Changes in the prescription patterns of psychotropic drugs for cancer patients during a 10-year period

Traditional Herbal Medicine for Insomnia in Patients With Cancer: A Systematic Review and Meta-Analysis

Background: Insomnia is one of the most prevalent cancer-related symptoms and has a severe impact on the quality of life. This study aimed to evaluate the efficacy and safety of traditional herbal medicine (THM) for improving sleep quality in patients with cancer. Methods: Randomized controlled trials (RCTs) evaluating orally administered THM in a cancer population with insomnia were searched using nine electronic databases up to November 30, 2020. The outcome measurements were sleep quality measured by validated questionnaire such as the Pittsburgh Sleep Quality Index (PSQI), total effective rate, and adverse effects. The included studies were appraised using the Cochrane risk of bias tool and meta-analyzed. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Results: Fourteen RCTs were included in the systematic review, and 10 RCTs were analyzed quantitatively. Compared to hypnotics, THM showed a significant improvement in sleep quality by reducing the PSQI score [mean difference (MD) -2.25, 95% confidence interval (CI) -3.46 to -1.05, I 2 = 84%] and increasing the total effective rate [risk ratio (RR) 1.26, 95% CI 1.07 to 1.48, I 2 = 70%] with low quality of evidence. Compared to placebo, THM also reduced the PSQI score significantly (MD -2.56, 95% CI -3.81 to -1.31, I 2 = 91%) with moderate quality of evidence. The most frequently used herbs were Ziziphus jujuba Mill. No serious adverse events were observed. Conclusion: This review suggests that THM may be an effective therapeutic option for insomnia in patients with cancer. However, considering the limited methodological qualities and inconsistent results of the included trials, further rigorous RCTs are required. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero], PROSPERO 2021 [CRD42021265070].

Mind-Body Therapies for Cancer Patients Living with Depression, Anxiety or Insomnia (MIRACLE): A Systematic Review with Individual Participant Data Network Meta-Analysis

Depression, anxiety, and insomnia are common in cancer patients. Mind-body therapies (MBTs) are promising forms of treatment for cancer patients living with depression, anxiety, and insomnia. The objective of this study is to assess the effectiveness and acceptability of MBTs in cancer patients living with depression, anxiety, or insomnia. EMBase, PubMed, Cinahl, PsychINFO, IndMED, CSI-NISCAIR, CNKI, Clinicaltrial.gov, ChiCTR, and CTRI will be searched until October 2020 for relevant studies. Randomized controlled studies in which MBTs were tested in a cancer population will be selected. The authors of the selected studies will be contacted to obtain individual participant data. The participants who reached a defined clinical threshold for depression, anxiety, or insomnia will be selected for the three sub-studies on depression, anxiety, and insomnia, respectively. Pairwise and network meta-analyses will be used to assess the changes in depression, anxiety, sleep quality, and completion rate. We will assess the effect of the treatment dose (number and frequency of interventions) on effectiveness. The results of this study will inform clinical decision-making for the treatment of psychological disturbances in cancer patients. If MBTs are found effective, they will potentially be recommended as treatments for cancer patients with psychological symptoms.

Fatigue in patients on oral targeted or chemotherapy for cancer and associations with anxiety, depression, and quality of life

OBJECTIVES

Oral treatment (targeted or chemotherapy) for cancer is being increasingly used. While fatigue is a known side effect of intravenous chemotherapy, the rate of fatigue and the impact of fatigue on other patient-reported outcomes are not well described.

METHOD

At Massachusetts General Hospital Cancer Center, 180 adult patients prescribed oral targeted or chemotherapy for various malignancies enrolled in a randomized controlled trial of adherence and symptom management. Patients completed baseline self-reported measures of fatigue (Brief Fatigue Inventory; BFI), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale; HADS), and quality of life, including subscales for physical, social, emotional, and functional well-being ([QOL] Functional Assessment of Cancer Therapy - General; FACT-G). We examined clinically relevant fatigue using a validated cut-off score for moderate-severe fatigue (BFI global fatigue ≥4) and tested the associations with anxiety symptoms, depressive symptoms, and QOL with independent samples t-tests.

RESULTS

At baseline, 45 of 180 participants (25.0%) reported moderate-severe fatigue. Fatigued patients experienced more anxiety symptoms (mean diff. 3.73, P < 0.001), more depressive symptoms (mean diff. 4.14, P < 0.001), and worse QOL on the total FACT-G score (mean diff. -19.58, P < 0.001) and all subscales of the FACT-G compared to patients without moderate-severe fatigue.

SIGNIFICANCE OF RESULTS

One in four patients on oral treatment for cancer experienced clinically relevant fatigue that is associated with greater anxiety and depressive symptoms and worse QOL.

Prevalence of Insomnia in an Oncology Patient Population: An Irish Tertiary Referral Center Experience

BACKGROUND

The NCCN Guidelines for Survivorship recommend dedicated sleep assessment. Reported insomnia prevalence in the general Irish population is 6% to 15%. Reported insomnia prevalence internationally among new/recently diagnosed patients with cancer varies from 30.9% to 54.3%. Insomnia prevalence has not been previously quantified in an Irish oncology cohort.

METHODS

A 40-item questionnaire was prospectively administered to ambulatory patients with cancer aged ≥18 years. Prespecified criteria to define insomnia syndrome combined those of the International Classification of Sleep Disorders, version 1, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The Hospital Anxiety and Depression Scale-Depression/Anxiety (HADS-D/A) was used to screen for potential confounding variables.

RESULTS

The response rate to the questionnaire was 87% (294/337). The predominant respondent age group was 55 to 64 years (26%; 77/294), 70.7% were female (208/294), and the most common cancer subtypes were breast (37.4%), colorectal (12.9%), and lung (12.2%). A total of 62% (183/294) of patients reported sleep disturbance after diagnosis, 63% (115/183) reported moderate/severe distress related to this disturbance, and 37% (61/183) reported a significant impact on physical function. Although 33% (98/294) met insomnia syndrome criteria, only 34% (33/98) of these patients had a preexisting history of sleep disturbance. Female sex, age <65 years, cancer subtype, alcohol consumption, and HADS-D/A ≥11 were associated with statistically significant higher odds ratios (OR) of insomnia syndrome. Multivariate analysis identified breast cancer (OR, 3.17; P=.01), age <65 years (OR, 1.8; P=.03), and alcohol consumption (OR, 2.3; P=.005) as independent predictors of insomnia syndrome.

CONCLUSIONS

Insomnia syndrome prevalence in this cohort is comparable to that reported previously and supports dedicated sleep assessment. This study identifies potentially modifiable risk factors for insomnia and demonstrates additional utility of the HADS score in identifying patients at risk.

Real-World Direct Health Care Costs Associated with Psychotropic Polypharmacy Among Adults with Common Cancer Types in the United States

BACKGROUND

Psychotropic polypharmacy is not uncommon among cancer patients and may contribute to the increased direct health care cost burden in this population.

OBJECTIVE

To estimate average direct health care costs in the year following cancer diagnosis among cancer patients receiving psychotropic polypharmacy compared with those without psychotropic polypharmacy, using a multivariable analysis framework.

METHODS

A retrospective cross-sectional study was conducted among patients aged 18 years and older diagnosed with the most commonly occurring cancers (breast, prostate, lung, and colorectal) in the United States during 2011-2012 using the deidentified Optum Clinformatics Data Mart commercial claims database. Psychotropic polypharmacy was defined as concurrent use of 2 or more psychotropic medications for at least 90 days. Direct health care costs in the year following cancer diagnosis were estimated as total medical payments made by the health plans and were derived from claims files. A generalized linear regression model with log-link function and gamma distribution was used to model average direct health care costs, controlling for baseline patient demographic and clinical covariates.

RESULTS

Average annual direct health care costs for cancer patients with psychotropic polypharmacy ($53,497; SD $72,590) were higher than those without psychotropic polypharmacy ($38,255; SD $59,844), with an unadjusted average cost difference of $15,242 (P < 0.0001). In the adjusted regression model, the average difference in costs shrunk to $5,888 but remained notable. When examined by type of cancer, average direct health care costs for all cancer patients with psychotropic polypharmacy were significantly higher than those for patients without psychotropic polypharmacy, except for colorectal cancer patients.

CONCLUSIONS

Overall health care costs were higher among cancer patients with psychotropic polypharmacy compared with those without psychotropic polypharmacy. Our findings support the need for future research to better understand the benefits and risks of psychotropic polypharmacy, given its potential to cause adverse health outcomes and avoidable health care utilization and costs for this vulnerable patient population.

DISCLOSURES

This study was funded by the American Association of Colleges of Pharmacy (AACP) New Investigator Award mechanism, which was received by Vyas. Aroke was partially supported by the AACP grant for conducting data analysis of the study. Kogut is partially supported by Institutional Development Award Number U54GM115677 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health and the AACP. The authors report no conflicts of interest. An abstract of this study was presented as a poster at the American Association of Colleges of Pharmacy Annual Meeting on July 22, 2018, in Boston, MA.

Prevalence of Psychotropic Polypharmacy and Associated Healthcare Resource Utilization during Initial Phase of Care among Adults with Cancer in USA

BACKGROUND

The use of psychotropic medications is not uncommon among patients with newly diagnosed cancer. However, the impact of psychotropic polypharmacy on healthcare utilization during the initial phase of cancer care is largely unknown.

METHODS

We used a claims database to identify adults with incident breast, prostate, lung, and colorectal cancers diagnosed during 2011-12. Psychotropic polypharmacy was defined as concurrent use of two or more psychotropic medication classes for at least 90 days. A multivariable logistic regression was performed to identify significant predictors of psychotropic polypharmacy. Multivariable Poisson and negative binomial regressions were used to assess the associations between psychotropic polypharmacy and healthcare utilization.

RESULTS

Among 5604 patients included in the study, 52.6% had breast cancer, 30.6% had prostate cancer, 11.4% had colorectal cancer, and 5.5% had lung cancer. During the year following incident cancer diagnosis, psychotropic polypharmacy was reported in 7.4% of patients, with the highest prevalence among patients with lung cancer (14.4%). Compared with patients without psychotropic polypharmacy during the initial phase of care, patients with newly diagnosed cancer with psychotropic polypharmacy had a 30% higher rate of physician office visits, an 18% higher rate of hospitalization, and a 30% higher rate of outpatient visits. The rate of emergency room visits was similar between the two groups.

CONCLUSION

Psychotropic polypharmacy during the initial phase of cancer care was associated with significantly increased healthcare resource utilization, and the proportion of patients receiving psychotropic polypharmacy differed by type of cancer.

IMPACT

Findings emphasize the importance of evidence-based psychotropic prescribing and close surveillance of events causing increased healthcare utilization among patients with cancer receiving psychotropic polypharmacy.

Antidepressants in Cancer Pain

Studies conducted in recent years have helped define the role of antidepressant drugs in the management of cancer pain. The anti-nociceptive action of these agents seems to be independent of beneficial effect on depression or mood. Among antidepressant drugs, those of the tricyclic class are preferred when an analgesic effect is sought. Their primary application is for pain due to nerve injury, so-called “neuropathic pain”. Although the co-administration of tricyclic antidepressants may increase plasma morphine concentrations, any potentiation of morphine analgesia is thought not to be due to an increased bioavailability of the opiate, but to an intrinsic analgesic effect of antidepressants. On this basis, the use of antidepressants in combination with opioids for the treatment of cancer pain is suitable when a component of deafferentation is present or when there is concomitant depressive illness.

Efficacy and Safety of the Traditional Herbal Medicine, Gamiguibi-tang, in Patients With Cancer-Related Sleep Disturbance: A Prospective, Randomized, Wait-List-Controlled, Pilot Study

Background: Sleep disturbance is the second most bothersome symptom in patients with cancer, and it can significantly impair their quality of life. The aim of this study was to investigate the efficacy and safety of the traditional herbal medicine Gamiguibi-tang (GGBT) in patients with cancer-related sleep disturbance. Methods: We conducted a prospective, randomized, wait-list-controlled, open-label pilot clinical trial on cancer-related sleep disturbance. Patients with cancer experiencing poor sleep quality with a Pittsburgh Sleep Quality Index of at least 6 were randomly assigned to the GGBT and wait-list groups to receive GGBT and conventional care, respectively, for 2 weeks. The primary endpoint was the Insomnia Severity Index (ISI) score. Fatigue, depression, and cognitive impairment were assessed as the secondary endpoints by using the Brief Fatigue Inventory (BFI), Beck Depression Inventory (BDI), and Montreal Cognitive Assessment (MoCA). Results: Thirty participants who met the eligibility criteria were enrolled. Sleep disturbance assessed using the ISI improved significantly more in the GGBT group than in the wait-list group (−5.5 ± 4.4 vs 0.1 ± 1.1, P < .001). Fatigue level determined using the BFI also improved significantly more in the GGBT group than in the wait-list group (−0.8 ± 0.8 vs 0.0 ± 0.3, P = .002). The BDI and MoCA scores showed no significant changes. Adverse events were reported in two patients in the GGBT group and consisted of mild dyspepsia and mild edema. Conclusion: GGBT may be a potential treatment option for cancer-related sleep disturbance. Further research is needed to investigate the efficacy and safety of GGBT.

Acupuncture for Managing Cancer-Related Insomnia: A Systematic Review of Randomized Clinical Trials

BACKGROUND

Insomnia is a prominent complaint of cancer patients that can significantly affect their quality of life and symptoms related to sleep quality. Conventional drug approaches have a low rate of success in alleviating those suffering insomnia. The aim of this systematic review was to assess the efficacy of acupuncture in the management of cancer-related insomnia.

METHODS

A total of 12 databases were searched from their inception through January 2016 without language restriction. Randomized controlled trials (RCTs) and quasi-RCTs were included if acupuncture was used as the sole intervention or as an adjunct to another standard treatment for any cancer-related insomnia. The data extraction and the risk of bias assessments were performed by 2 independent reviewers.

RESULTS

Of the 90 studies screened, 6 RCTs were included. The risk of bias was generally unclear or low. Three RCTs showed equivalent effects on the Pittsburgh Sleep Quality Index and 2 RCTs showed the similar effects on response rate to those of conventional drugs at the end of treatment. The other RCT showed acupuncture was better than hormone therapy in the numbers of hours slept each night and number of times woken up each night. The 3 weeks of follow-up in 2 RCTs showed superior effects of acupuncture compared with conventional drugs, and a meta-analysis showed significant effects of acupuncture. Two RCTs tested the effects of acupuncture on cancer-related insomnia compared with sham acupuncture. One RCT showed favourable effects, while the other trial failed to do so.

CONCLUSION

There is a low level of evidence that acupuncture may be superior to sham acupuncture, drugs or hormones therapy. However, the number of studies and effect size are small for clinical significance. Further clinical trials are warranted.

A systematic review and meta-analysis of prescribing practices of antidepressants in cancer patients

BACKGROUND

Antidepressants are commonly used for the pharmacological treatment of depression. We aimed to summarise the prevalence of antidepressant prescription to cancer patients, and differences by study or patient characteristics.

METHODS

PubMed, Embase, Web of Science, Scopus and psychINFO were searched using keywords 'psychotropic', 'antidepressants', 'prescription' and 'cancer'. Prevalence of antidepressants, type, dose and follow-up of antidepressants and prescriber details were extracted.

RESULTS

Overall, 1537 articles between 1979 and February 2015 were found, 38 met the inclusion criteria and were reviewed according to PRISMA guidelines. The prevalence rate of prescribing antidepressants to cancer patients was 15.6% (95% CI = 13.3-18.3). Prescription was significantly less common in studies from Asia (7.4%; 95% CI = 4.3-12.5), more common in female (22.6%; 95% CI = 16.0-31.0) or breast cancer patients (22.6%; 95% CI = 16.0-30.9). Selective serotonin reuptake inhibitors were the most frequently prescribed antidepressants. General practitioners and psychiatrists, followed by oncologists, were identified as the major providers of antidepressant prescriptions to cancer patients. Few studies reported the exact dose, length of time drugs were prescribed for or follow-up regimens.

CONCLUSIONS

There is considerable variation in the prescribing patterns of antidepressants across the world, with few studies reporting robust data on exact dose or follow-up regimens. Prospective studies that monitor antidepressant prescribing, including details of reasons for prescribing and the healthcare providers involved, dose, change in dose or type of medication and follow-up are needed to ascertain whether patients are being treated optimally and if side effects or drug-drug interactions are identified and managed. Copyright © 2016 John Wiley & Sons, Ltd.

Patterns and predictors of antidepressant use in ambulatory cancer patients with common solid tumors

PURPOSE

Depressive symptoms and antidepressant use are prevalent among cancer patients. We sought to identify determinants of prescribing commonly used antidepressants.

PATIENTS AND METHODS

This multi-institutional study enrolled 3106 ambulatory patients with cancer of the breast, prostate, colon/rectum, or lung. Five case-finding methods were used to identify patients with depressive symptoms. Logistic models were used to examine factors that impact antidepressant use.

RESULTS

Approximately, 47% of patients were defined as having depressive symptoms. Clinicians rated being sad/depressed as one of the top three priority problems for 10.5% of patients. Antidepressants were prescribed in 19% of all patients, 25% with depressive symptoms and 14% nondepressed patients. After adjusting for other covariates, these variable categories were significantly associated with greater use of antidepressants: depressive symptoms, family history of depression, concurrent medication use, cancer treatment status, and certain other clinical and demographic variables. The strongest individual predictors were concurrent use of more than 10 medications (odds ratio [OR] = 3.3), a family history of depression (OR = 2.2), sedative use (OR = 2.1), non-Hispanic white race (OR = 2.0), and anxiolytics use (OR = 2.0).

CONCLUSIONS

Depressive symptoms are found in nearly half of outpatients with cancer, and one-fourth of patients with depressive symptoms are taking an antidepressant. Patients receiving antidepressants are more often those taking multiple medications, those with a depression diathesis, and those with more extensive cancer treatment. Patients who were younger, white, and female were also more likely to be taking antidepressants.

Efficacy and safety of pharmacotherapy in cancer-related psychiatric disorders across the trajectory of cancer care: a review

At least 25-30% of patients with cancer and an even higher percentage of patients in an advanced phase of illness meet the criteria for a psychiatric diagnosis, including depression, anxiety, stress-related syndromes, adjustment disorders, sleep disorders and delirium. A number of studies have accumulated over the last 35 years on the use of psychotropic drugs as a pillar in the treatment of psychiatric disorders. Major advances in psycho-oncology research have also shown the efficacy of psychotropic drugs as adjuvant treatment of cancer-related symptoms, such as pain, hot flushes, pruritus, nausea and vomiting, fatigue, and cognitive impairment. The knowledge about pharmacokinetics and pharmacodynamics, clinical use, safety, side effects and efficacy of psychotropic drugs in cancer care is essential for an integrated and multidimensional approach to patients treated in different settings, including community-based centres, oncology, and palliative care. A search of the major databases (MEDLINE, Embase, PsycLIT, PsycINFO, the Cochrane Library) was conducted in order to summarize relevant data concerning the efficacy and safety of pharmacotherapy for cancer-related psychiatric disorders in cancer patients across the trajectory of the disease.

Psychopharmacology in psycho-oncology

Psychopharmacological intervention is a major clinical and research area in oncology and palliative care. Over the last 35 years, psychotropic drugs have been shown to have a number of important indications for the treatment of the most common psychiatric disorders, such as depression, anxiety, stress-related syndromes, severe adjustment disorders, sleep disorders and delirium, which combined affect at least 30-40% of patients with cancer and even a higher percentage of patients in an advanced phase of illness. The availability of new drugs, with less side-effects and safer pharmacological profiles, has been a major advance in clinical psycho-oncology. Interestingly, several drugs have also been found to be helpful for the adjuvant treatment of cancer-related symptoms, such as pain, hot flashes, pruritus, nausea and vomiting, fatigue, and cognitive impairment, making psychopharmacology an important tool for the improvement of cancer patients' quality of life. The aim of this paper is to summarize recent relevant data concerning the use of psychotropic drugs, namely antidepressants, anxiolytics, antipsychotics, anticonvulsants and psychostimulants in patients with cancer.

Use of psychotropic medications by US cancer survivors

OBJECTIVES

This study aimed to describe national utilization of psychotropic medications by adult cancer survivors in the USA and to estimate the extra use of psychotropic medications that is attributable to cancer survivorship.

METHODS

Prescription data for 2001-2006 from the Medical Expenditure Panel Survey (MEPS) were linked to the data identifying cancer survivors from the National Health Interview Survey, the MEPS sampling frame. The sample was limited to adults 25 years of age and older. Propensity score matching was used to estimate the effects of cancer survivorship on utilization of psychotropic medications by comparing cancer survivors and other adults in MEPS. Utilization was measured as any use during a calendar year and the number of prescriptions purchased (including refills). Analyses were stratified by gender and age, distinguishing adults younger than 65 years from those 65 years and older.

RESULTS

Nineteen percent of cancer survivors under age 65 years and 16% of survivors age 65 years and older used psychotropic medications. Sixteen percent of younger survivors used antidepressants, 7% used antianxiety medications. For older survivors, utilization rates for these two drug types were 11% and 7%, respectively. The increase in any use attributable to cancer amounted to 4-5 percentage points for younger survivors (p < 0.05) and 2-3 percentage points for older survivors (p < 0.05), depending on gender.

CONCLUSION

Increased use of psychotropic medications by cancer survivors, compared with other adults, suggests that survivorship presents ongoing psychological challenges.

Sleep disorders in children with cancer

Approximately three-fourths of all pediatric cancer patients will be long-term survivors; however, there can be a steep cost for cancer survivorship. Cancer treatment involves exposure to chemotherapy, surgical intervention, and radiation, which can cause lasting long-term toxicities. Children with brain tumors have the highest prevalence of long-term morbidities. These effects can be attributed to direct neurologic damage to the developing brain caused by tumor, hydrocephalus, surgical removal of the tumor, and the effects of irradiation. The late effects experienced by childhood cancer survivors involve multiple domains, one of which is sleep disorders. Sleep dysfunction has an increased prevalence in the pediatric cancer survivor population. These issues are disruptive to patients and cause a decrease in quality of life. This review focuses on sleep disorders that occur in pediatric cancer survivors and discusses the possible causes, the assessments used to determine specific sleep disorders, and treatment modalities used to ameliorate this dysfunction with the hope of improving patient's quality of life.

Drug interaction in psycho-oncology: antidepressants and antineoplastics

BACKGROUND AND OBJECTIVES

Although there is a growing impact of psychiatric and depressive disorders in cancer patients, literature on the idiosyncrasies of antidepressants (ADs) used in those conditions and their interactions with antineoplastic agents (ANs) is scarce. Sharing the same biotransformation pathways enhances the risk of drug interaction between ADs and ANs, specifically when compounds are inducers, inhibitors or substrates of cytochrome P450 (CYP 450). In cancer patients, such drug interactions may result in less efficacy of the drug and/or increase of their side effects. Therefore, the choice of AD should be cautious (safe and effective) and well supported. The main purpose of this review was to analyze the individual pharmacokinetic properties of the most used ADs and ANs in order to summarize the risk of possible drug interactions between them, anticipating the consequences of their coadministration.

METHODS

The authors reviewed books and PubMed online articles published in the last 6 years.

RESULTS

Most of the ANs are subject to transformation by CYP 450 3A4 and their coadministration with ADs, that have inhibitory properties of this CYP isoform, such as fluoxetine, sertraline, paroxetine and fluvoxamine, may result in the loss of the AN's efficacy or higher toxicity.

CONCLUSION

Among the ADs, escitalopram, citalopram, venlafaxine, mirtazapine and milnacipran stand out for their weak CYP 450 inhibitory potential and their safety profile in those patients.

Clinically relevant drug interactions between anticancer drugs and psychotropic agents

Drug interactions are commonly seen in the treatment of cancer patients. Psychotropics are often indicated for these patients since they may also suffer from pre-existing psychological disorders or experience insomnia and anxiety associated with cancer therapy. Thus, the risk of anticancer drug (ACD)-psychotropic drug-drug interactions (DDIs) is high. Drug interactions were compiled from the British National Formulary (53rd edn), Lexi-Comp's Drug Information Handbook (15th edn), Micromedex (v5.1), Hansten & Horn's Drug Interactions (2000) and Drug Interaction Facts (2008 edn). Product information of the individual drugs, as well as documented literature on ACD-psychotropic interactions from PubMed and other databases was also incorporated. This paper identifies clinically important ACD-psychotropic DDIs that are frequently observed. Pharmacokinetic DDIs were observed for tyrosine kinase inhibitors, corticosteroids and antimicrotubule agents due to their inhibitory or inductive effects on cytochrome P450 isoenzymes. Pharmacodynamic DDIs were identified for thalidomide with central nervous system depressants, procarbazine with antidepressants, myelosuppressive ACDs with clozapine and anthracyclines with QT-prolonging psychotropics. Clinicians should be vigilant when psychotropics are prescribed concurrently with ACDs. Close monitoring of plasma drug levels should be carried out to avoid toxicity in the patient, as well as to ensure adequate chemotherapeutic and psychotropic coverage.

The use of Valeriana officinalis (Valerian) in improving sleep in patients who are undergoing treatment for cancer: a phase III randomized, placebo-controlled, double-blind study (NCCTG Trial, N01C5)

Sleep disorders are a substantial problem for cancer survivors, with prevalence estimates ranging from 23% to 61%. Although numerous prescription hypnotics are available, few are approved for long-term use or have demonstrated benefit in this circumstance. Hypnotics may have unwanted side effects and are costly, and cancer survivors often wish to avoid prescription drugs. New options with limited side effects are needed. The purpose of this trial was to evaluate the efficacy of a Valerian officinalis supplement for sleep in people with cancer who were undergoing cancer treatment. Participants were randomized to receive 450 mg of valerian-or placebo orally 1 hour before bedtime for 8 weeks. The primary end point was area under the curve (AUC) of the overall Pittsburgh Sleep Quality Index (PSQI). Secondary outcomes included the Functional Outcomes of Sleep Questionnaire, the Brief Fatigue Inventory (BFI), and the Profile of Mood States (POMS). Toxicity was evaluated with both self-reported numeric analogue scale questions and the Common Terminology Criteria for Adverse Events (CTCAE), version 3.0. Questionnaires were completed at baseline and at 4 and 8 weeks. A total of 227 patients were randomized into this study between March 19, 2004, and March 9, 2007, with 119 being evaluable for the primary end point. The AUC over the 8 weeks for valerian was 51.4 (SD = 16), while that for placebo was 49.7 (SD = 15), with a P value of 0.6957. A supplemental, exploratory analysis revealed that several fatigue end points, as measured by the BFI and POMS, were significantly better for those taking valerian over placebo. Participants also reported less trouble with sleep and less drowsiness on valerian than placebo. There were no significant differences in toxicities as measured by self-report or the CTCAE except for mild alkaline phosphatase increases, which were slightly more common in the placebo group. This study failed to provide data to support the hypothesis that valerian, 450 mg, at bedtime could improve sleep as measured by the PSQI. However, exploratory analyses revealed improvement in some secondary outcomes, such as fatigue. Further research with valerian exploring physiologic effects in oncology symptom management may be warranted.

Inadequate symptom control in advanced cancer patients across Europe

PURPOSE

The purpose of this study is to examine the adequacy of treatment for constipation, nausea, depression and poor sleep and the factors associated with inadequate symptom control in cancer patients receiving opioids.

METHODS

Patients receiving strong opioids for cancer pain were recruited from 17 centres in 11 European countries. By using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30, 1,938 patients reported their symptoms at four-point scales. Health care providers assessed symptoms at corresponding four-point scales and registered use of medications, demographic and disease-related variables. Symptomatic treatment was scored as 1 if not administered during the past 24 h and as 2 if administered. Adequacy of treatment was evaluated by subtracting the patients' symptom score from the treatment score. Negative scores, caused by either no treatment or ineffective treatment of a symptom, were interpreted as inadequate treatment.

RESULTS

Approximately 60% of patients with constipation, depression or poor sleep and 45% of nauseated patients were inadequately treated. Numbers of inadequately treated patients varied between countries. In general, underestimation of symptom intensity by health care providers (p < 0.001), low performance status (p < 0.05) and recent initiation of opioids (p < 0.05) increased the risk of inadequate treatment. The subset of demographic- and disease-related factors associated with inadequate treatment varied between the symptoms investigated.

CONCLUSIONS

Inadequate treatment, either no treatment or ineffective treatment, was frequent in cancer patients. There were subgroups of patients at particular risk for inadequate treatment, which might need additional attention from health care providers for achievement of adequate symptom control.

Sleep disturbances and quality of life in lung cancer patients undergoing chemotherapy

This study described the sleep disturbances of 115 lung cancer patients undergoing their fourth cycle of chemotherapy and examined the impact of sleep disturbances on quality of life and functional performance status while controlling for pain, depression, fatigue, and dyspnea. Sleep disturbance and quality of life were assessed by the Pittsburg Sleep Quality Index (PSQI), and European Organization for Research and Treatment Quality of Life Questionnaire-Cancer 30 (EORTC), respectively. Data were also collected on covariates of sleep disturbance: performance status, pain, fatigue, depression and dyspnea. Patients' mean PSQI global scores for days with chemotherapy (6.86+/-3.83) and for days without chemotherapy (6.23+/-3.47) were both higher than the cut-off of 5, indicating poor quality of sleep during the fourth cycle of chemotherapy. After controlling for covariates, sleep disturbance was significantly associated with impaired cognitive function (EORTC) and poorer functional status. Our results suggest that clinicians should routinely assess sleep problems in lung cancer patients.

Beck Depression Inventory: exploring its psychometric properties in a palliative care population of advanced cancer patients

To validate the Greek version of the Beck Depression Inventory (BDI)-21 items in advanced cancer patents attending a palliative care unit. The scale was translated with the forward-backward procedure into Greek. It was administered twice, with a 1-week interval, to 105 patients with advanced cancer. The patients also completed the Hospital Anxiety and Depression (HAD) scale, while researchers recorded data on demographic characteristics, disease status and treatment regimen. The Greek version of the BDI had overall Cronbach's alpha 0.906. The most significant correlations were found between BDI and performance status (P < 0.0005), gender (P = 0.031) and family status (P = 0.009). The test-retest reliability in terms of Spearman-rho, Pearson-rho coefficient and Kendall's tau-b was also satisfactory (P < 0.0005). Validity as performed using known-group analysis showed good results. The Inventory discriminated well between subgroups of patients differing in disease severity as defined by the Eastern Cooperative Oncology Group performance status. Correlations between the BDI and the HAD scale was 0.544 for the anxiety subscale and 0.657 for the depression subscale. Multiple regression analysis was conducted and predicted that the contribution of gender, family status and performance status to BDI is high. These psychometric properties of the Greek version of the BDI confirm it as a valid and reliable measure when administered to patients with advanced cancer.

Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer

The growing interest in the psychological morbidity of patients with cancer has been the major reason for conducting this study. The measurements used were the Beck Depression Inventory, the Beck Hopelessness Scale, the Mini Mental State Examination, the Greek Brief Pain Inventory, and the Spiritual Involvement and Beliefs Scale. The analysis was conducted in 82 patients with advanced cancer. Significant associations were found between pain interference in "mood" and in "enjoyment of life" and hopelessness, as well as between worse pain and pain interference items with depression and cognitive status. Significant correlations were found between hopelessness, depression, and cognitive condition. These findings demonstrate the physical, psychological, and cognitive aspects of patients with cancer.

Cancer‐Related Fatigue and Sleep Disorders

Sleep disorders, such as difficulty falling asleep, problems maintaining sleep, poor sleep efficiency, early awakening, and excessive daytime sleepiness, are prevalent in patients with cancer. Such problems can become chronic in some patients, persisting for many months or years after completion of cancer therapy. For patients with cancer, sleep is potentially affected by a variety of factors, including the biochemical changes associated with the process of neoplastic growth and anticancer treatments, and symptoms that frequently accompany cancer, such as pain, fatigue, and depression. Fatigue is highly prevalent and persistent in patients with cancer and cancer survivors. Although cancer-related fatigue and cancer-related sleep disorders are distinct, a strong interrelationship exists between these symptoms, and a strong possibility exists that they may be reciprocally related. The majority of studies that have assessed both sleep and fatigue in patients with cancer provide evidence supporting a strong correlation between cancer-related fatigue and various sleep parameters, including poor sleep quality, disrupted initiation and maintenance of sleep, nighttime awakening, restless sleep, and excessive daytime sleepiness. This paper reviews the data from these studies with a view toward suggesting further research that could advance our scientific understanding both of potential interrelationships between sleep disturbance and cancer-related fatigue and of clinical interventions to help with both fatigue and sleep disturbance. Disclosure of potential conflicts of interest is found at the end of this article.

Amisulpride in the short-term treatment of depressive and physical symptoms in cancer patients during chemotherapies

INTRODUCTION

Amisulpride is a substituted benzamide that, at low doses, selectively blocks D2 and D3 presynaptic dopamine receptors, enhancing dopaminergic transmission in frontal cortex and limbic areas. Many clinical studies versus placebo, tricyclic antidepressants and selective serotonin reuptake inhibitors showed amisulpride antidepressant effect, supporting its safety and rapid onset of action. In oncological population, depression is quite frequent and difficult to treat because of the particular sensitivity of cancer patients to the antidepressants' side effects.

GOALS OF WORK

The aims of this study were to evaluate efficacy, safety and tolerability of low doses of amisulpride (50 mg) in oncological, depressed patients during chemotheraphy.

MATERIALS AND METHODS

One hundred six consecutive cancer outpatients with depressive symptoms were treated in a prospective, intention to treat, 4-week study, and were evaluated in single-blind with Montgomery Asberg rating scale for depression (MADRS), clinical global impression (CGI) and dosage record treatment emergent symptom scale (DOTES) to assess side effects of treatment.

MAIN RESULTS

After 4 weeks of treatment, scores of MADRS and CGI significantly improved (p < 0.002; p < 0.001, respectively), with a reduction of depressive symptoms concerning both emotional (such as apparent sadness, reported sadness, inner tension, etc.) and physical cluster (such as lack of appetite, reduction in weight, tiredness and insomnia) with good tolerability (only two patients dropped out).

CONCLUSIONS

This study is the first trial on the use of amisulpride in a cohort of oncological, depressed patients during chemotherapy. Amisulpride demonstrated high efficacy and safety. Controlled studies are needed to confirm these preliminary data.

Delirium in Hospitalized Older Patients With Cancer

PURPOSE/OBJECTIVES

To examine key aspects of delirium in a sample of hospitalized older patients with cancer.

DESIGN

Secondary analysis of data from studies on acute confusion in hospitalized older adults.

SETTING

Tertiary teaching hospital in the southeastern United States.

SAMPLE

76 hospitalized older patients with cancer (mean age = 74.4 years) evenly divided by gender and ethnicity and with multiple cancer diagnoses.

METHODS

Data were collected during three studies of acute confusion in hospitalized older patients. Delirium was measured with the NEECHAM Confusion Scale on admission, daily during hospitalization, and at discharge. Patient characteristics and clinical risk markers were determined at admission.

MAIN RESEARCH VARIABLES

Prevalent and incident delirium, etiologic risk patterns, and patient characteristics.

FINDINGS

Delirium was noted in 43 (57%) patients; 29 (38%) were delirious on admission. Fourteen of 47 (30%) who were not delirious at admission became delirious during hospitalization. Delirium was present in 30 patients (39%) at discharge. Most delirious patients had evidence of multiple (mean = 2.3) etiologic patterns for delirium.

CONCLUSIONS

Delirium was common in this sample of hospitalized older patients with cancer. Patients with delirium were more severely ill, were more functionally impaired, and exhibited more etiologic patterns than nondelirious patients.

IMPLICATIONS FOR NURSING

Nurses caring for older patients with cancer should perform systematic and ongoing assessments of cognitive behavioral performance to detect delirium early. The prevention and management of delirium hinge on the identification and treatment of the multiple risk factors and etiologic mechanisms that underlie delirium. The large number of patients discharged while still delirious has significant implications for posthospital care and recovery.

Insomnia and its treatment in women with breast cancer

Insomnia is a common complaint in breast cancer patients and has been shown to have a host of psychological and medical correlates and consequences. Typically insomnia is treated pharmacologically, however more recent findings from randomized controlled clinical trials support the use of cognitive behavioral therapies. The aim of this article is to review the empirically supported breast cancer literature on insomnia, briefly present and explain the insomnia treatment options available, and extrapolate research guidelines for future directions in this growing field. Behavioral therapeutic approaches for insomnia seem particularly suitable to use in the breast cancer populations because they have lower risk of interacting with the cancer treatment, do not burden the patients with additional pharmacological treatments, and can target the treatment towards ameliorating specific symptoms, like fatigue, that are characteristic in this population. However, there is a need for replication of efficacy studies of cognitive behavioral treatments for insomnia in breast cancer, as well as studies investigating vulnerability, risk and protective factors that might ultimately lead to insomnia prevention programs for use in this population.

Clinical assessment of depression in terminally ill cancer patients: A practical guide

Depression is commonly experienced by cancer patients at the end of life. The identification of patients suffering from depression is essential to provide clinicians with an opportunity to relieve considerable suffering. However, the assessment of depressive symptoms is complex and often challenging in a terminally ill cancer population. This article offers practical guidelines to assist clinicians with the diagnosis of depression, reviews the defining symptoms of depression and their unique presentation in patients at the end of life, suggests modifications of the standard diagnostic interview, and provides examples of specific assessment questions to target depressive symptoms at the end of life.

Randomized Study on the Efficacy of Cognitive-Behavioral Therapy for Insomnia Secondary to Breast Cancer, Part I: Sleep and Psychological Effects

Purpose

Chronic insomnia is highly prevalent in cancer patients. Cognitive-behavioral therapy (CBT) is considered the treatment of choice for chronic primary insomnia. However, no randomized controlled study has been conducted on its efficacy for insomnia secondary to cancer. Using a randomized controlled design, this study conducted among breast cancer survivors evaluated the effect of CBT on sleep, assessed both subjectively and objectively, and on hypnotic medication use, psychological distress, and quality of life.

Patients and Methods

Fifty-seven women with insomnia caused or aggravated by breast cancer were randomly assigned to CBT (n = 27) or a waiting-list control condition (n = 30). The treatment consisted of eight weekly sessions administered in a group and combined the use of stimulus control, sleep restriction, cognitive therapy, sleep hygiene, and fatigue management. Follow-up evaluations were carried out 3, 6, and 12 months after the treatment.

Results

Participants who received the insomnia treatment had significantly better subjective sleep indices (daily sleep diary, Insomnia Severity Index), a lower frequency of medicated nights, lower levels of depression and anxiety, and greater global quality of life at post-treatment compared with participants of the control group after their waiting period. Results were more equivocal on polysomnographic indices. Therapeutic effects were well maintained up to 12 months after the intervention and generally were clinically significant.

Conclusion

This study supports the efficacy of CBT for insomnia secondary to breast cancer.

Impaired sleep and rhythms in persons with cancer

This review includes research findings from sleep-related studies on specific types of cancers, on specific types of treatment protocols, and on persons with end-stage cancer regardless of treatment protocol. Since treatment protocols have evolved in the past decade, literature since 1990 is emphasized. We conclude that researchers should design studies that attend to prior sleep history, gender, type of cancer and treatment modalities, and the specific type of sleep problems experienced over the course of diagnosis, treatment, and recovery. More research is also needed to understand sleep problems in children with cancer and sleep problems in family caregivers. Research is also needed on effective pharmacological and non-pharmacological interventions. Daytime functioning, daytime sleepiness, and altered circadian rhythms should be considered salient outcomes in addition to severity of cancer-related fatigue. Clinicians should consider whether a patient's sleep problem has been chronic and unrelated to cancer, or precipitated by diagnosis and treatment. The specific type of sleep problem should be ascertained so that appropriate interventions can be prescribed. Appropriate interventions can include either pharmacological medication or behavioral strategies, and each has the potential to promote restorative sleep and thereby improve the patient's quality of life, daytime functioning, and well-being.

Sleep-wake disturbances in people with cancer part II: evaluating the evidence for clinical decision making

PURPOSE/OBJECTIVES

To evaluate the quality of evidence on sleep-wake disturbances in people with cancer as a basis for clinical decision making and to discuss implications of the evidence for oncology clinicians, educators, and researchers.

DATA SOURCES

Published, peer-reviewed articles.

DATA SYNTHESIS

Members of the 2001 Oncology Nursing Society (ONS) Advanced Practice Nurse Retreat Evidence-Based Practice Sleep Working Group selected and evaluated data sources using criteria and processes outlined by ONS.

CONCLUSIONS

The development of nursing science related to sleep-wake disturbances among people with cancer and the application of research findings to clinical decision making are limited by the quantity and quality of published evidence.

IMPLICATIONS FOR NURSING

Clinicians are challenged to develop a plan of care that includes the assessment of sleep-wake disturbances and interventions to address them. Nurse educators are challenged to include sleep-wake content and skills to evaluate empirical data and interventions for sleep-wake disturbances in degree and continuing education curricula. Nurse researchers are challenged to specify consistent conceptual and operational definitions of key variables in sleep-wake models, use measurement instruments with evidence of reliability and validity, and design clinical trials to test interventions for sleep-wake disturbances among people with cancer.

Antidepressant prescribing in community cancer care

GOALS

To describe patterns of antidepressant (ADs) prescribing in community oncology practice.

PATIENTS AND METHODS

Data were collected using an electronic medical record on all staged breast, colon, and lung cancer patients in three community-based oncology practices. The data were analyzed retrospectively, using descriptive and bivariate analyses and multivariate logistic regression modeling. There were 850 breast, 299 colon, and 473 lung cancer patients identified in this analysis.

MAIN RESULTS

Overall, 19.2% of breast, 11% of colon, and 13.7% of lung cancer patients had been prescribed ADs during the 2-year period. The clinic in which cancer treatment was received predicted AD prescribing. The relationship between AD administration and age proved to be nonlinear; the pattern exhibited an "inverted U" shape. Patients with comorbidities and on pain medications were more likely to be administered ADs. Colon cancer patients on pain medications were five times more likely to be administered ADs than those not on pain medications.

CONCLUSIONS

While some predictors of AD prescribing appear to be consistent with other studies, such as being on pain medication, there is still a great amount of variability in prescribing patterns across community practices, age groups, and cancer diagnoses. This study demonstrates that prescriptions of ADs seem to be influenced by parameters other than psychopathology. Given the importance of major depression in oncology care, diagnosis of psychiatric disorders and prescription patterns of psychotropics should be part of the routine monitoring and quality management in oncology patient care.