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Hui D, Yennurajalingam S. The role of corticosteroids in the palliation of dyspnea in cancer patients: an evidence-based review. Curr Opin Support Palliat Care 2023; 17:270-276. [PMID: 37773042 DOI: 10.1097/spc.0000000000000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
PURPOSE OF REVIEW To provide an evidence-based review on the use of corticosteroids for dyspnea in cancer patients. RECENT FINDINGS Corticosteroids are commonly used for palliation of dyspnea; however, there is wide variation in how they are prescribed due to the paucity of high-quality evidence. Some clinicians would offer corticosteroids routinely regardless of the causes of dyspnea, while others would only prescribe corticosteroids selectively for specific indications, such as lymphangitic carcinomatosis, upper airway obstruction, superior vena cava obstruction, and cancer treatment-induced pneumonitis. Few mechanistic studies have been conducted to support the use of corticosteroids in cancer patients. Two double-blind, placebo-controlled randomized trials have examined the routine use of high-dose dexamethasone for dyspnea in cancer patients. A pilot study suggested some benefits, but the larger confirmatory trial revealed no improvement compared to the placebo and significantly more adverse events. The selective use of corticosteroids use is only based on observational studies such as case series. SUMMARY The unfavorable risk:benefit ratio of high-dose dexamethasone suggests that it should not be routinely prescribed for dyspnea in cancer patients. More research is needed to assess the selective use of corticosteroids and identify patients most likely be benefit from corticosteroid use.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Mori M, Miwa S, Ikari T, Kako J, Hasegawa T, Matsunuma R, Suzuki K, Matsuda Y, Watanabe H, Morita T, Yamaguchi T. Current Management Options for Dyspnea in Cancer Patients. Curr Treat Options Oncol 2023; 24:565-579. [PMID: 37037975 DOI: 10.1007/s11864-023-01081-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/12/2023]
Abstract
OPINION STATEMENT Dyspnea is one of the most frequent and distressing symptoms in patients with advanced cancer. As dyspnea deteriorates patients' quality of life markedly and tends to worsen as the disease progresses, comprehensive assessment and timely treatment of the underlying etiologies are essential. International guidelines recommend various non-pharmacological and pharmacological management options. However, there is a scarcity of confirmatory clinical trials on cancer dyspnea, and the overall level of evidence is weak. Recently, observational and survey studies indicated a wide range of practice patterns of palliative care specialists, providing important insight into the real-world management of dyspnea. In this paper, we summarize current management options for dyspnea in cancer patients, highlight major controversies in the literature, and propose future research directions toward quality care for patients with dyspnea and their families.
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Affiliation(s)
- Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, 433-8558, Japan.
| | - Satoru Miwa
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tomoo Ikari
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Ryo Matsunuma
- Division of Palliative Care, Konan Medical Center, Konan, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | | | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, 433-8558, Japan
| | - Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Hui D, Puac V, Shelal Z, Dev R, Hanneman SK, Jennings K, Ma H, Urbauer DL, Shete S, Fossella F, Liao Z, Blumenschein G, Chang JY, O'Reilly M, Gandhi SJ, Tsao A, Mahler DA, Bruera E. Effect of dexamethasone on dyspnoea in patients with cancer (ABCD): a parallel-group, double-blind, randomised, controlled trial. Lancet Oncol 2022; 23:1321-1331. [PMID: 36087590 PMCID: PMC10618956 DOI: 10.1016/s1470-2045(22)00508-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Systemic corticosteroids are commonly prescribed for palliation of dyspnoea in patients with cancer, despite scarce evidence to support their use. We aimed to assess the effect of high-dose dexamethasone versus placebo on cancer-related dyspnoea. METHODS The parallel-group, double-blind, randomised, controlled ABCD (Alleviating Breathlessness in Cancer Patients with Dexamethasone) trial was done at the at the University of Texas MD Anderson Cancer Center and the general oncology clinic at Lyndon B Johnson General Hospital (both in Houston, TX, USA). Ambulatory patients with cancer, aged 18 years or older, and with an average dyspnoea intensity score on an 11-point numerical rating scale (NRS; 0=none, 10=worst) over the past week of 4 or higher were randomly assigned (2:1) to receive dexamethasone 8 mg orally every 12 h for 7 days followed by 4 mg orally every 12 h for 7 days, or matching placebo capsules for 14 days. Pharmacists did permuted block randomisation with a block size of six, and patients were stratified by baseline dyspnoea score (4-6 vs 7-10) and study site. Patients, research staff, and clinicians were masked to group assignment. The primary outcome was change in dyspnoea NRS intensity over the past 24 h from baseline to day 7 (±2 days). Analyses were done by modified intention-to-treat (ie, including all patients who were randomly assigned and started the study treatment, regardless of whether they completed the study). Enrolment was stopped after the second preplanned interim analysis, when the futility criterion was met. This study is registered with ClinicalTrials.gov (NCT03367156) and is now completed. FINDINGS Between Jan 11, 2018, and April 23, 2021, we screened 2867 patients, enrolled 149 patients, and randomly assigned 128 to dexamethasone (n=85) or placebo (n=43). The mean change in dyspnoea NRS intensity from baseline to day 7 (±2 days) was -1·6 (95% CI -2·0 to -1·2) in the dexamethasone group and -1·6 (-2·3 to -0·9) in the placebo group, with no significant between-group difference (mean 0 [95% CI -0·8 to 0·7]; p=0·48). The most common all-cause grade 3-4 adverse events were infections (nine [11%] of 85 patients in the dexamethasone group vs three [7%] of 43 in the placebo group), insomnia (seven [8%] vs one [2%]), and neuropsychiatric symptoms (three [4%] vs none [0%]). Serious adverse events, all resulting in hospital admissions, were reported in 24 (28%) of 85 patients in the dexamethasone group and in three (7%) of 43 patients in the placebo group. No treatment-related deaths occurred in either group. INTERPRETATION High-dose dexamethasone did not improve dyspnoea in patients with cancer more effectively than placebo and was associated with a higher frequency of adverse events. These data suggest that dexamethasone should not be routinely given to unselected patients with cancer for palliation of dyspnoea. FUNDING US National Cancer Institute.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Veronica Puac
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeena Shelal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rony Dev
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sandra K Hanneman
- Cizik School of Nursing at UTHealth, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kristofer Jennings
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hilary Ma
- Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana L Urbauer
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanjay Shete
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Frank Fossella
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George Blumenschein
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe Y Chang
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael O'Reilly
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Saumil J Gandhi
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne Tsao
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Respiratory Services, Valley Regional Hospital, Claremont, NH, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Wang Y, Yang M, Tao M, Liu P, Kong C, Li H, Chen Y, Yin X, Yan X. Corticosteroid administration for cancer-related indications is an unfavorable prognostic factor in solid cancer patients receiving immune checkpoint inhibitor treatment. Int Immunopharmacol 2021; 99:108031. [PMID: 34358857 DOI: 10.1016/j.intimp.2021.108031] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/14/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Immunotherapies targeting immune checkpoints have achieved encouraging survival benefits in patients with various solid cancers. Corticosteroids are frequently administrated for cancer/non-cancer related indications and immune-related adverse events (irAEs). This study aimed to clarify the prognostic significance of corticosteroid administration in solid cancer patients receiving immune checkpoint inhibitor (ICI) treatment. METHOD First, a meta-analysis was performed using the literatures searched from PubMed, Cochrane Library, Web of Science, Embase, and Clinicaltrials.gov before January 2021. The Hazard ratios (HRs) coupled with 95% confidence intervals (CIs) were used to evaluate the correlation of corticosteroid administration with overall survival (OS) and progression-free survival (PFS). Then, a retrospective analysis enrolling 118 ICI-treated cancer patients was performed for validation, among which 26 patients received corticosteroids for cancer-related indications. RESULT In the meta-analysis, corticosteroid administration for cancer-related indications was significantly correlated with worse PFS (HR = 1.735(1.381-2.180)) and OS (HR = 1.936(1.587-2.361)) of the ICI-treated patients. However, corticosteroid administration for non-cancer-related indications and irAEs was unrelated with PFS (non-cancer-related indications: HR = 0.830(0.645-1.067); irAEs: HR = 1.302(0.628-2.696)) and OS (non-cancer-related indications: HR = 0.786(0.512-1.206); irAEs: HR = 1.107(0.832-1.474)) of the ICI-treated patients. The following retrospective analysis identified corticosteroid administration for cancer-related indications was an independent unfavorable predictor for PFS (P = 0.006) and OS (P = 0.044) of the ICI-treated patients. The subgroup analysis based on non-small cell lung cancer (NSCLC) demonstrated the similar results (P = 0.002 for PFS and P = 0.047 for OS). CONCLUSION Our study demonstrated corticosteroid administration for cancer-related indications is an unfavorable prognostic factor in solid cancer patients receiving ICI treatment. Therefore, careful selection of corticosteroid-treated patients for ICI therapy is quite necessary in individualized clinical management.
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Affiliation(s)
- Ying Wang
- Department of Oncology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Mengxue Yang
- Department of Oncology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Mingyang Tao
- Department of Oncology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Peipei Liu
- Department of Oncology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Cheng Kong
- Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Institute of Intestinal Diseases, Tongji University School of Medicine, Shanghai, China
| | - Hao Li
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA; Institute of Intestinal Diseases, Tongji University School of Medicine, Shanghai, China
| | - Yingmei Chen
- Department of Oncology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China.
| | - Xudong Yin
- Department of Oncology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China.
| | - Xuebing Yan
- Department of Oncology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China.
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Matsuda Y, Matsunuma R, Suzuki K, Mori M, Watanabe H, Yamaguchi T. Physician-Perceived Predictive Factors for the Effectiveness of Drugs for Treating Cancer Dyspnea: Results of a Nationwide Survey of Japanese Palliative Care Physicians. Palliat Med Rep 2021; 1:97-102. [PMID: 34223464 PMCID: PMC8241347 DOI: 10.1089/pmr.2020.0050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Dyspnea is a common and distressing symptom in patients with advanced cancer. Opioids, benzodiazepines, and corticosteroids are commonly prescribed pharmacological treatments for cancer dyspnea. Objective: The objective of this survey was to investigate physician-perceived predictive factors for the effectiveness of opioids, benzodiazepines, and corticosteroids in treating cancer dyspnea. Design: This study involves a nationwide survey using self-report questionnaires. Setting/Subjects: Random sampling selected 268 Japanese certified palliative care physicians in Japan. Measurements: We inquired about the 12 physician-perceived predictive factors for the effectiveness of drugs (opioids, benzodiazepines, and corticosteroids) in treating cancer dyspnea. Results: The frequently selected physician-perceived predictive factors for the effectiveness of opioids were tachypnea, respiratory effort, opioid naive, Eastern Cooperative Oncology Group Performance Status 0–2, multiple lung tumors, dry cough, pleural effusion, and pleural lesion. Benzodiazepines were predicted to be effective against dyspnea in patients with depression and severe anxiety. Meanwhile, corticosteroids were predicted to be effective against dyspnea in patients with lymphangitis carcinomatosa, superior vena cava syndrome, major airway obstruction, and audible wheezing. Japanese palliative care physicians anticipate that different drug classes will be effective for treating dyspnea in patients with specific factors. Conclusions: Japanese palliative care physicians expect that different drugs will be effective for dyspnea in patients with specific predictive factors. Future prospective studies are required to assess the effectiveness of each drug class against specific dyspnea.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan
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Matsunuma R, Suzuki K, Matsuda Y, Mori M, Watanabe H, Yamaguchi T. Palliative care physicians' perspectives of management for terminally ill cancer patients with death rattle: a nationwide survey. Jpn J Clin Oncol 2020; 50:830-833. [PMID: 32419027 DOI: 10.1093/jjco/hyaa044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/14/2020] [Accepted: 12/12/2019] [Indexed: 11/14/2022] Open
Abstract
Death rattle occurs during the last days of life, and relatives of those afflicted frequently report that it is very distressful. However, there is no effective treatment for it. The purpose of this study was to investigate the perceptions of Japanese palliative care physicians in clinical practice in Japan. We conducted a nationwide survey of 268 physicians via an anonymous, self-report questionnaire. We assessed pharmacological and non-pharmacological management and anticholinergic agent choice. One hundred eighty-nine physicians (70.5%) returned the questionnaires. Fifty-five participants (29.1%) treating patients with Type-1 (real death rattle) and 36 participants (19%) treating patients with Type-2 (pseudo-death rattle) death rattle reported that they would frequently administer an anticholinergic agent. One-fourth would administer scopolamine butylbromide or scopolamine hydrobromide. In conclusion, more Japanese palliative care physicians thought that anticholinergic agents might be effective for treating Type-1 death rattle rather than Type-2. Further clinical trials of these agents are needed.
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Affiliation(s)
- Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer, and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan
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