PC = 0.80; P = 0.03). Positive associations were found, indicating that higher pain levels are positively correlated with PI and PC, which go hand in hand with higher levels of fatigue and sleep problems.

CONCLUSION

PI is an important mediator in the relationship of pain on fatigue and sleep, while PC is a mediator on fatigue after cancer treatment. These findings highlight that both appraisals are understudied and open new perspectives regarding treatment strategies in BCS.

Physicians' perceptions of the factors influencing disclosure of secondary findings in tumour genomic profiling in Japan: a qualitative study

Tumour genomic profiling (TGP), conducted in search of therapeutics, sometimes reveals potentially pathogenic germline variants as secondary findings (SFs). Physicians involved in TGP are often specialised in oncology and not in clinical genetics. To better utilise SFs, we explored issues physicians have during disclosure and the potential for collaborations with clinical genetics professionals. Semi-structured interviews were conducted with 14 physicians who had experience in handling outpatient TGP at designated core hospitals for cancer genomic medicine in Japan. The data were analysed thematically. The difficulties physicians experienced during informed consent (IC) included educating patients about SFs, providing detailed information on SFs, and explaining the impact of SFs on patients' family members. When SFs were detected, physicians had reservations regarding the relevance of the disclosure criteria. Confirmatory germline tests were performed using peripheral blood when tumour-only tests detected suspected SFs. Some physicians had reservations about the necessity of confirmatory tests when they did not affect the patients' treatment options. To encourage patients to receive confirmatory tests, improvements are necessary in the healthcare system, such as insurance reimbursements, education for physicians so that they can provide a better explanation to their patients, and genetic literacy of physicians and patients. The physicians offered insights into the challenges they experienced related to IC, disclosure of SFs, and expectations for active collaborations with clinical genetics professionals. Wider healthcare insurance coverage and better genetic literacy of the population may lead to more patients taking confirmatory tests when SFs are suspected.

Cancer-related fatigue: benefits of information booklets to improve patients' knowledge and empowerment

PURPOSE

To investigate cancer patients' knowledge and attitudes regarding fatigue and the potential benefits and acceptability of a brief information booklet.

METHODS

The CARPE DIEM study assessed knowledge and attitudes regarding fatigue in a diverse group of 50 cancer patients before (T0) and about one (T1) and four months (T2) after reading the booklet. At T1, participants additionally rated its usefulness.

RESULTS

At baseline, 37.5% of respondents did not know the term "fatigue" or what it meant. Those who already knew something about fatigue mainly had obtained their information from booklets, books, or articles (63.3%) and/or the internet (46.7%). Overall, knowledge gaps existed, particularly about potential fatigue treatment options and whether fatigue is an indicator of cancer progression. Furthermore, 56.4% felt poorly informed, and 46.1% reported feeling helpless in the face of fatigue. Lower knowledge at baseline was significantly associated with lower education and older age. At T1 and T2, there were significant improvements in several knowledge questions and attitudes. Patient-reported benefits included getting new information about fatigue (91.1%), awareness of not being alone with their problems (89.7%), taking appropriate actions (72.9%), and encouragement to talk about their fatigue with family/friends (55.3%) or with a health professional (52.7%).

CONCLUSIONS

Specific gaps were identified in the provision of information and education for cancer patients about fatigue. A low-cost intervention asking to read a brief information booklet was associated with improved knowledge. This could be considered as a first step offered as part of a bundle of further efforts to improve knowledge and care of fatigue.

Practice review: Evidence-based and effective management of fatigue in patients with advanced cancer

BACKGROUND

Fatigue affects most patients living with advanced cancer and is a symptom that healthcare professionals can find difficult to manage.

AIM

To provide healthcare professionals with a pragmatic overview of approaches to management of fatigue in patients with advanced cancer that are commonly recommended by guidelines and to evaluate evidence underpinning them.

DESIGN

Scoping review methodology was used to determine the strength of evidence supporting use of interventions recommended in management of fatigue in patients with advanced cancer.

DATA SOURCES

National or international guidelines were examined if they described the management of fatigue in adult cancer patients and were written within the last 6 years (2015-2021) in English. The Cochrane Database of Systematic Reviews (January 2011-December 2021) was searched for 'cancer' AND 'fatigue' in title, abstract or keywords. A PubMed search was also made.

RESULTS

Evidence indicates physical exercise interventions are effective and patients may benefit from energy conservation tactics. Evidence does not support use of psychostimulants such as methylphenidate. Limited data were found on efficacy of corticosteroids, psychological interventions, nutritional intervention, sleep optimization or complementary therapies for management of fatigue in advanced cancer.

CONCLUSION

We recommend regular assessment, review and acknowledgement of the impact of fatigue. Exercise and energy conservation should be considered. Pharmacological interventions are not endorsed as a routine approach. Many interventions currently recommended by guidelines are not supported by a robust evidence base and further research on their efficacy is required.

Fatigue in Cirrhosis

Fatigue is a common symptom in patients with liver disease and has a significant impact on the health-related quality of life (HR-QoL). Its pathogenesis is poorly understood and is considered multifactorial. The liver is central in the pathogenesis of fatigue because it uniquely regulates much of the production, storage, and release of substrate for energy generation. Also, the liver "cross-talks" with the key organs that are responsible for this symptom complex-gut, skeletal muscle, and brain. Fatigue can have both peripheral (i.e., neuromuscular) and central (i.e., resulting from changes in neurotransmission within the brain) components. The treatment strategies for the management of fatigue are behavioral changes and pharmacotherapy, along with dietetic intervention and exercise. However, there is no consensus on management strategies for fatigue in patients with liver disease. This article gives an overview of fatigue as a concept, its pathophysiology, measures to evaluate fatigue in patients with liver disease, the impact of fatigue on chronic liver disease, assessment of fatigue in an appropriate clinical setting, and various interventions to manage fatigue.

A review of the content and psychometric properties of cancer-related fatigue (CRF) measures used to assess fatigue in intervention studies

PURPOSE

Cancer-related fatigue (CRF) is a common and debilitating consequence of cancer and its treatment. Numerous supportive care interventions have been developed to alleviate CRF; however, the diversity of outcome measures used to assess CRF limits comparability of findings. We aimed to evaluate the content and psychometric properties of measures used to assess CRF in interventions targeting fatigue, to inform the selection of suitable measures in future research.

METHODS

Included measures were identified from a systematic review of interventions targeting CRF. General characteristics of each measure were extracted, and item content was assessed against domains specified by the National Comprehensive Cancer Network (NCCN) definition of CRF. Psychometric properties were evaluated against COnsensus-based Standards for the selection of heath Measurement INstruments (COSMIN) criteria.

RESULTS

Of 54 measures identified, 25 met inclusion criteria. Seventeen were fatigue-specific and eight a fatigue subscale or single item within a broader measure. Only 14 (56%) were specifically developed for cancer populations. Content coverage according to the NCCN CRF definition ranged from 0 to 75%. Evidence for fulfilment of COSMIN criteria in cancer populations ranged from 0 to 93%, with only five measures meeting > 70% of the COSMIN criteria.

CONCLUSION

The Piper Fatigue Scale-Revised had good content coverage, but did not comprehensively address COSMIN criteria. The EORTC-FA12 and FACIT/FACT-F had excellent psychometric properties, with each capturing different aspects of fatigue. Ultimately, the choice of CRF measure should be guided by the research question and the CRF domains most relevant to the particular research context.

The relationship between rumination, fatigue and psychological resilience among cancer survivors

AIM AND OBJECTIVES

The study's purpose was to examine the association between rumination, fatigue and psychological resilience among cancer survivors.

BACKGROUND

Cancer is a disease that causes difficult lives in individuals. Individuals can struggle with cancer-related fatigue (CRF) and ruminative thoughts during and after the disease process. However, it can also be seen that some individuals make sense out of their cancer experience and turn into stronger individuals.

DESIGN

A cross-sectional design.

METHODS

This study was conducted from February through November 2020. Data were collected from 159 cancer survivors using Event Related Rumination Inventory, Cancer Fatigue Scale and Connor-Davidson Resilience Scale.

RESULTS

The findings showed that intrusive rumination significantly and negatively mediated psychological resilience but significantly and positively mediated with CRF. In contrast, deliberate rumination was significantly and positively mediated psychological resilience but significantly and negatively mediated with CRF. The effects of intrusive and deliberate rumination on fatigue were .431 (CI =0.042-0.635) and -.285 (CI = -0.163 to 0.491), respectively. In addition, the effects of intrusive and deliberate rumination on psychological resilience were -.253 (CI = -0.177 to 0.447) and .304 (CI = 0.045-0.124), respectively.

CONCLUSIONS

The findings underline the mediating role of rumination on CRF and psychological resilience among cancer survivors. The findings also delineate the associations between rumination, CRF and psychological resilience, which differ based on rumination type.

RELEVANCE TO CLINICAL PRACTICE

The findings are particularly important to oncology nurses, who are the main sources of psychosocial care. To support cancer survivors and mobilise their resources, oncology nurses should be made aware of the different types and effects of rumination. With the help of this awareness, oncology nurses can enhance managing intrusive rumination, replacing intrusive ruminations with deliberate ones, mobilising resources and promoting psychological resilience.

Cancer outcomes research - a European challenge Part II: Opportunities and priorities

In Part I of our review of cancer outcome research, we analysed pros and cons of various measures relevant to quantifying the burden of cancer. Based on our recommendations in Part I, we now discuss in Part II opportunities and priorities in four areas of outcome research: primary prevention; early detection screening; treatment; and quality‐of‐life assessment. We recommend the establishment of an infrastructure that facilitates high‐quality research in these areas: (a) progress in primary prevention can be assessed most directly by monitoring cancer incidence although the interpretation of temporal trends is notoriously confounded by numerous factors that complicate causal inference. (b) preventive screening, with the aim to prevent advanced disease, appears to work well in in some tumours but not in others. It will require randomized control trials (RCTs) to quantify benefits and harms although conclusive studies are increasingly difficult to undertake. We therefore propose learning screening programmes (randomization at the time of rolling out population‐based programmes) as the most feasible approach. (c) New therapeutic interventions tailored to the individual patient often require assessment in RCTs with rather complex and dynamic structure, making their design and analyses increasingly challenging but also more suited to be executed as academic, PI‐initiated trials. (d) We next discuss assessment of quality‐of‐life aspects. Quality of life is a neglected component in outcome research with an urgent need for development, validation and standardization. We finally recommend four initiatives that would pave the way for a valid and informative assessment of the goals for improved cancer control in Europe as defined by the European Academy of Cancer Sciences.

Revealing the Mechanism of Astragali Radix against Cancer-Related Fatigue by Network Pharmacology and Molecular Docking

Background

Cancer-related fatigue (CRF) is an increasingly appreciated complication in cancer patients, which severely impairs their quality of life for a long time. Astragali Radix (AR) is a safe and effective treatment to improve CRF, but the related mechanistic studies are still limited.

Objective

To systematically analyze the mechanism of AR against CRF by network pharmacology.

Methods

TCMSP was searched to obtain the active compounds and targets of AR. The active compound-target (AC-T) network was established and exhibited by related visualization software. The GeneCards database was searched to acquire CRF targets, and the intersection targets with AR targets were used to make the Venny diagram. The protein-protein interaction (PPI) network of intersection targets was established, and further, the therapeutic core targets were selected by topological parameters. The selected core targets were uploaded to Metascape for GO and KEGG analysis. Finally, AutoDock Vina and PyMOL were employed for molecular docking validation.

Results

16 active compounds of AR were obtained, such as quercetin, kaempferol, 7-O-methylisomucronulatol, formononetin, and isorhamnetin. 57 core targets were screened, such as AKT1, TP53, VEGFA, IL-6, and CASP3. KEGG analysis manifested that the core targets acted on various pathways, including 137 pathways such as TNF, IL-17, and the AGE-RAGE signaling pathway. Molecular docking demonstrated that active compounds docked well with the core targets.

Conclusion

The mechanism of AR in treating CRF involves multiple targets and multiple pathways. The present study laid a theoretical foundation for the subsequent research and clinical application of AR and its extracts against CRF.

TANGO: effect of tango Argentino on cancer-associated fatigue in breast cancer patients-study protocol for a randomized controlled trial

BACKGROUND

The majority of breast cancer patients suffer from persistent impairments after completion of their primary oncological therapy. Cancer-related fatigue (CRF) in particular is a multidimensional syndrome having a profound negative impact on the quality of life. To counter CRF symptoms, physical activities are suggested as first-line interventions, mind-body therapies have been shown to be effective, and music therapy can also reduce anxiety and stress in breast cancer patients. Tango therapy that combines various elements can have an impact on physical, psychological, and cognitive abilities and could therefore have a beneficial effect on breast cancer patients. The purpose of this study is to investigate whether a 6-week tango module is suited as a therapeutic approach for people after primary breast cancer therapy to favorably influence their quality of life, especially CRF levels.

METHODS

Sixty patients with a diagnosis for stage I-III breast cancer 12-48 months before enrollment and with CRF (age > 18) will be recruited and randomized 1:1 to a tango or a waiting-list group. Movement concepts using elements of Argentine tango (self-awareness, musical and spatial perception, self-perception, playfulness, shared experience) will be examined with the participants during six consecutive weekly 1-h tango sessions. The primary outcome will be the improvement of CRF (German version of the Cancer Fatigue Scale), and the secondary outcomes will be the improvement in sleep quality (Pittsburgh Sleep Quality Index) and quality of life (EORTC-QLQ-C30). Patient-reported outcomes will be measured at baseline and 6 weeks later; follow-up will be performed 6, 12, and 24 months after baseline. An evaluation will be performed by means of descriptive data analyses.

DISCUSSION

Argentine tango, as a music-based movement therapy, can influence different skills and may improve several outcomes. The therapeutic use of Argentine tango in the care of breast cancer patients has not yet been reported. It is anticipated that participants receiving the tango module will have improved CRF, sleep, and quality of life scores compared to a waitlist control.

TRIAL REGISTRATION

German Clinical Trials Registry (DRKS) DRKS00021601 . Retrospectively registered on 21 August 2020.

Effects from physical exercise on reduced cancer-related fatigue: a systematic review of systematic reviews and meta-analysis

BACKGROUND

Cancer-related fatigue is one of the most prevalent and distressing symptoms among cancer patients, resulting in a great cancer research challenge. Numerous systematic reviews of physical training interventions have been conducted to find the most effective approach. However, evidence remains fragmented, and in which cancer population physical training is more effective than other populations is still unclear. Thus, this study critically appraised systematic reviews and meta-analyses on physical training to reduce adults' cancer-related fatigue.

METHODS

A systematic review of systematic reviews and meta-analysis (PROSPERO: CRD42020189049), assessing the efficacy of exercise training for reducing cancer-related fatigue in adults, was conducted in PubMed, CINAHL, Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects, and Pedro. The selected studies (standardized mean difference, SMD; 95%CI), was quantitatively pooled using a random-effects model. Heterogeneity was tested using chi-squared (Q) and I-square statistics (I²).

RESULTS

Of 1438 identified articles, 11 met the inclusion criteria, and ten were meta-analyzed. The results yielded a positive effect of physical training on fatigue in all cancer populations, SMD = -0.33 (-0.43, -0.23). Subgroup analysis based on tumor localization showed a slightly higher physical training effect on fatigue in adults with breast cancer, SMD = -0.36 (-0.57, -0.15), and prostate cancer SMD = -0.34 (-0.45, -.0.22).

CONCLUSIONS

Our analysis demonstrated some potential improvement in cancer-related fatigue in adult patients undergoing physical training during and after cancer treatments, particularly in patients with breast or prostate cancer.

Transcutaneous electrical acupoint stimulation (TEAS) for cancer-related fatigue: study protocol for a systematic review and meta-analysis

INTRODUCTION

Cancer-related fatigue (CRF) is a prevalent symptom in cancer survivors. Transcutaneous electrical acupoint stimulation (TEAS) has been reported as a promising therapy for CRF. This protocol is proposed for a systematic review that aims to assess the efficacy and safety of TEAS for CRF.

METHODS AND ANALYSIS

Cochrane Central Register of Controlled Trials, PubMed, Medline, Embase, Chinese National Knowledge Infrastructure, VIP, Wanfang database, Chinese Biomedical Literature Database, Chinese Clinical Trial Registry System, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform will be searched from inception to 31 January 2021 without language limitations. The eligible randomised controlled trials will be included. The primary outcomes include changes in the revised Piper fatigue scale, the Brief fatigue inventory, the Multidimensional fatigue inventory and the Functional assessment of chronic illness therapy fatigue. The secondary outcomes are the quality-of-life measurement index, the Hamilton anxiety scale, the Hamilton depression scale and adverse events. The selection of studies, data extraction and assessment of risk of bias will be conducted independently by two reviewers. Data synthesis will be performed using RevMan V.5.4.1. The quality of evidence will be evaluated with the Grading of Recommendations, Assessment, Development and Evaluation system. This study will strictly adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is a systematic review and meta-analysis based on previously published studies involving no private information of patients. The results of this study will be disseminated in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020220282.

Cancer-Related Fatigue After Esophageal Cancer Surgery: Impact of Postoperative Complications

Background

The impact of postoperative complications on cancer-related fatigue is unknown. This nationwide prospective cohort study aimed to assess the trajectory of cancer-related fatigue and the influence of predefined postoperative complications on cancer-related fatigue up to 2 years after esophageal cancer surgery.

Methods

The patients in this study underwent esophagectomy between 2013 and 2019 in Sweden. The exposure was predefined postoperative complications. The outcome was cancer-related fatigue measured by the fatigue scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the EORTC QLQ-Fatigue 12 (QLQ-FA12) questionnaire. Linear mixed-effects models provided adjusted fatigue scores and mean score differences (MDs) with 95% confidence intervals (CIs) between patients with and without predefined complications.

Results

The study enrolled 331 patients. The QLQ-C30 fatigue score increased with clinical relevance among patients with any complications (MD, 5.8; 95% CI, 2.6–9.0) who had a higher Clavien-Dindo classification (grades 2 to 3a: MD, 7.3; 95% CI, 3.1–11.5), a medical complication (MD, 6.9; 95% CI, 3.0–10.7), or a pulmonary complication (MD, 6.9; 95% CI, 2.1–11.6) for 1–1.5 years and remained stable until 2 years after esophagectomy. Similar patterns were found in the QLQ-FA12 fatigue and QLQ-FA12 physical and emotional subscales, but not in the cognitive subscales.

Conclusions

Complications in general and medical and pulmonary complications in particular might be associated with increased cancer-related fatigue after esophagectomy.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11049-z.