Practical management of tyrosine kinase inhibitor-associated side effects in GIST

Patients diagnosed with advanced gastrointestinal stromal tumor (GIST) are currently treated with oral tyrosine kinase inhibitors (TKIs). Imatinib mesylate is the standard first-line treatment, and sunitinib malate is administered second-line for patients who are intolerant or progress on imatinib. Imatinib has recently been approved for adjuvant treatment of GIST patients who have a significant risk for relapse. In both the metastatic and adjuvant settings, patients may be on these TKIs for many years. Low plasma imatinib levels have been reported to be associated with a short median time to progression of advanced GIST, stressing the importance of maintaining optimal drug levels. We summarize management of the most frequent and clinically significant adverse effects of imatinib and sunitinib in the treatment of GIST in the context of current guidelines, published literature, and the experience of three large GIST referral centers. The adverse events reviewed include nausea and vomiting, diarrhea, skin rash, musculoskeletal complaints, fatigue, hemorrhage, edema, hand-foot skin reaction, skin and hair discoloration, mucositis, hypertension, cardiac toxicity, hypothyroidism, liver transaminase changes, and hematological toxicity of imatinib and sunitinib. Potential drug-drug interactions with each respective agent are also discussed. With prudent use of supportive care measures, many side effects can be managed without dose reduction or interruption of treatment. On the other hand, individualized tailoring of the dose is often required to manage severe toxicity, such as painful hand-foot skin reactions, fatigue, hepatotoxicity, or cardiac toxicity. Management of many TKI-related adverse effects require further evaluation in prospective clinical trials.

Does effective management of sleep disorders reduce cancer-related fatigue?

Cancer and cancer therapy are often associated with symptoms such as fatigue and sleep disturbances, before, during and after therapy. These symptoms of fatigue and poor sleep often occur in parallel having a significant impact on the physical functioning of patients with cancer. A strong correlation between cancer-related fatigue (CRF) and sleep has been observed in several studies, suggesting that they may be reciprocally related. The co-clustering of these symptoms suggests that they may have similar underlying aetiology and that treatments targeting either symptom may positively affect the other. Studies examining these clusters have shown that these symptoms often co-vary together. The potential mechanisms that link the relationship between insomnia and CRF are intriguing but require further investigation. Despite the high prevalence of insomnia and the often bidirectional relationship between poor sleep and fatigue, there are limited data to support the use of sleep management interventions as a means to reduce fatigue in patients with cancer. Assessment of the available evidence across trials is complicated by different study designs, patient selection criteria, stage of cancer treatment and by the nature of the interventions studied. Improvements from baseline in both sleep parameters and CRF have been documented in a limited number of studies, including two randomized-controlled trials using cognitive behavioural therapy for insomnia (CBT-I). In contrast, the efficacy of pharmacological therapies in reducing both insomnia and CRF is largely lacking. Clearly, treating clinically significant insomnia is likely to have benefits for the patient with cancer and for those who are recovering from cancer. In particular, pharmacotherapies for insomnia, singly or in combination with CBT-I, should be evaluated in multicentre randomized clinical trials to examine their efficacy in improving sleep quality and reducing associated CRF.

Circadian Disruption, Fatigue, and Anorexia Clustering in Advanced Cancer Patients: Implications for Innovative Therapeutic Approaches

A disruption of the circadian timing system, as identified by monitoring of marker biorhythms, is common in cancer patients. The recording of the rest—activity rhythm with a wrist actigraph has been commonly used. This noninvasive monitoring allows a robust estimation of circadian disruption. The authors have previously found that altered patterns of circadian rest—activity rhythms are significantly and independently associated with the severity of fatigue and anorexia in patients with metastatic colorectal cancer. Elevated proinflammatory cytokines could partly account for this circadian disruption and its associated constitutional symptoms. Here, the authors present and discuss the data supporting the hypothesis that circadian disruption is often associated with fatigue and anorexia, which in turn further alter and dampen circadian synchronization, thus, creating a vicious cycle. This body of evidence paves the path for innovative therapeutic approaches targeting the circadian timing system in an effort to diminish constitutional symptoms induced by cancer and some anticancer treatments.

Tumorbedingte Fatigue

Zusammenfassung. Die tumorbedingte Fatigue ist ein verbreitetes und den Patienten sehr belastendes Syndrom im Rahmen der Krebserkrankung und -therapie. Tumorbedingte Fatigue (im angloamerikanischen Sprachraum als cancer-related fatigue, CRF, bezeichnet) geht einher mit dem subjektiven Gefühl von physischer und mentaler Müdigkeit, Erschöpfung, Energieverlust und wenig Möglichkeiten der Erholung. Es geht weit über das „normale” Maß an Erschöpfung hinaus, was gesunde Personen erleben. Tumorbedingte Fatigue kommt als Folge der Krebserkrankung selbst und als Nebeneffekt der Krebstherapie vor. Das genaue Ursachengefüge ist jedoch bislang nicht genau geklärt. Zum Diagnosezeitpunkt leiden bis zu 40%, im weiteren Verlauf der Krebsbehandlung mehr als 90% der Patienten unter tumorbedingter Fatigue. Unter der Strahlentherapie tritt die tumorbedingte Fatigue bei über 90%, während der Chemotherapie bei bis zu 80% der Betroffenen auf. Tumorbedingte Fatigue neigt zur Chronifizierung auch nach Abschluss der Therapie und ist dann umso belastender für die Patienten, da eine Ursachenzuschreibung erschwert ist. Die Beeinträchtigungen durch die tumorbedingte Fatigue sind beträchtlich, die Lebensqualität, das psychische Wohlbefinden so wie die Teilhabe am Alltagsleben und die berufliche Leistungsfähigkeit sind in aller Regel massiv eingeschränkt. Trotz dieser hohen Relevanz für Patienten und Behandler hat sich die Forschung über tumorbedingte Fatigue, im Vergleich zu anderen Begleitsymptomen der Krebserkrankung und -therapie, erst in den letzten Jahren intensiviert. Die vorliegende Arbeit gibt einen systematischen Überblick über epidemiologische Grundlagen, krankheitsbegleitende Aspekte sowie evaluierte nicht-medikamentöse Interventionen und ihren Stellenwert innerhalb der Behandlung tumorbedingter Fatigue.

A pilot study evaluating the safety and efficacy of modafinal for cancer-related fatigue

BACKGROUND

Fatigue is a common symptom that lowers the quality of life of patients with cancer, affecting between 60% and 90% of patients. Relatively few options are available for the treatment of this debilitating condition. Modafinal, a psychostimulant developed for the treatment of narcolepsy, has been used to treat fatigue in other diseases such as multiple sclerosis, but little data support its use in cancer patients.

OBJECTIVE AND DESIGN

The primary objective of this open-label pilot study was to evaluate the safety, and efficacy of modafinil in improving cancer-related fatigue (CRF) as measured by the Brief Fatigue Inventory (BFI). The effect of this agent on depression, quality of life, functional status, and cognitive function was also assessed. Modafinal was self-administered at a dose of 100 mg/d during weeks 1-2, and 200 mg during weeks 3-4. Assessments were performed at baseline, 2, and 4 weeks.

RESULTS

BFI score was improved in 46% of patients at 2 weeks and 75% at 4 weeks (p = 0.025). Hospital Anxiety and Depression Scale scores declined at 2 and 4 weeks (p < 0.001). Most scales for neurocognitive function were unchanged. Score for all Functional Assessment of Cancer Therapy-Brain (FACT-BR) subscales (measuring quality of life), except social/family well-being, were improved (p < 0.05) at 2 and 4 weeks. Significant changes in Eastern Cooperative Oncology Group (ECOG) performance status were noted, with 40% of patients improving at least one level. Modafinil was well-tolerated with only one patient discontinuing treatment due to drug-related toxicity.

CONCLUSION

In this pilot study modafinil was well-tolerated and effective for fatigue in patients with cancer. Improvements were also seen in mood, quality of life, and functional status.

Erythropoietin or Darbepoetin for patients with cancer--meta-analysis based on individual patient data

BACKGROUND

Erythropoiesis-stimulating agents (ESAs) reduce anemia in cancer patients and may improve quality of life, but there are concerns that ESAs might increase mortality.

OBJECTIVES

Our objectives were to examine the effect of ESAs and identify factors that modify the effects of ESAs on overall survival, progression free survival, thromboembolic and cardiovascular events as well as need for transfusions and other important safety and efficacy outcomes in cancer patients.

SEARCH STRATEGY

We searched the Cochrane Library, Medline, Embase and conference proceedings for eligible trials. Manufacturers of ESAs were contacted to identify additional trials.

SELECTION CRITERIA

We included randomized controlled trials comparing epoetin or darbepoetin plus red blood cell transfusions (as necessary) versus red blood cell transfusions (as necessary) alone, to prevent or treat anemia in adult or pediatric cancer patients with or without concurrent antineoplastic therapy.

DATA COLLECTION AND ANALYSIS

We performed a meta-analysis of randomized controlled trials comparing epoetin alpha, epoetin beta or darbepoetin alpha plus red blood cell transfusions versus transfusion alone, for prophylaxis or therapy of anemia while or after receiving anti-cancer treatment. Patient-level data were obtained and analyzed by independent statisticians at two academic departments, using fixed-effects and random-effects meta-analysis. Analyses were according to the intention-to-treat principle. Primary endpoints were on study mortality and overall survival during the longest available follow-up, regardless of anticancer treatment, and in patients receiving chemotherapy. Tests for interactions were used to identify differences in effects of ESAs on mortality across pre-specified subgroups. The present review reports only the results for the primary endpoint.

MAIN RESULTS

A total of 13933 cancer patients from 53 trials were analyzed, 1530 patients died on-study and 4993 overall. ESAs increased on study mortality (combined hazard ratio [cHR] 1.17; 95% CI 1.06-1.30) and worsened overall survival (cHR 1.06; 95% CI 1.00-1.12), with little heterogeneity between trials (I(2) 0%, p=0.87 and I(2) 7.1%, p=0.33, respectively). Thirty-eight trials enrolled 10441 patients receiving chemotherapy. The cHR for on study mortality was 1.10 (95% CI 0.98-1.24) and 1.04; 95% CI 0.97-1.11) for overall survival. There was little evidence for a difference between trials of patients receiving different cancer treatments (P for interaction=0.42).

AUTHORS' CONCLUSIONS

ESA treatment in cancer patients increased on study mortality and worsened overall survival. For patients undergoing chemotherapy the increase was less pronounced, but an adverse effect could not be excluded.

Recombinant human erythropoiesis-stimulating agents and mortality in patients with cancer: a meta-analysis of randomised trials

BACKGROUND

Erythropoiesis-stimulating agents reduce anaemia in patients with cancer and could improve their quality of life, but these drugs might increase mortality. We therefore did a meta-analysis of randomised controlled trials in which these drugs plus red blood cell transfusions were compared with transfusion alone for prophylaxis or treatment of anaemia in patients with cancer.

METHODS

Data for patients treated with epoetin alfa, epoetin beta, or darbepoetin alfa were obtained and analysed by independent statisticians using fixed-effects and random-effects meta-analysis. Analyses were by intention to treat. Primary endpoints were mortality during the active study period and overall survival during the longest available follow-up, irrespective of anticancer treatment, and in patients given chemotherapy. Tests for interactions were used to identify differences in effects of erythropoiesis-stimulating agents on mortality across prespecified subgroups.

FINDINGS

Data from a total of 13 933 patients with cancer in 53 trials were analysed. 1530 patients died during the active study period and 4993 overall. Erythropoiesis-stimulating agents increased mortality during the active study period (combined hazard ratio [cHR] 1.17, 95% CI 1.06-1.30) and worsened overall survival (1.06, 1.00-1.12), with little heterogeneity between trials (I(2) 0%, p=0.87 for mortality during the active study period, and I(2) 7.1%, p=0.33 for overall survival). 10 441 patients on chemotherapy were enrolled in 38 trials. The cHR for mortality during the active study period was 1.10 (0.98-1.24), and 1.04 (0.97-1.11) for overall survival. There was little evidence for a difference between trials of patients given different anticancer treatments (p for interaction=0.42).

INTERPRETATION

Treatment with erythropoiesis-stimulating agents in patients with cancer increased mortality during active study periods and worsened overall survival. The increased risk of death associated with treatment with these drugs should be balanced against their benefits.

FUNDING

German Federal Ministry of Education and Research, Medical Faculty of University of Cologne, and Oncosuisse (Switzerland).