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Talebi S, Zeraattalab‐Motlagh S, Barkhordar M, Vaezi M, Ghoreishy SM, Ghavami A, Hosseini Y, Travica N, Mohammadi H. Dose-dependent effect of megestrol acetate supplementation in cancer patients with anorexia-cachexia syndrome: A meta-analysis. J Cachexia Sarcopenia Muscle 2024; 15:1254-1263. [PMID: 39031821 PMCID: PMC11294013 DOI: 10.1002/jcsm.13500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/10/2024] [Accepted: 04/23/2024] [Indexed: 07/22/2024] Open
Abstract
There is inconsistent evidence relating to the effects of megestrol acetate (MA) supplementation on cancer patients suffering from anorexia-cachexia syndrome. This review aimed to examine the dose-response effect of MA supplementation in patients with cancer-associated anorexia/cachexia. Relevant keywords were searched in PubMed, Scopus and ISI Web of Science from inception to June 2023 for randomized controlled trials (RCTs) examining the effect of MA on pathologies in patients with cancer-associated cachexia. Our primary outcomes were changes in body weight and appetite. However, fatigue and quality of life were secondary outcomes. The mean difference (MD) and 95% confidence interval (95% CI) were estimated using the random-effects method. Thirteen trials comprising 1229 participants (mean age 60 years) were identified. The results of our highest versus lowest analysis revealed that MA supplementation was not associated with any increase in body weight (MD: 0.64 kg, 95% CI [-0.11, 1.38], P = 0.093, I2 = 69.1%; GRADE = very low certainty). Twelve trials, including 14 effect sizes derived from 1369 patients (intervention = 689, control = 680), provided data on the effect of MA on body weight. Subgroup analyses showed a significant increase in body weight following short-term intervention (≤8 weeks) and a combination of radiation/chemotherapy as concurrent treatment. A linear dose-response meta-analysis indicated that each 200 mg/day increment in MA consumption had a significant increase in weight gain (MD: 0.44; 95% CI [0.13, 0.74], P = 0.005; I2 = 97.1%); however, the magnitude of the effect was small. MA administration significantly affected the quality of life based on pooled effect sizes (MD: 1.15, 95% CI [0.76, 1.54], P < 0.001, I2 = 0%; n = 2 RCTs including 176 patients; GRADE = very low certainty). However, no significant effect of MA supplementation was observed on appetite (MD: 0.29, 95% CI [-0.05, 0.64], P = 0.096, I2 = 18.3%; n = 3 RCTs including 163 patients; GRADE = very low certainty) and fatigue (MD: 0.14, 95% CI [-0.09, 0.36], P = 0.236, I2 = 0%; n = 2 RCTs including 300 patients; GRADE = very low certainty). With very low certainty of the evidence, MA supplementation may not lead to a significantly increased weight gain and other outcomes.
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Affiliation(s)
- Sepide Talebi
- Students' Scientific Research Center (SSRC)Tehran University of Medical SciencesTehranIran
- Department of Clinical Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical SciencesTehranIran
| | | | - Maryam Barkhordar
- Cell Therapy and Hematopoietic Stem Cell Transplantation Research CenterTehran University of Medical SciencesTehranIran
- Research Institute for Oncology, Hematology and Cell TherapyTehran University of Medical SciencesTehranIran
| | - Mohammad Vaezi
- Hematology, Oncology and Stem Cell Transplantation Research CenterTehran University of Medical SciencesTehranIran
- Research Institute for Oncology, Hematology and Cell TherapyTehran University of Medical SciencesTehranIran
| | - Seyed Mojtaba Ghoreishy
- Department of Nutrition, School of Public HealthIran University of Medical SciencesTehranIran
- Student Research Committee, School of Public HealthIran University of Medical SciencesTehranIran
| | - Abed Ghavami
- Department of Clinical Nutrition, School of Nutrition and Food ScienceIsfahan University of Medical SciencesIsfahanIran
| | - Yasaman Hosseini
- Department of Clinical Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical SciencesTehranIran
| | - Nikolaj Travica
- IMPACT—Institute for Mental and Physical Health and Clinical Translation, Food and Mood Centre, School of Medicine, Barwon HealthDeakin UniversityGeelongAustralia
| | - Hamed Mohammadi
- Department of Clinical Nutrition, School of Nutritional Sciences and DieteticsTehran University of Medical SciencesTehranIran
- Research Institute for Oncology, Hematology and Cell TherapyTehran University of Medical SciencesTehranIran
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Hjermstad MJ, Jakobsen G, Arends J, Balstad TR, Brown LR, Bye A, Coats AJ, Dajani OF, Dolan RD, Fallon MT, Greil C, Grzyb A, Kaasa S, Koteng LH, May AM, McDonald J, Ottestad I, Philips I, Roeland EJ, Sayers J, Simpson MR, Skipworth RJ, Solheim TS, Sousa MS, Vagnildhaug OM, Laird BJ. Quality of life endpoints in cancer cachexia clinical trials: Systematic review 3 of the cachexia endpoints series. J Cachexia Sarcopenia Muscle 2024; 15:794-815. [PMID: 38553255 PMCID: PMC11154790 DOI: 10.1002/jcsm.13453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/22/2023] [Accepted: 02/14/2024] [Indexed: 06/07/2024] Open
Abstract
The use of patient-reported outcomes (PROMs) of quality of life (QOL) is common in cachexia trials. Patients' self-report on health, functioning, wellbeing, and perceptions of care, represent important measures of efficacy. This review describes the frequency, variety, and reporting of QOL endpoints used in cancer cachexia clinical trials. Electronic literature searches were performed in Medline, Embase, and Cochrane (1990-2023). Seven thousand four hundred thirty-five papers were retained for evaluation. Eligibility criteria included QOL as a study endpoint using validated measures, controlled design, adults (>18 years), ≥40 participants randomized, and intervention exceeding 2 weeks. The Covidence software was used for review procedures and data extractions. Four independent authors screened all records for consensus. Papers were screened by titles and abstracts, prior to full-text reading. PRISMA guidance for systematic reviews was followed. The protocol was prospectively registered via PROSPERO (CRD42022276710). Fifty papers focused on QOL. Twenty-four (48%) were double-blind randomized controlled trials. Sample sizes varied considerably (n = 42 to 469). Thirty-nine trials (78%) included multiple cancer types. Twenty-seven trials (54%) featured multimodal interventions with various drugs and dietary supplements, 11 (22%) used nutritional interventions alone and 12 (24%) used a single pharmacological intervention only. The median duration of the interventions was 12 weeks (4-96). The most frequent QOL measure was the EORTC QLQ-C30 (60%), followed by different FACIT questionnaires (34%). QOL was a primary, secondary, or exploratory endpoint in 15, 31 and 4 trials respectively, being the single primary in six. Statistically significant results on one or more QOL items favouring the intervention group were found in 18 trials. Eleven of these used a complete multidimensional measure. Adjustments for multiple testing when using multicomponent QOL measures were not reported. Nine trials (18%) defined a statistically or clinically significant difference for QOL, five with QOL as a primary outcome, and four with QOL as a secondary outcome. Correlation statistics with other study outcomes were rarely performed. PROMs including QOL are important endpoints in cachexia trials. We recommend using well-validated QOL measures, including cachexia-specific items such as weight history, appetite loss, and nutritional intake. Appropriate statistical methods with definitions of clinical significance, adjustment for multiple testing and few co-primary endpoints are encouraged, as is an understanding of how interventions may relate to changes in QOL endpoints. A strategic and scientific-based approach to PROM research in cachexia trials is warranted, to improve the research base in this field and avoid the use of QOL as supplementary measures.
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Affiliation(s)
- Marianne J. Hjermstad
- Department of OncologyOslo University HospitalOsloNorway
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Gunnhild Jakobsen
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)OsloNorway
- Cancer Clinic, St. Olavs HospitalTrondheim University HospitalTrondheimNorway
| | - Jann Arends
- Department of Medicine I, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Trude R. Balstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNTNU–Norwegian University of Science and TechnologyTrondheimNorway
- Department of Clinical Medicine, Clinical Nutrition Research Group, UiTThe Arctic University of NorwayTromsøNorway
| | - Leo R. Brown
- Department of Clinical SurgeryUniversity of EdinburghEdinburghUK
- Royal Infirmary of EdinburghEdinburghUK
| | - Asta Bye
- Department of OncologyOslo University HospitalOsloNorway
- Department of Nursing and Health Promotion, Faculty of Health SciencesOsloMet – Oslo Metropolitan UniversityOsloNorway
| | | | - Olav F. Dajani
- Department of OncologyOslo University HospitalOsloNorway
| | - Ross D. Dolan
- Academic Unit of SurgeryUniversity of Glasgow, Glasgow Royal InfirmaryGlasgowUK
| | - Marie T. Fallon
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
- St Columba's HospiceEdinburghUK
| | - Christine Greil
- Department of Medicine I, Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | | | - Stein Kaasa
- Department of OncologyOslo University HospitalOsloNorway
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital, and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Lisa H. Koteng
- Department of OncologyOslo University HospitalOsloNorway
| | - Anne M. May
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | | | - Inger Ottestad
- Department of Nutrition, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
- Department of Clinical Service, Division of Cancer Medicine, Section of Clinical NutritionOslo University HospitalOsloNorway
| | - Iain Philips
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Eric J. Roeland
- Oregon Health and Science UniversityKnight Cancer InstitutePortlandORUSA
| | - Judith Sayers
- Academic Unit of SurgeryUniversity of Glasgow, Glasgow Royal InfirmaryGlasgowUK
| | - Melanie R. Simpson
- Department of Public Health and NursingNorwegian University of Science and TechnologyTrondheimNorway
| | | | - Tora S. Solheim
- Department of Public Health and Nursing, Cancer Clinic, St Olavs HospitalTrondheim University HospitalTrondheimNorway
- Department of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
| | - Mariana S. Sousa
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT)University of TechnologySydneyNSWAustralia
| | - Ola M. Vagnildhaug
- Department of Public Health and Nursing, Cancer Clinic, St Olavs HospitalTrondheim University HospitalTrondheimNorway
- Department of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
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Brown LR, Sousa MS, Yule MS, Baracos VE, McMillan DC, Arends J, Balstad TR, Bye A, Dajani O, Dolan RD, Fallon MT, Greil C, Hjermstad MJ, Jakobsen G, Maddocks M, McDonald J, Ottestad IO, Phillips I, Sayers J, Simpson MR, Vagnildhaug OM, Solheim TS, Laird BJ, Skipworth RJ. Body weight and composition endpoints in cancer cachexia clinical trials: Systematic Review 4 of the cachexia endpoints series. J Cachexia Sarcopenia Muscle 2024; 15:816-852. [PMID: 38738581 PMCID: PMC11154800 DOI: 10.1002/jcsm.13478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/12/2024] [Accepted: 03/16/2024] [Indexed: 05/14/2024] Open
Abstract
Significant variation exists in the outcomes used in cancer cachexia trials, including measures of body composition, which are often selected as primary or secondary endpoints. To date, there has been no review of the most commonly selected measures or their potential sensitivity to detect changes resulting from the interventions being examined. The aim of this systematic review is to assess the frequency and diversity of body composition measures that have been used in cancer cachexia trials. MEDLINE, Embase and Cochrane Library databases were systematically searched between January 1990 and June 2021. Eligible trials examined adults (≥18 years) who had received an intervention aiming to treat or attenuate the effects of cancer cachexia for >14 days. Trials were also of a prospective controlled design and included body weight or at least one anthropometric, bioelectrical or radiological endpoint pertaining to body composition, irrespective of the modality of intervention (e.g., pharmacological, nutritional, physical exercise and behavioural) or comparator. Trials with a sample size of <40 patients were excluded. Data extraction used Covidence software, and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. This review was prospectively registered (PROSPERO: CRD42022276710). A total of 84 clinical trials, comprising 13 016 patients, were eligible for inclusion. Non-small-cell lung cancer and pancreatic cancer were studied most frequently. The majority of trial interventions were pharmacological (52%) or nutritional (34%) in nature. The most frequently reported endpoints were assessments of body weight (68 trials, n = 11 561) followed by bioimpedance analysis (BIA)-based estimates (23 trials, n = 3140). Sixteen trials (n = 3052) included dual-energy X-ray absorptiometry (DEXA)-based endpoints, and computed tomography (CT) body composition was included in eight trials (n = 841). Discrepancies were evident when comparing the efficacy of interventions using BIA-based estimates of lean tissue mass against radiological assessment modalities. Body weight, BIA and DEXA-based endpoints have been most frequently used in cancer cachexia trials. Although the optimal endpoints cannot be determined from this review, body weight, alongside measurements from radiological body composition analysis, would seem appropriate. The choice of radiological modality is likely to be dependent on the trial setting, population and intervention in question. CT and magnetic resonance imaging, which have the ability to accurately discriminate tissue types, are likely to be more sensitive and provide greater detail. Endpoints are of particular importance when aligned with the intervention's mechanism of action and/or intended patient benefit.
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Affiliation(s)
- Leo R. Brown
- Clinical SurgeryThe University of Edinburgh, Royal Infirmary of EdinburghEdinburghUK
| | - Mariana S. Sousa
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT)University of Technology SydneySydneyAustralia
| | - Michael S. Yule
- Clinical SurgeryThe University of Edinburgh, Royal Infirmary of EdinburghEdinburghUK
- Institute of Genetics and CancerThe University of Edinburgh, Western General HospitalEdinburghUK
- St Columba's Hospice CareEdinburghUK
| | | | - Donald C. McMillan
- Academic Unit of SurgeryUniversity of Glasgow, Glasgow Royal InfirmaryGlasgowUK
| | - Jann Arends
- Department of Medicine I, Medical Centre—University of Freiburg Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | - Trude R. Balstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNorwegian University of Science and TechnologyTrondheimNorway
- Department of Clinical Medicine, Clinical Nutrition Research GroupUiT The Arctic University of NorwayTromsøNorway
| | - Asta Bye
- Department of OncologyOslo University HospitalOsloNorway
- Department of Nursing and Health Promotion, Faculty of Health SciencesOslo Metropolitan UniversityOsloNorway
| | - Olav Dajani
- Department of OncologyOslo University HospitalOsloNorway
| | - Ross D. Dolan
- Academic Unit of SurgeryUniversity of Glasgow, Glasgow Royal InfirmaryGlasgowUK
| | - Marie T. Fallon
- Institute of Genetics and CancerThe University of Edinburgh, Western General HospitalEdinburghUK
- St Columba's Hospice CareEdinburghUK
| | - Christine Greil
- Department of Medicine I, Medical Centre—University of Freiburg Faculty of MedicineUniversity of FreiburgFreiburgGermany
| | | | - Gunnhild Jakobsen
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and TechnologyTrondheimNorway
- Cancer ClinicSt. Olav's Hospital, Trondheim University HospitalTrondheimNorway
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - James McDonald
- Institute of Genetics and CancerThe University of Edinburgh, Western General HospitalEdinburghUK
- St Columba's Hospice CareEdinburghUK
| | - Inger O. Ottestad
- Department of Nutrition, Institute of Basic Medical SciencesUniversity of OsloOsloNorway
- The Clinical Nutrition Outpatient Clinic, Section of Clinical Nutrition, Department of Clinical Service, Division of Cancer MedicineOslo University HospitalOsloNorway
| | - Iain Phillips
- Edinburgh Cancer CentreWestern General HospitalEdinburghUK
| | - Judith Sayers
- Clinical SurgeryThe University of Edinburgh, Royal Infirmary of EdinburghEdinburghUK
- Institute of Genetics and CancerThe University of Edinburgh, Western General HospitalEdinburghUK
- St Columba's Hospice CareEdinburghUK
| | - Melanie R. Simpson
- Department of Nursing and Health Promotion, Faculty of Health SciencesOslo Metropolitan UniversityOsloNorway
| | - Ola M. Vagnildhaug
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNorwegian University of Science and TechnologyTrondheimNorway
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and TechnologyTrondheimNorway
| | - Tora S. Solheim
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNorwegian University of Science and TechnologyTrondheimNorway
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and TechnologyTrondheimNorway
| | - Barry J.A. Laird
- Institute of Genetics and CancerThe University of Edinburgh, Western General HospitalEdinburghUK
- St Columba's Hospice CareEdinburghUK
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Chowdhury IH, Rahman MS, Chowdhury MNK, Afroze YJ, Tabassum M, Marnush M, Zerin N. Mirtazapine versus megestrol acetate in treatment of anorexia-cachexia in advanced cancer patients: a randomized, double-blind trial. Jpn J Clin Oncol 2024; 54:530-536. [PMID: 38323684 DOI: 10.1093/jjco/hyae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024] Open
Abstract
OBJECTIVE Cancer-related anorexia-cachexia comprises one of the most common syndromes of advanced cancer patients. The management of cancer-related anorexia-cachexia is a great challenge in clinical practice. There are no definite practice guidelines yet for the prevention and treatment of cancer-related anorexia-cachexia. This study is considered to find out whether there is any role of mirtazapine in the improvement of anorexia in cancer patients. METHODS A total of 80 cancer-anorexia patients were enrolled. Patients in the trial arm received the standard chemotherapy medication plus one tablet of mirtazapine 15 mg daily at night orally for 8 weeks starting from the day of an initial assessment. The control arm received the standard chemotherapy medication plus one tablet of megestrol acetate 160 mg daily orally for 8 weeks starting from the day of an initial assessment. Each patient was assessed by validated versions of Functional Assessment of Anorexia/Cachexia Therapy Anorexia/Cachexia Sub Scale v 4 questionnaires. RESULTS After 4 and 8 weeks each patient was evaluated again using the Functional Assessment of Anorexia/Cachexia Therapy Anorexia/Cachexia Sub Scale tool. The quality of life of each patient was assessed by European Organization for Research and Treatment QLQ-C30 v 3.0. After 4 to 8 weeks of treatment, the Functional Assessment of Anorexia/Cachexia Therapy Anorexia/Cachexia Sub Scale score in cancer anorexia patients in the mirtazapine improved anorexia significantly. However, the improvement after 4 to 8 weeks was not statistically significant when it was compared with the megestrol acetate (P > 0.05). CONCLUSIONS Therefore, the findings of this study reveal that mirtazapine might be a potential alternative to megestrol acetate, as it has shown potential efficacy as like as megestrol acetate.
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Affiliation(s)
| | - Md Sayedur Rahman
- Department of Pharmacology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Yeasmin Jahan Afroze
- Department of Facio-Maxillary Surgical Oncology, National Institute of Cancer Research & Hospital, Dhaka, Bangladesh
| | - Masuma Tabassum
- Department of Pharmacology, Dhaka Medical College, Dhaka, Bangladesh
| | - Muhammad Marnush
- Department of Pharmacology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Nusrat Zerin
- Department of Biochemistry, Shaheed Suhrawardy Medical College, Dhaka, Bangladesh
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Vagnildhaug OM, Balstad TR, Ottestad I, Bye A, Greil C, Arends J, Baracos V, Brown LR, Dajani OF, Dolan RD, Fallon M, Fraser E, Grzyb A, Hjermstad MJ, Jakobsen G, Kaasa S, McDonald J, Philips I, Sayers J, Simpson MR, Sousa MS, Skipworth RJ, Laird BJ, Solheim TS. Appetite and dietary intake endpoints in cancer cachexia clinical trials: Systematic Review 2 of the cachexia endpoints series. J Cachexia Sarcopenia Muscle 2024; 15:513-535. [PMID: 38343065 PMCID: PMC10995275 DOI: 10.1002/jcsm.13434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 04/06/2024] Open
Abstract
There is no consensus on the optimal endpoint(s) in cancer cachexia trials. Endpoint variation is an obstacle when comparing interventions and their clinical value. The aim of this systematic review was to summarize and evaluate endpoints used to assess appetite and dietary intake in cancer cachexia clinical trials. A search for studies published from 1 January 1990 until 2 June 2021 was conducted using MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Eligible studies examined cancer cachexia treatment versus a comparator in adults with assessments of appetite and/or dietary intake as study endpoints, a sample size ≥40 and an intervention lasting ≥14 days. Reporting was in line with PRISMA guidance, and a protocol was published in PROSPERO (2022 CRD42022276710). This review is part of a series of systematic reviews examining cachexia endpoints. Of the 5975 articles identified, 116 were eligible for the wider review series and 80 specifically examined endpoints of appetite (65 studies) and/or dietary intake (21 studies). Six trials assessed both appetite and dietary intake. Appetite was the primary outcome in 15 trials and dietary intake in 7 trials. Median sample size was 101 patients (range 40-628). Forty-nine studies included multiple primary tumour sites, while 31 studies involved single primary tumour sites (15 gastrointestinal, 7 lung, 7 head and neck and 2 female reproductive organs). The most frequently reported appetite endpoints were visual analogue scale (VAS) and numerical rating scale (NRS) (40%). The appetite item from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30/C15 PAL (38%) and the appetite question from North Central Cancer Treatment Group anorexia questionnaire (17%) were also frequently applied. Of the studies that assessed dietary intake, 13 (62%) used food records (prospective registrations) and 10 (48%) used retrospective methods (24-h recall or dietary history). For VAS/NRS, a mean change of 1.3 corresponded to Hedge's g of 0.5 and can be considered a moderate change. For food records, a mean change of 231 kcal/day or 11 g of protein/day corresponded to a moderate change. Choice of endpoint in cachexia trials will depend on factors pertinent to the trial to be conducted. Nevertheless, from trials assessed and available literature, NRS or EORTC QLQ C30/C15 PAL seems suitable for appetite assessments. Appetite and dietary intake endpoints are rarely used as primary outcomes in cancer cachexia. Dietary intake assessments were used mainly to monitor compliance and are not validated in cachexia populations. Given the importance to cachexia studies, dietary intake endpoints must be validated before they are used as endpoints in clinical trials.
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Affiliation(s)
- Ola Magne Vagnildhaug
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
- Cancer Clinic, St. Olavs HospitalTrondheim University HospitalTrondheimNorway
| | - Trude R. Balstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
- Department of Clinical Medicine, Clinical Nutrition Research GroupUiT The Arctic University of NorwayTromsøNorway
| | - Inger Ottestad
- Department of Nutrition, Institute of Basic Medical Sciences, Faculty of MedicineUniversity of OsloOsloNorway
- The Clinical Nutrition Outpatient Clinic, Section of Clinical Nutrition, Department of Clinical Service, Division of Cancer MedicineOslo University HospitalOsloNorway
| | - Asta Bye
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University HospitalUniversity of OsloOsloNorway
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Nursing and Health Promotion, Faculty of Health SciencesOsloMet—Oslo Metropolitan UniversityOsloNorway
| | - Christine Greil
- Department of Medicine I, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburg im BreisgauGermany
| | - Jann Arends
- Department of Medicine I, Medical Center—University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburg im BreisgauGermany
| | - Vickie Baracos
- Department of OncologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Leo R. Brown
- Clinical SurgeryUniversity of Edinburgh, Royal Infirmary of EdinburghEdinburghUK
| | - Olav F. Dajani
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University HospitalUniversity of OsloOsloNorway
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Ross D. Dolan
- Academic Unit of SurgeryUniversity of Glasgow, Glasgow Royal InfirmaryGlasgowUK
| | - Marie Fallon
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Eilidh Fraser
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Aleksandra Grzyb
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Marianne J. Hjermstad
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University HospitalUniversity of OsloOsloNorway
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Gunnhild Jakobsen
- Cancer Clinic, St. Olavs HospitalTrondheim University HospitalTrondheimNorway
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Stein Kaasa
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University HospitalUniversity of OsloOsloNorway
- European Palliative Care Research Centre (PRC), Department of Oncology, Oslo University Hospital and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - James McDonald
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | - Iain Philips
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Judith Sayers
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
- St Columba's HospiceEdinburghUK
| | - Melanie R. Simpson
- Department of Public Health and Nursing, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Mariana S. Sousa
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT)University of Technology SydneySydneyNew South WalesAustralia
| | | | - Barry J.A. Laird
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
- St Columba's HospiceEdinburghUK
| | - Tora S. Solheim
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology (NTNU)TrondheimNorway
- Cancer Clinic, St. Olavs HospitalTrondheim University HospitalTrondheimNorway
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Ispoglou T, McCullough D, Windle A, Nair S, Cox N, White H, Burke D, Kanatas A, Prokopidis K. Addressing cancer anorexia-cachexia in older patients: Potential therapeutic strategies and molecular pathways. Clin Nutr 2024; 43:552-566. [PMID: 38237369 DOI: 10.1016/j.clnu.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
Cancer cachexia (CC) syndrome, a feature of cancer-associated muscle wasting, is particularly pronounced in older patients, and is characterised by decreased energy intake and upregulated skeletal muscle catabolic pathways. To address CC, appetite stimulants, anabolic drugs, cytokine mediators, essential amino acid supplementation, nutritional counselling, cognitive behavioural therapy, and enteral nutrition have been utilised. However, pharmacological treatments that have also shown promising results, such as megestrol acetate, anamorelin, thalidomide, and delta-9-tetrahydrocannabinol, have been associated with gastrointestinal and cardiovascular complications. Emerging evidence on the efficacy of probiotics in modulating gut microbiota also presents a promising adjunct to traditional therapies, potentially enhancing nutritional absorption and systemic inflammation control. Additionally, low-dose olanzapine has demonstrated improved appetite and weight management in older patients undergoing chemotherapy, offering a potential refinement to current therapeutic approaches. This review aims to elucidate the molecular mechanisms underpinning CC, with a particular focus on the role of anorexia in exacerbating muscle wasting, and to propose pharmacological and non-pharmacological strategies to mitigate this syndrome, particularly emphasising the needs of an older demographic. Future research targeting CC should focus on refining appetite-stimulating drugs with fewer side-effects, specifically catering to the needs of older patients, and investigating nutritional factors that can either enhance appetite or minimise suppression of appetite in individuals with CC, especially within this vulnerable group.
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Affiliation(s)
| | | | - Angela Windle
- Department of Nursing and Midwifery, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK; School of Medicine, University of Leeds, Leeds, UK
| | | | - Natalie Cox
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen White
- School of Health, Leeds Beckett University, Leeds, UK
| | - Dermot Burke
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Konstantinos Prokopidis
- Department of Musculoskeletal and Ageing Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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7
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McDonald J, Sayers J, Anker SD, Arends J, Balstad TR, Baracos V, Brown L, Bye A, Dajani O, Dolan R, Fallon MT, Fraser E, Griel C, Grzyb A, Hjermstad M, Jamal‐Hanjani M, Jakobsen G, Kaasa S, McMillan D, Maddocks M, Philips I, Ottestad IO, Reid KF, Sousa MS, Simpson MR, Vagnildhaug OM, Skipworth RJE, Solheim TS, Laird BJA. Physical function endpoints in cancer cachexia clinical trials: Systematic Review 1 of the cachexia endpoints series. J Cachexia Sarcopenia Muscle 2023; 14:1932-1948. [PMID: 37671529 PMCID: PMC10570071 DOI: 10.1002/jcsm.13321] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/19/2023] [Accepted: 08/02/2023] [Indexed: 09/07/2023] Open
Abstract
In cancer cachexia trials, measures of physical function are commonly used as endpoints. For drug trials to obtain regulatory approval, efficacy in physical function endpoints may be needed alongside other measures. However, it is not clear which physical function endpoints should be used. The aim of this systematic review was to assess the frequency and diversity of physical function endpoints in cancer cachexia trials. Following a comprehensive electronic literature search of MEDLINE, Embase and Cochrane (1990-2021), records were retrieved. Eligible trials met the following criteria: adults (≥18 years), controlled design, more than 40 participants, use of a cachexia intervention for more than 14 days and use of a physical function endpoint. Physical function measures were classified as an objective measure (hand grip strength [HGS], stair climb power [SCP], timed up and go [TUG] test, 6-min walking test [6MWT] and short physical performance battery [SPPB]), clinician assessment of function (Karnofsky Performance Status [KPS] or Eastern Cooperative Oncology Group-Performance Status [ECOG-PS]) or patient-reported outcomes (physical function subscale of the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaires [EORTC QLQ-C30 or C15]). Data extraction was performed using Covidence and followed PRISMA guidance (PROSPERO registration: CRD42022276710). A total of 5975 potential studies were examined and 71 were eligible. Pharmacological interventions were assessed in 38 trials (54%). Of these, 11 (29%, n = 1184) examined megestrol and 5 (13%, n = 1928) examined anamorelin; nutritional interventions were assessed in 21 trials (30%); and exercise-based interventions were assessed in 6 trials (8%). The remaining six trials (8%) assessed multimodal interventions. Among the objective measures of physical function (assessed as primary or secondary endpoints), HGS was most commonly examined (33 trials, n = 5081) and demonstrated a statistically significant finding in 12 (36%) trials (n = 2091). The 6MWT was assessed in 12 trials (n = 1074) and was statistically significant in 4 (33%) trials (n = 403), whereas SCP, TUG and SPPB were each assessed in 3 trials. KPS was more commonly assessed than the newer ECOG-PS (16 vs. 9 trials), and patient-reported EORTC QLQ-C30 physical function was reported in 25 trials. HGS is the most commonly used physical function endpoint in cancer cachexia clinical trials. However, heterogeneity in study design, populations, intervention and endpoint selection make it difficult to comment on the optimal endpoint and how to measure this. We offer several recommendations/considerations to improve the design of future clinical trials in cancer cachexia.
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Affiliation(s)
- James McDonald
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
- St Columba's HospiceEdinburghUK
| | - Judith Sayers
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
- St Columba's HospiceEdinburghUK
- Clinical SurgeryUniversity of Edinburgh, Royal Infirmary of EdinburghEdinburghUK
| | - Stefan D. Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) partner site BerlinCharité UniversitätsmedizinBerlinGermany
- Institute of Heart DiseasesWroclaw Medical UniversityWroclawPoland
- German Centre for Cardiovascular Research (DZHK) partner site BerlinCharité Universitätsmedizin BerlinBerlinGermany
| | - Jann Arends
- Department of Medicine I, Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburg im BreisgauGermany
| | - Trude Rakel Balstad
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNTNU–Norwegian University of Science and TechnologyTrondheimNorway
- Department of Clinical Medicine, Clinical Nutrition Research GroupUiT The Arctic University of NorwayTromsøNorway
| | - Vickie Baracos
- Division of Palliative Care Medicine, Department of OncologyUniversity of AlbertaEdmontonABCanada
| | - Leo Brown
- Clinical SurgeryUniversity of Edinburgh, Royal Infirmary of EdinburghEdinburghUK
| | - Asta Bye
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University Hospital/European Palliative Care Research Centre (PRC), and Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of Nursing and Health Promotion, Faculty of Health SciencesOslo Metropolitan UniversityOsloNorway
| | - Olav Dajani
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University Hospital/European Palliative Care Research Centre (PRC), and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Ross Dolan
- Academic Unit of SurgeryUniversity of Glasgow, Glasgow Royal InfirmaryGlasgowUK
| | - Marie T. Fallon
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Eilidh Fraser
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Christine Griel
- Department of Medicine I, Medical Center – University of Freiburg, Faculty of MedicineUniversity of FreiburgFreiburg im BreisgauGermany
| | - Aleksandra Grzyb
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Marianne Hjermstad
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University Hospital/European Palliative Care Research Centre (PRC), and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Mariam Jamal‐Hanjani
- Cancer Research UK Lung Cancer Centre of ExcellenceUniversity College London Cancer InstituteLondonUK
- Cancer Metastasis LaboratoryUniversity College London Cancer InstituteLondonUK
- Department of OncologyUniversity College London HospitalsLondonUK
| | - Gunnhild Jakobsen
- Department of Public Health and NursingNorwegian University of Science and TechnologyTrondheimNorway
| | - Stein Kaasa
- Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University Hospital/European Palliative Care Research Centre (PRC), and Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Donald McMillan
- Academic Unit of SurgeryUniversity of Glasgow, Glasgow Royal InfirmaryGlasgowUK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Iain Philips
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
| | - Inger O. Ottestad
- Department of Nutrition, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway and The Clinical Nutrition Outpatient Clinic, Section of Clinical Nutrition, Department of Clinical Service, Division of Cancer MedicineHarvard Medical SchoolOslo University HospitalNorway
| | - Kieran F. Reid
- Laboratory of Exercise Physiology and Physical Performance, Boston Claude D. Pepper Older Americans Independence Center for Function Promoting Therapies, Brigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | - Mariana S. Sousa
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT)University of Technology SydneySydneyNSWAustralia
| | - Melanie R. Simpson
- Department of Public Health and NursingNorwegian University of Science and TechnologyTrondheimNorway
| | - Ola Magne Vagnildhaug
- Cancer ClinicSt Olavs Hospital – Trondheim University HospitalTrondheimNorway
- Department of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
| | | | - Tora S. Solheim
- Cancer ClinicSt Olavs Hospital – Trondheim University HospitalTrondheimNorway
- Department of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
| | - Barry J. A. Laird
- Edinburgh Cancer Research CentreUniversity of EdinburghEdinburghUK
- St Columba's HospiceEdinburghUK
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8
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Yennurajalingam S, Lu Z, Rozman De Moraes A, Tull NN, Kubiak MJ, Geng Y, Andersen CR, Bruera E. Meta-Analysis of Pharmacological, Nutraceutical and Phytopharmaceutical Interventions for the Treatment of Cancer Related Fatigue. Cancers (Basel) 2022; 15:cancers15010091. [PMID: 36612088 PMCID: PMC9817820 DOI: 10.3390/cancers15010091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Purpose: In this study we aimed to estimate the effectiveness of pharmacological, nutraceutical, and phytopharmaceutical treatments on CRF. Methods: Ovid MEDLINE, Ovid Embase, Ovid Psych info, CINHAHL and Cochrane Library databases were searched up to 30 September 2021. Randomized controlled trials of pharmacological, nutraceutical and phytopharmaceutical interventions for treatment of CRF for at least one week duration and have used valid tool to assess severity of CRF as a primary or secondary outcome were considered. Results: 32 eligible studies (4896 patients) were reviewed. For the overall meta-analysis, the random effect models yielded the treatment effect (95% CI) of −0.29 (−0.48,−0.09), p < 0.001. The meta-analysis did not show significant reduction of CRF with treatment with ginseng (n = 6), guarana (n = 3), megestrol (n = 2), mistletoe (n = 3), psychostimulants (n = 14), SSRI/antidepressants (n = 2). Corticosteroids (n = 2) showed significant reduction in CRF with treatment effects of 0.94 (−1.21, −0.67), p <0.0001, respectively. Conclusions: In this study, overall meta-analysis of all studies demonstrates significant reduction of CRF using Pharmacological, Nutraceutical and Phytopharmaceutical interventions with a pooled standardized treatment effect of −0.29. Metanalysis of Corticosteroids studies showed significant reduction in CRF. Further studies are needed.
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Affiliation(s)
- Sriram Yennurajalingam
- Department of Palliative Care Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-(713)-792-3930; Fax: +1-(713)-792-6092
| | - Zhanni Lu
- Department of Palliative Care Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Aline Rozman De Moraes
- Department of Palliative Care Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Nhu Nhu Tull
- Department of Palliative Care Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Michal J. Kubiak
- Department of Palliative Care Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yimin Geng
- Research Medical Library, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Clark R. Andersen
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Eduardo Bruera
- Department of Palliative Care Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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9
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Gaafer OU, Zimmers TA. Nutrition challenges of cancer cachexia. JPEN J Parenter Enteral Nutr 2021; 45:16-25. [PMID: 34897740 DOI: 10.1002/jpen.2287] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 12/11/2022]
Abstract
Cancer cachexia, or progressive weight loss, often despite adequate nutrition contributes greatly to cancer morbidity and mortality. Cachexia is metabolically distinct from starvation or protein malnutrition, although many patients with cancer and cachexia exhibit lowered appetite and food consumption. Tumors affect neural mechanisms that regulate appetite and energy expenditure, while promoting wasting of peripheral tissues via catabolism of cardiac and skeletal muscle, adipose, and bone. These multimodal actions of tumors on the host suggest a need for multimodal interventions. However, multiple recent consensus guidelines for management of cancer cachexia differ in treatment recommendations, highlighting the lack of effective, available therapies. Challenges to defining appropriate nutrition or other interventions for cancer cachexia include lack of consensus on definitions, low strength of evidence from clinical trials, and a scarcity of robust, rigorous, and mechanistic studies. However, efforts to diagnose, stage, and monitor cachexia are increasing along with clinical trial activity. Furthermore, preclinical models for cancer cachexia are growing more sophisticated, encompassing a greater number of tumor types in organ-appropriate contexts and for metastatic disease to model the clinical condition more accurately. It is expected that continued growth, investment, and coordination of research in this topic will ultimately yield robust biomarkers, clinically useful classification and staging algorithms, targetable pathways, pivotal clinical trials, and ultimately, cures. Here, we provide an overview of the clinical and scientific knowledge and its limitations around cancer cachexia.
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Affiliation(s)
- Omnia U Gaafer
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Teresa A Zimmers
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, Indiana, USA.,Indiana Center for Musculoskeletal Health, Indianapolis, Indiana, USA.,Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
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10
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Chen Y, Tang Y, Nie JZ, Zhang Y, Nie D. Megestrol acetate is a specific inducer of CYP3A4 mediated by human pregnane X receptor. Cancer Chemother Pharmacol 2021; 88:985-996. [PMID: 34524495 DOI: 10.1007/s00280-021-04352-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 09/01/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Megestrol acetate is a synthetic progestogen used to treat some cancers and cancer-associated cachexia, but its potential interactions with other drugs are not well known. This study aims to determine the regulation of drug metabolizing enzymes by megestrol acetate. METHODS Primary human hepatocytes were treated and analyzed by PCR array to identify genes involved in drug metabolism that are impacted by megestrol acetate. P450 3A4 (CYP3A4) reporter gene assay and HPLC analyses of nifedipine metabolites were used to determine CYP3A4 gene expression and activities. Competitive ligand binding assay was used to determine the affinity of megestrol acetate toward human pregnane x receptor (hPXR). Electrophoretic mobility shift assay and mammalian two hybrid assay were used to determine the mechanism of megestrol to activate hPXR. RESULTS The levels and activities of CYP3A4 were significantly induced (> 4-folds) by megestrol acetate in human hepatocytes and HepG2 cells. Megestrol treatment induced CYP3A4 through the activation of hPXR, a ligand-activated transcription factor that plays a role in drug metabolism and transport. Other tested nuclear receptors showed no response. The mechanism studies showed that megestrol activated hPXR by binding to the ligand binding domain (LBD) of hPXR and increasing the recruitment of the cofactors such as steroid receptor cofactor (SRC-1). CONCLUSION The results suggest that megestrol acetate is a specific inducer of CYP3A4 mediated by hPXR and therefore has the potential to cause drug interactions, especially in the co-administration with drugs that are substrates of CYP3A4.
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Affiliation(s)
- Yakun Chen
- Department of Medical Microbiology, Immunology and Cell Biology, Southern Illinois University School of Medicine and Simmons Cancer Institute, Springfield, IL, 62794-9626, USA
| | - Yong Tang
- Department of Medical Microbiology, Immunology and Cell Biology, Southern Illinois University School of Medicine and Simmons Cancer Institute, Springfield, IL, 62794-9626, USA
| | - Jeffrey Z Nie
- Department of Medical Microbiology, Immunology and Cell Biology, Southern Illinois University School of Medicine and Simmons Cancer Institute, Springfield, IL, 62794-9626, USA
| | - Yuanqin Zhang
- Department of Medical Microbiology, Immunology and Cell Biology, Southern Illinois University School of Medicine and Simmons Cancer Institute, Springfield, IL, 62794-9626, USA
| | - Daotai Nie
- Department of Medical Microbiology, Immunology and Cell Biology, Southern Illinois University School of Medicine and Simmons Cancer Institute, Springfield, IL, 62794-9626, USA.
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11
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Ulutin HC, Arpaci F, Pak Y. Megestrol Acetate for Cachexia and Anorexia in Advanced Non-small Cell Lung Cancer: A Randomized Study Comparing Two Different Doses. TUMORI JOURNAL 2018; 88:277-80. [PMID: 12400976 DOI: 10.1177/030089160208800406] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The primary aim of the study was to compare two different dose levels of megestrol acetate, administered for cancer-related anorexia and cachexia for 3 months. Methods From August 1996 to December 2000, 119 patients with advanced non-small cell lung cancer were randomized to take 160 mg/day or 320 mg/day of megestrol acetate for 3 months at the Gülhane Military Medicine Academy of Ankara, Turkey. Patients were controlled at biweekly periods. Results There were 59 patients in the single dose arm (group 1) and 60 patients in the twice a day dose arm (group 2). The mean percentages of weight loss were 16.9% and 16.7% in group 1 and 2, respectively. In the first and the second month of weight gain, there were no significant differences in the two groups (P = 0.23 and P = 0.11). In the third month, weight gain was significantly higher in group 2 than in group 1 (P = 0.038). Toxicity was similar for both dose levels. Conclusions Megestrol acetate can be safely and effectively given to patients with advanced non-small cell lung cancer. Although lower doses of megestrol acetate can be effective for anorexia and cachexia, the higher dose level seems to be more efficient.
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Affiliation(s)
- H Cüneyt Ulutin
- Department of Radiation Oncology, Gülhane Military Medicine Academy, Faculty of Medicine, Ankara, Turkey.
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12
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Tomlinson D, Robinson P, Oberoi S, Cataudella D, Culos-Reed N, Davis H, Duong N, Gibson F, Götte M, Hinds P, Nijhof S, van der Torre P, Cabral S, Dupuis L, Sung L. Pharmacologic interventions for fatigue in cancer and transplantation: a meta-analysis. Curr Oncol 2018; 25:e152-e167. [PMID: 29719440 PMCID: PMC5927795 DOI: 10.3747/co.25.3883] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Our objective was to determine whether, compared with control interventions, pharmacologic interventions reduce the severity of fatigue in patients with cancer or recipients of hematopoietic stem-cell transplantation (hsct). Methods For a systematic review, we searched medline, embase, the Cochrane Central Register of Controlled Trials, cinahl, and Psychinfo for randomized trials of systemic pharmacologic interventions for the management of fatigue in patients with cancer or recipients of hsct. Two authors independently identified studies and abstracted data. Methodologic quality was assessed using the Cochrane Risk of Bias tool. The primary outcome was fatigue severity measured using various fatigue scales. Data were synthesized using random-effects models. Results In the 117 included trials (19,819 patients), the pharmacologic agents used were erythropoietins (n = 31), stimulants (n = 19), l-carnitine (n = 6), corticosteroids (n = 5), antidepressants (n = 5), appetite stimulants (n = 3), and other agents (n = 48). Fatigue was significantly reduced with erythropoietin [standardized mean difference (smd): -0.52; 95% confidence interval (ci): -0.89 to -0.14] and with methylphenidate (smd: -0.36; 95% ci: -0.56 to -0.15); modafinil (or armodafinil) and corticosteroids were not effective. Conclusions Erythropoietin and methylphenidate significantly reduced fatigue severity in patients with cancer and in recipients of hsct. Concerns about the safety of those agents might limit their usefulness. Future research should identify effective interventions for fatigue that have minimal adverse effects.
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Affiliation(s)
- D. Tomlinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON
| | | | - S. Oberoi
- Pediatric Oncology Group of Ontario, Toronto, ON
| | - D. Cataudella
- Department of Pediatric Psychology, Children’s Hospital, London Health Sciences Centre, London, ON
| | - N. Culos-Reed
- Faculty of Kinesiology, University of Calgary, Calgary, AB
| | - H. Davis
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON
| | - N. Duong
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON
| | - F. Gibson
- Centre for Outcomes and Experiences Research in Children’s Health, Illness, and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, and School of Health Sciences, University of Surrey, Guildford, U.K
| | - M. Götte
- University Hospital Essen, Center for Child and Adolescent Medicine, Department of Pediatric Hematology/Oncology, Essen, Germany
| | - P. Hinds
- Department of Nursing Science, Professional Practice, and Quality, Children’s National Health System; and Department of Pediatrics, George Washington University, Washington, DC, U.S.A
| | - S.L. Nijhof
- Division of Pediatrics, Wilhelmina Children’s Hospital (part of UMC Utrecht), Utrecht, Netherlands
| | - P. van der Torre
- Division of Pediatrics, Wilhelmina Children’s Hospital (part of UMC Utrecht), Utrecht, Netherlands
| | - S. Cabral
- Pediatric Oncology Group of Ontario, Toronto, ON
| | - L.L. Dupuis
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON
- Department of Pharmacy, The Hospital for Sick Children; and Leslie Dan Faculty of Pharmacy, University of Toronto, The Hospital for Sick Children, Toronto, ON
| | - L. Sung
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON
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13
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Abstract
Cancer patients experience multiple symptoms throughout their illness trajectory. Symptoms consistently occurring together, known as symptom clusters, share common pathophysiologic mechanisms. Understanding and targeting such symptom clusters may allow for more effective and efficient use of treatments for a variety of symptoms. Fatigue-anorexia-cachexia is one of the most prevalent symptom clusters and significantly impairs quality of life. In this review, we explore the fatigue-anorexia-cachexia symptom cluster and focus on current and emerging therapies with an emphasis on pharmacologic management.
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14
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Mücke M, Cuhls H, Peuckmann-Post V, Minton O, Stone P, Radbruch L. Pharmacological treatments for fatigue associated with palliative care. Cochrane Database Syst Rev 2015; 2015:CD006788. [PMID: 26026155 PMCID: PMC6483317 DOI: 10.1002/14651858.cd006788.pub3] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This review updates the original review, 'Pharmacological treatments for fatigue associated with palliative care' and also incorporates the review 'Drug therapy for the management of cancer-related fatigue'.In healthy individuals, fatigue is a protective response to physical or mental stress, often relieved by rest. By contrast, in palliative care patients' fatigue can be severely debilitating and is often not counteracted with rest, thereby impacting daily activity and quality of life. Fatigue frequently occurs in patients with advanced disease (e.g. cancer-related fatigue) and modalities used to treat cancer can often contribute. Further complicating issues are the multidimensionality, subjective nature and lack of a consensus definition of fatigue. The pathophysiology is not fully understood and evidence-based treatment approaches are needed. OBJECTIVES To evaluate the efficacy of pharmacological treatments for fatigue in palliative care, with a focus on patients at an advanced stage of disease, including patients with cancer and other chronic diseases. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO and EMBASE, and a selection of cancer journals up to 28 April 2014. We searched the references of identified articles and contacted authors to obtain unreported data. To validate the search strategy we selected sentinel references. SELECTION CRITERIA We considered randomised controlled trials (RCTs) concerning adult palliative care with a focus on pharmacological treatment of fatigue compared to placebo, application of two drugs, usual care or a non-pharmacological intervention. The primary outcome had to be non-specific fatigue (or related terms such as asthenia). We did not include studies on fatigue related to antineoplastic treatment (e.g. chemotherapy, radiotherapy, surgical intervention). We also included secondary outcomes that were assessed in fatigue-related studies (e.g. exhaustion, tiredness). DATA COLLECTION AND ANALYSIS Two review authors (MM and MC) independently assessed trial quality and extracted data. We screened the search results and included studies if they met the selection criteria. If we identified two or more studies that investigated a specific drug with the same dose in a population with the same disease and using the same assessment instrument or scale, we conducted meta-analysis. In addition, we compared the type of drug investigated in specific populations, as well as the frequent adverse effects of fatigue treatment, by creating overview tables. MAIN RESULTS For this update, we screened 1645 publications of which 45 met the inclusion criteria (20 additional studies to the previous reviews). In total, we analysed data from 18 drugs and 4696 participants. There was a very high degree of statistical and clinical heterogeneity in the trials and we discuss the reasons for this in the review. There were some sources of potential bias in the included studies, including a lack of description of the methods of blinding and allocation concealment, and the small size of the study populations. We included studies investigating pemoline and modafinil in participants with multiple sclerosis (MS)-associated fatigue and methylphenidate in patients suffering from advanced cancer and fatigue in meta-analysis. Treatment results pointed to weak and inconclusive evidence for the efficacy of amantadine, pemoline and modafinil in multiple sclerosis and for carnitine and donepezil in cancer-related fatigue. Methylphenidate and pemoline seem to be effective in patients with HIV, but this is based only on one study per intervention, with only a moderate number of participants in each study. Meta-analysis shows an estimated superior effect for methylphenidate in cancer-related fatigue (standardised mean difference (SMD) 0.49, 95% confidence interval (CI) 0.15 to 0.83). Therapeutic effects could not be described for dexamphetamine, paroxetine or testosterone. There were a variety of results for the secondary outcomes in some studies. Most studies had low participant numbers and were heterogeneous. In general, adverse reactions were mild and had little or no impact. AUTHORS' CONCLUSIONS Based on limited evidence, we cannot recommend a specific drug for the treatment of fatigue in palliative care patients. Fatigue research in palliative care seems to focus on modafinil and methylphenidate, which may be beneficial for the treatment of fatigue associated with palliative care although further research about their efficacy is needed. Dexamethasone, methylprednisolone, acetylsalicylic acid, armodafinil, amantadine and L-carnitine should be further examined. Consensus is needed regarding fatigue outcome parameters for clinical trials.
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Affiliation(s)
- Martin Mücke
- Department of Palliative Medicine, University Hospital of Bonn, Sigmund-Freud-Str. 25, Bonn, Germany, 53127
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15
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Chan A, Lim E, Ng T, Shih V, Quek R, Cheung YT. Symptom burden and medication use in adult sarcoma patients. Support Care Cancer 2014; 23:1709-17. [PMID: 25430481 DOI: 10.1007/s00520-014-2533-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 11/17/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Limited data are available on how symptom burden affects health-related quality of life (HRQoL) in patients with sarcoma. This study aims to describe the symptom burden, HRQoL, and medication use in adult sarcoma patients. METHODS A single-center, cross-sectional study was conducted, and 79 patients were evaluated using three tools: the Rotterdam Symptom Checklist (RSCL), the Beck Anxiety Inventory (BAI), and the Functional Assessment of Cancer Therapy scale-General (FACT-G). Patients' demographic and clinical information, medication history, and use of concomitant medications were recorded. The proportion of patients with clinically significant RSCL score for a particular symptom was compared with the percentage of patients receiving medication for that symptom. RESULTS The mean age was 57.3 ± 15.2 years, with majority of the patients diagnosed with stromal tumor (46.8 %), leiomyosarcoma (15.2 %), and liposarcoma (10.1 %). The most prevalent physical symptoms experienced were tiredness (2.38 ± 1.00), lack of energy (2.04 ± 1.02), and difficulty sleeping (2.00 ± 1.15). The most common psychological symptoms experienced were irritability (1.92 ± 1.01), worrying (1.86 ± 0.90), and anxiety (1.68 ± 0.74). Few (6.3 %) patients received hypnotics while 33.0 % of patients reported difficulty sleeping. A proportion of patients (27.9 %) reported experiencing lack of appetite with only 1.3 % received appetite stimulants. CONCLUSION Adult sarcoma patients experience significant physiological and psychological symptom burden, which has a strong negative impact on HRQoL, with a number of physiological symptoms undertreated with pharmacotherapy.
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Affiliation(s)
- Alexandre Chan
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science 4, Block S4, Singapore, 117543, Singapore,
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16
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Sigurdardottir KR, Oldervoll L, Hjermstad MJ, Kaasa S, Knudsen AK, Løhre ET, Loge JH, Haugen DF. How are palliative care cancer populations characterized in randomized controlled trials? A literature review. J Pain Symptom Manage 2014; 47:906-914.e17. [PMID: 24018205 DOI: 10.1016/j.jpainsymman.2013.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 06/05/2013] [Accepted: 06/14/2013] [Indexed: 02/08/2023]
Abstract
CONTEXT The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research. OBJECTIVES To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs). METHODS The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles. RESULTS The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported. CONCLUSION A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population.
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Affiliation(s)
- Katrin Ruth Sigurdardottir
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Sunniva Centre for Palliative Care, Haraldsplass Deaconess Hospital, Bergen, Norway; Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway.
| | - Line Oldervoll
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Røros Rehabilitation Centre, Røros, Norway
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Regional Centre for Excellence in Palliative Care, South Eastern Norway, Oslo University Hospital, Oslo, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne Kari Knudsen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erik Torbjørn Løhre
- Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jon Håvard Loge
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; National Resource Centre for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Dagny Faksvåg Haugen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
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Tan CR, Yaffee PM, Jamil LH, Lo SK, Nissen N, Pandol SJ, Tuli R, Hendifar AE. Pancreatic cancer cachexia: a review of mechanisms and therapeutics. Front Physiol 2014; 5:88. [PMID: 24624094 PMCID: PMC3939686 DOI: 10.3389/fphys.2014.00088] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 02/13/2014] [Indexed: 12/18/2022] Open
Abstract
Over the last decade, we have gained new insight into the pathophysiology of cachexia associated with pancreatic cancer. Unfortunately, its treatment is complex and remains a challenge. Pancreatic cancer cachexia is a multifactorial syndrome characterized by uncompensated adipose tissue and skeletal muscle loss in the setting of anorexia that leads to progressive functional impairment. This paper will review the current concepts of pancreatic cancer cachexia, its assessment and pathophysiology as well as current and future treatments. The successful management of pancreatic cancer cachexia will likely require a multimodal approach that includes nutritional support and combination pharmaceutical interventions.
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Affiliation(s)
- Carlyn R Tan
- Samuel Oschin Comprehensive Cancer Center, Cedars Sinai Medical Center Los Angeles, CA, USA
| | - Patrick M Yaffee
- Samuel Oschin Comprehensive Cancer Center, Cedars Sinai Medical Center Los Angeles, CA, USA
| | - Laith H Jamil
- Department of Medicine, David Geffen School of Medicine Los Angeles, CA, USA
| | - Simon K Lo
- Department of Medicine, Cedars Sinai Medical Center Los Angeles, CA, USA
| | - Nicholas Nissen
- Samuel Oschin Comprehensive Cancer Center, Cedars Sinai Medical Center Los Angeles, CA, USA
| | - Stephen J Pandol
- Department of Medicine, Cedars Sinai Medical Center Los Angeles, CA, USA
| | - Richard Tuli
- Samuel Oschin Comprehensive Cancer Center, Cedars Sinai Medical Center Los Angeles, CA, USA
| | - Andrew E Hendifar
- Samuel Oschin Comprehensive Cancer Center, Cedars Sinai Medical Center Los Angeles, CA, USA ; Department of Medicine, David Geffen School of Medicine Los Angeles, CA, USA
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Li F, Zou XJ, Zheng H, Xiang Y. LC-MS/MS method for determination of megestrol in human plasma and its application in bioequivalence study. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2013; 33:912-916. [PMID: 24337858 DOI: 10.1007/s11596-013-1221-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/10/2013] [Indexed: 06/03/2023]
Abstract
A rapid and highly selective liquid chromatography-tandem mass spectrometric (LC-MS/MS) method for the determination of megestrol in human plasma was described using medrysone as internal standard (IS). Blood samples were collected from 20 healthy volunteers after oral administration of 160 mg megestrol acetate dispersible tablets. The analytes were extracted by liquid-liquid extraction procedure and separated on a hanbon lichrospher column with the mobile phase of methanol and water containing 0.1% formic acid and 20 mmol/L ammonium acetate (5:1, v/v). Positive ion electrospray ionization with multiple reaction-monitoring mode (MRM) was employed by monitoring the transitions m/z 385.5-325.4 and m/z 387.5-327.4 for megestrol and medrysone, respectively. Under the isocratic separation conditions, the chromatographic run time was approximately 2.54 min for megestrol and 2.59 min for medrysone. The calibration curve range was from 0.5 to 200.0 ng/mL. The inter-batch and intra-batch precision and accuracy were less than 5.2% relative standard deviation (RSD) and 6.4% relative error (RE). The proposed method was successfully applied in the bioequivalence study of megestrol acetate dispersible tablets.
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Affiliation(s)
- Fan Li
- College of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiao-Juan Zou
- College of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Heng Zheng
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yi Xiang
- College of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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A systematic review of health-related quality of life instruments in patients with cancer cachexia. Support Care Cancer 2013; 21:2625-36. [PMID: 23797577 DOI: 10.1007/s00520-013-1881-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/06/2013] [Indexed: 01/06/2023]
Abstract
PURPOSE Assessing the health-related quality of life (HRQOL) of cancer patients with cachexia is particularly important because treatments for cachexia are currently aimed at palliation and treatment efficacy must be measured in ways other than survival. The aim of this systematic review was to evaluate HRQOL assessment in cancer patients with cachexia. METHODS Using guidance from the Centre for Reviews and Dissemination, relevant databases were searched from January 1980 to January 2012 with terms relating to cancer, cachexia and HRQOL for papers including adult cancer patients with cachexia or documented weight loss at baseline. RESULTS We found one cachexia-specific instrument, the Functional Assessment of Anorexia/Cachexia Therapy, but the tool has not been fully validated, does not cover all the relevant domains and the consensus-based standards for the selection of health status measurement instruments checklist highlighted a number of weaknesses in the methodological quality of the validation study. Sixty-seven studies assessed HRQOL in cachectic or weight-losing cancer patients. Most used generic cancer HRQOL instruments, limiting the amount of useful information they provide. A modified version of the Efficace minimum data checklist demonstrated that the quality of reporting on HRQOL tool use was inadequate in many of the studies. A negative relationship between HRQOL and weight loss was found in 23 of the 27 studies which directly examined this. CONCLUSION There is a pressing need for a well-designed HRQOL tool for use with this patient group in both clinical trials and clinical practice.
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Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Marti S. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev 2013; 2013:CD004310. [PMID: 23543530 PMCID: PMC6418472 DOI: 10.1002/14651858.cd004310.pub3] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND This is an updated version of a previously published review in The Cochrane Library (2005, Issue 2) on 'Megestrol acetate for the treatment of anorexia-cachexia syndrome'. Megestrol acetate (MA) is currently used to improve appetite and to increase weight in cancer-associated anorexia. In 1993, MA was approved by the US Food and Drug Administration for the treatment of anorexia, cachexia or unexplained weight loss in patients with AIDS. The mechanism by which MA increases appetite is unknown and its effectiveness for anorexia and cachexia in neoplastic and AIDS (acquired immunodeficiency syndrome) patients is under investigation. OBJECTIVES To evaluate the efficacy, effectiveness and safety of MA in palliating anorexia-cachexia syndrome in patients with cancer, AIDS and other underlying pathologies. SEARCH METHODS We sought studies through an extensive search of electronic databases, journals, reference lists, contact with investigators and other search strategies outlined in the methods. The most recent search for this update was carried out in May 2012. SELECTION CRITERIA Studies were included in the review if they assessed MA compared to placebo or other drug treatments in randomised controlled trials of patients with a clinical diagnosis of anorexia-cachexia syndrome related to cancer, AIDS or any other underlying pathology. DATA COLLECTION AND ANALYSIS Two independent review authors conducted data extraction and evaluated methodological quality. We performed quantitative analyses using appetite and quality of life as a dichotomous variable, and analysed weight gain as continuous and dichotomous variables. MAIN RESULTS We included 35 trials in this update, the same number but not the same trials as in the previous version of the review. The trials comprised 3963 patients for effectiveness and 3180 for safety. Sixteen trials compared MA at different doses with placebo, seven trials compared different doses of MA with other drug treatments and 10 trials compared different doses of MA. Meta-analysis showed a benefit of MA compared with placebo, particularly with regard to appetite improvement and weight gain in cancer, AIDS and other underlying conditions, and lack of benefit in the same patients when MA was compared to other drugs. There was insufficient information to define the optimal dose of MA, but higher doses were more related to weight improvement than lower doses. Quality of life improvement in patients was seen only when comparing MA versus placebo but not other drugs in both subcategories: cancer and AIDS. Oedema, thromboembolic phenomena and deaths were more frequent in the patients treated with MA. More than 40 side effects were studied. AUTHORS' CONCLUSIONS This review shows that MA improves appetite and is associated with slight weight gain in cancer, AIDS and in patients with other underlying pathology. Despite the fact that these patients are receiving palliative care they should be informed of the risks involved in taking MA.
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Affiliation(s)
- Vicente Ruiz Garcia
- Unidad de Hospitalización a Domicilio & CASP Spain, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
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21
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Nutrition chez le patient adulte atteint de cancer : orexigènes et autres médicaments anticachectisants. NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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22
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The impact of individual quality of life assessment on psychosocial attention in patients with chest malignancies: a randomized study. Support Care Cancer 2012; 21:87-95. [DOI: 10.1007/s00520-012-1496-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 05/09/2012] [Indexed: 11/12/2022]
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Chow PKH, Machin D, Chen Y, Zhang X, Win KM, Hoang HH, Nguyen BD, Jin MY, Lobo R, Findlay M, Lim CH, Tan SB, Gandhi M, Soo KC. Randomised double-blind trial of megestrol acetate vs placebo in treatment-naive advanced hepatocellular carcinoma. Br J Cancer 2011; 105:945-52. [PMID: 21863030 PMCID: PMC3185948 DOI: 10.1038/bjc.2011.333] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths worldwide. We tested megestrol acetate (MA) against placebo in the treatment of advanced HCC. Methods: From 2002 through 2007, this randomised double-blind trial enrolled 204 patients with treatment-naive advanced HCC (Eastern Cooperative Oncology Group (ECOG) performance rating of 0-3) from specialist care centres in six Asia-Pacific nations. Patients received placebo or MA (320 mg day−1). End points were overall survival (OS) and quality of life. Results: An adverse but not statistically significant difference in OS was found for MA vs placebo: median values 1.88 and 2.14 months, respectively (hazard ratio (HR)=1.25, 95% CI=0.92–1.71, P=0.16). However, OS was similar among patients of good functional status (Child-Pugh A and ECOG 0, 1 or 2) (44.3%) in both treatment groups, with the adverse effect of MA confined to those of poor status. Megestrol acetate patients had a worse global health status (not statistically significant) but reduced levels of appetite loss and nausea/vomiting. Conclusion: Megestrol acetate has no role in prolonging OS in advanced treatment-naive HCC. Overall survival with placebo differed markedly from that in similar trials conducted elsewhere, suggesting therapeutic outcomes may be strongly dependent on ECOG status and Child-Pugh score.
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Affiliation(s)
- P K H Chow
- Department of General Surgery, Singapore General Hospital, Outram Road, 169608 Singapore.
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Minton O, Richardson A, Sharpe M, Hotopf M, Stone P. Drug therapy for the management of cancer-related fatigue. Cochrane Database Syst Rev 2010:CD006704. [PMID: 20614448 DOI: 10.1002/14651858.cd006704.pub3] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in issue 1 2008 (Minton 2008). Cancer-related fatigue (CRF) is common, under-recognised and difficult to treat. There have been studies looking at drug interventions to improve CRF but results have been conflicting depending on the population studied and outcome measures used. No previous reviews of this topic have been exhaustive or have synthesised all available data. OBJECTIVES To assess the efficacy of drugs for the management of CRF. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (from Issue 2 2007) MEDLINE and EMBASE from January 2007 to October 2009 and a selection of cancer journals. We searched references of identified articles and contacted authors to obtain unreported data. SELECTION CRITERIA Studies were included in the review if they 1) assessed drug therapy for the management of CRF compared to placebo, usual care or a non-pharmacological intervention in 2) randomised controlled trials (RCT) of 3) adult patients with a clinical diagnosis of cancer. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. Meta-analyses were performed on different drug classes using continuous variable data. MAIN RESULTS Fifty studies met the inclusion criteria. Six additional studies were identified since the original review. Only 31 of these studies involving 7104 participants were judged to have used a sufficiently robust measure of fatigue and thus were deemed suitable for detailed analysis. The drugs were still analysed by class (psychostimulants; haemopoietic growth factors; antidepressants and progestational steroids). Methylphenidate showed a small but significant improvement in fatigue over placebo (Z = 2.83; P = 0.005). Since the publication of the original review increased safety concerns have been raised regarding erythropoietin and this cannot now be recommended in practice.There was a very high degree of statistical and clinical heterogeneity in the trials and the reasons for this are discussed. AUTHORS' CONCLUSIONS There is increasing evidence that psychostimulant trials provide evidence for improvement in CRF at a clinically meaningful level. There is still a requirement for a large scale RCT of methylphenidate to confirm the preliminary results from this review. There is new safety data which indicates that the haemopoietic growth factors are associated with increased adverse outcomes. These drugs can no longer be recommended in the treatment of CRF. Readers of the first review should re-read the document in full.
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Affiliation(s)
- Ollie Minton
- Division of Mental Health, St George's University of London, Cranmer Terrace, London, UK, SW17 0RE
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25
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Penel N, Clisant S, Dansin E, Desauw C, Dégardin M, Mortier L, Vanhuyse M, Bonodeau F, Fournier C, Cazin JL, Adenis A. Megestrol acetate versus metronomic cyclophosphamide in patients having exhausted all effective therapies under standard care. Br J Cancer 2010; 102:1207-12. [PMID: 20354522 PMCID: PMC2856003 DOI: 10.1038/sj.bjc.6605623] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: To evaluate the antitumour activity and safety of metronomic cyclophosphamide vs megestrol acetate in progressive and advanced cancer patients having exhausted all effective therapies under standard care. Methods: Patients were randomly assigned to receive orally metronomic cyclophosphamide (50 mg b.i.d) or megestrol acetate (160 mg only daily) until intolerance or progression (RECIST 1.0). The primary efficacy end point was a 2-month progression-free rate (PFR2m). According to Optimal Simon's design and the following assumptions, namely, P0=5%, P1=20%, α=β=10%, the treatment is considered as effective if atleast 5 out of 44 patients achieved PFR2m. Results: Between September 2006 and January 2009, 88 patients were enrolled. Two patients experienced grade 3–4 toxicities in each arm (4%). One toxic death occurred in the megestrol acetate arm as a consequence of thrombosis. The metronomic cyclophosphamide arm reached the predefined level of efficacy with a PFR2m rate of 9 out of 44 and a PFR4m rate of 5 out of 44. The MA arm failed to achieve the level of efficacy with a PFR2m of 4 out of 44 and a PFR4m of 1 out of 44. The median overall survival was 195 and 144 days in the metronomic cyclophosphamide arm and megestrol acetate arm, respectively. Conclusion: Metronomic cyclophosphamide is well tolerated and provides stable disease in such vulnerable and poor-prognosis cancer patients. This regimen warrants further evaluations.
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Affiliation(s)
- N Penel
- Centre Oscar Lambret, Lille, France.
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Riechelmann RP, Burman D, Tannock IF, Rodin G, Zimmermann C. Phase II Trial of Mirtazapine for Cancer-Related Cachexia and Anorexia. Am J Hosp Palliat Care 2009; 27:106-10. [DOI: 10.1177/1049909109345685] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We performed an open-label single-institution phase II trial of mirtazapine (15-30 mg by mouth [po] every day [qd]), a tetracyclic antidepressant that may lead to weight gain, for 8 weeks in nondepressed patients with cancer-related cachexia/anorexia (CRCA). The primary end point was the proportion of patients who gained ≥1 kg at week 4. Secondary end points were quality of life and appetite. From June 2006 to July 2007, 17 of 58 eligible patients were enrolled. On intention-to-treat analysis at week 4, 4 of 17 patients (24%) gained 1 kg or more, 1 patient maintained weight (gain of 400 g) and 2 patients lost weight (800 g and 1.2 kg); 24% and 6% improved appetite and health-related quality of life (HQOL), respectively. Mirtazapine is a promising agent for the treatment of CRCA.
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Affiliation(s)
- Rachel P. Riechelmann
- Department of Medical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Canada,
| | - Debika Burman
- Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Ian F. Tannock
- Department of Medical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Gary Rodin
- Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University of Toronto, Toronto, Canada
| | - Camilla Zimmermann
- Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University of Toronto, Toronto, Canada
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Abstract
Fatigue is a common symptom of advanced cancer limiting one's activity and affecting the quality of life. It is a multidimensional symptom complex with subjective and objective components. Hence, its definition and assessment seems arbitrary, incomplete, and elusive. Components of fatigue often merge with other 'disease states' as anemia, depression and so on, compounding difficulty to assess it separately. Fatigue has a high prevalence rate, and lasts longer in chronic diseases like cancer. Its association with treatment modalities like chemotherapy, radiotherapy alongside the primary disease process makes it seemingly ubiquitous in many cases. Systemic manifestation of cancer causes excess demand on body resources on cell repair, uncontrolled growth with metabolite accumulation causing fatigue. Co-morbid conditions of organic and psychological nature causes fatigue. There are many assessment tools for fatigue with different uses and objectives, simple and reproducible tools like Brief Fatigue Inventory, Edmonton Symptom assessment scale seem feasible in everyday practice. Management of fatigue is not straightforward and rewarding. Although treatment of cause appears to be an attractive option, it is not possible in all cases. Therapeutic agents targeting cytokine load is in early stages of study and available results are not favorable. Specific measures aimed at pain relief, prevention/treatment of sepsis, management of depression, avoidance of drugs causing fatigue, restoring the metabolic profile are important. Methyl phenidate, megestrol, and modafinil are some drugs with promising effect to treat fatigue, though confirmatory studies are yet to be established. Non-pharmacological methods are also helpful. Forewarning patients on upcoming fatigue, active regular exercise, and stress management are some of them. Fatigue being a multidimensional entity, single mode of therapy is insufficient. Combined modality tailored to individual patient need and understanding may be the right way to battle this ill-understood symptom. This review article examines the etiopathogenesis and management strategies of fatigue in cancer.
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Affiliation(s)
- Vijayakumar Narayanan
- Department of Oncology, St. Gregorios Medical Mission Hospital, Parumala, Pathanamthitta, India
| | - Cherian Koshy
- Department of Palliative Care, Regional Cancer Centre, Thiruvanathapuram, Kerala, India
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von Haehling S, Lainscak M, Springer J, Anker SD. Cardiac cachexia: a systematic overview. Pharmacol Ther 2008; 121:227-52. [PMID: 19061914 DOI: 10.1016/j.pharmthera.2008.09.009] [Citation(s) in RCA: 255] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2008] [Accepted: 09/03/2008] [Indexed: 01/10/2023]
Abstract
Cardiac cachexia as a terminal stage of chronic heart failure carries a poor prognosis. The definition of this clinical syndrome has been a matter of debate in recent years. This review describes the ongoing discussion about this issue and the complex pathophysiology of cardiac cachexia and chronic heart failure with particular focus on immunological, metabolic, and hormonal aspects at the intracellular and extracellular level. These include regulators such as neuropeptide Y, leptin, melanocortins, ghrelin, growth hormone, and insulin. The regulation of feeding is discussed as are nutritional aspects in the treatment of the disease. The mechanisms of wasting in different body compartments are described. Moreover, we discuss several therapeutic approaches. These include appetite stimulants like megestrol acetate, medroxyprogesterone acetate, and cannabinoids. Other drug classes of interest comprise angiotensin-converting enzyme inhibitors, beta-blockers, anabolic steroids, beta-adrenergic agonists, anti-inflammatory substances, statins, thalidomide, proteasome inhibitors, and pentoxifylline.
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Affiliation(s)
- Stephan von Haehling
- Applied Cachexia Research, Department of Cardiology, Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany.
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Minton O, Richardson A, Sharpe M, Hotopf M, Stone P. A Systematic Review and Meta-Analysis of the Pharmacological Treatment of Cancer-Related Fatigue. J Natl Cancer Inst 2008; 100:1155-66. [DOI: 10.1093/jnci/djn250] [Citation(s) in RCA: 195] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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30
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Abstract
Cystic fibrosis (CF) is an autosomal recessive disease. It affects multiple body organs. The lungs and pancreas are the most affected which results in progressive lung damage and pancreatic insufficiency. Due to the disease process, CF patients require significantly higher caloric intake than recommended for other individuals. The nutritional goal for CF patients is to achieve normal growth and development and, once genetic potential is reached, to maintain good nutritional status throughout life. Evidence has shown that lung function is closely associated with nutritional status in CF and that nutritional status is an independent predictor of survival. Most CF patients are on a high calorie diet to help achieve normal growth and development and maintain good lung function. Inadequate caloric intake in CF can lead to malnutrition. Malnutrition in CF requires careful, multidisciplinary history taking, physical exam, and overall patient/family assessment. Only by determining the actual cause of the malnutrition can appropriate and safe therapies be used to treat it. Appetite stimulants, although efficacious in treating malnutrition in CF, should only be prescribed if decreased food intake secondary to inadequate appetite is the principal cause of the malnutrition and all other contributing factors have been assessed, ruled-out or treated. In this review, we attempted to summarize the use of several appetite stimulants used in CF and other diseases to improve appetite and maximize caloric intake.
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Affiliation(s)
- Samya Z Nasr
- Pediatric Pulmonology, University of Michigan Health System, Ann Arbor, Michigan 48109-5212, USA.
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31
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Minton O, Stone P, Richardson A, Sharpe M, Hotopf M. Drug therapy for the management of cancer related fatigue. Cochrane Database Syst Rev 2008:CD006704. [PMID: 18254112 DOI: 10.1002/14651858.cd006704.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cancer related fatigue (CRF) is common, under-recognised and difficult to treat. There have been trials looking at drug interventions to improve CRF but results have been conflicting depending on the population studied and outcome measures used. No previous reviews of this topic have been exhaustive or have synthesised all available data. OBJECTIVES To assess the efficacy of drugs for the management of CRF. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (1st Quarter 2007), MEDLINE (1966 to March 2007) and a selection of cancer journals. We searched references of identified articles and contacted authors to obtain unreported data. SELECTION CRITERIA Trials were included in the review if they 1) assessed drug therapy for the management of CRF compared to placebo, usual care or a non-pharmacological intervention in 2) randomised controlled trials (RCT) of 3) adult patients with a clinical diagnosis of cancer. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. Meta-analyses were performed on different drug classes using continuous variable data. MAIN RESULTS Forty-five trials met the inclusion criteria. Only 27 of these trials involving 6746 participants were judged to have used a sufficiently robust measure of fatigue and thus were deemed suitable for detailed analysis. The drugs were analysed by class (psychostimulants; haemopoetic growth factors; antidepressants and progestational steroids). Methylphenidate showed a small but significant improvement in fatigue over placebo (Z = 2.40; P = 0.02). Erythropoietin showed a small but significant improvement in fatigue (for anaemic patients receiving chemotherapy) compared to placebo (Z = 2.67; P = 0.008). Darbopoietin also demonstrated a smaller but significant improvement in fatigue over placebo (Z = 1.96; P = 0.05). Paroxetine and progestational steroids demonstrated no superiority over placebo in treating CRF. There was a very high degree of statistical and clinical heterogeneity in the trials and the reasons for this are discussed. It was not possible to determine optimum doses as a result of this review. AUTHORS' CONCLUSIONS Erythropoietin and darbopoetin (for anaemic patients on chemotherapy) and psychostimulant trials provide evidence for improvement in CRF at a clinically meaningful level. There are no data to support the use of paroxetine or progestational steroids for the treatment of CRF. The obvious candidate drug for use in a large scale RCT is methylphenidate to confirm the preliminary results from this review.
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Affiliation(s)
- O Minton
- St George's University of London, Division of Mental Health, Cranmer Terrace, London, UK, SW17 0RE.
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Radbruch L, Strasser F, Elsner F, Gonçalves JF, Løge J, Kaasa S, Nauck F, Stone P. Fatigue in palliative care patients -- an EAPC approach. Palliat Med 2008; 22:13-32. [PMID: 18216074 DOI: 10.1177/0269216307085183] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Fatigue is one of the most frequent symptoms in palliative care patients, reported in .80% of cancer patients and in up to 99% of patients following radio- or chemotherapy. Fatigue also plays a major role in palliative care for noncancer patients, with large percentages of patients with HIV, multiple sclerosis, chronic obstructive pulmonary disease or heart failure reporting fatigue. This paper presents the position of an expert working group of the European Association for Palliative Care (EAPC), evaluating the available evidence on diagnosis and treatment of fatigue in palliative care patients and providing the basis for future discussions. As the expert group feels that culture and language influence the approach to fatigue in different European countries, a focus was on cultural issues in the assessment and treatment of fatigue in palliative care. As a working definition, fatigue was defined as a subjective feeling of tiredness, weakness or lack of energy. Qualitative differences between fatigue in cancer patients and in healthy controls have been proposed, but these differences seem to be only an expression of the overwhelming intensity of cancer-related fatigue. The pathophysiology of fatigue in palliative care patients is not fully understood. For a systematic approach, primary fatigue, most probably related to high load of proinflammatory cytokines and secondary fatigue from concurrent syndromes and comorbidities may be differentiated. Fatigue is generally recognized as a multidimensional construct, with a physical and cognitive dimension acknowledged by all authors. As fatigue is an inherent word only in the English and French language, but not in other European languages, screening for fatigue should include questions on weakness as a paraphrase for the physical dimension and on tiredness as a paraphrase for the cognitive dimension. Treatment of fatigue should include causal interventions for secondary fatigue and symptomatic treatment with pharmacological and nonpharmacological interventions. Strong evidence has been accumulated that aerobic exercise will reduce fatigue levels in cancer survivors and patients receiving cancer treatment. In the final stage of life, fatigue may provide protection and shielding from suffering for the patient and thus treatment may be detrimental. Identification of the time point, where treatment of fatigue is no longer indicated is important to alleviate distress at the end of life.
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Affiliation(s)
- Lukas Radbruch
- Department of Palliative Medicine, RWTH Aachen University, Aachen, Germany.
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Yavuzsen T, Davis MP, Walsh D, LeGrand S, Lagman R. Systematic Review of the Treatment of Cancer-Associated Anorexia and Weight Loss. J Clin Oncol 2005; 23:8500-11. [PMID: 16293879 DOI: 10.1200/jco.2005.01.8010] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose We systematically assessed the efficacy and safety of appetite stimulants in the management of cancer-related anorexia. Literature databases were searched for randomized controlled trials of appetite stimulants in the treatment of cancer anorexia. Materials and Methods Studies were graded according to quality. Fifty-five studies met inclusion criteria. Results Only two drugs have evidence to support their use for anorexia (progestins and corticosteroids). There is strong evidence against the use of hydrazine sulfate. The outcomes of these trials have been mixed and patient population heterogeneous. Conclusion The optimal dose, time to start, and duration of treatment for many appetite stimulants for cancer anorexia is still unknown. A more systematic approach to research methodology with universal outcome measure and prospective randomized studies are needed. Combination regimens are needed but this cannot at the present time be supported by the data presented.
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Affiliation(s)
- Tugba Yavuzsen
- Harry R. Horvitz Center for Palliative Medicine, The Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Dahele M, Wall L. Optimizing End Points and Outcomes in Cancer-Associated Wasting. J Clin Oncol 2005; 23:2871-2; author reply 2872-3. [PMID: 15838010 DOI: 10.1200/jco.2005.05.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
BACKGROUND Megestrol acetate (MA) is currently used to improve appetite and to increase weight in cancer-associated anorexia. In 1993 MA was approved by the USA's Federal Drug Administration for the treatment of anorexia, cachexia, or unexplained weight loss in patients with AIDS. The mechanism by which MA increases appetite is unknown, and its effectiveness for anorexia and cachexia in neoplastic and AIDS patients is under investigation. OBJECTIVES To evaluate the efficacy, effectiveness and safety of MA in palliating anorexia-cachexia syndrome in patients with cancer, AIDS and other underlying pathologies. SEARCH STRATEGY Studies were sought thorough an extensive search of the electronic databases, journals, reference lists, contact with investigators and other search strategies outlined in the methods. The most recent search was carried out on October 2002. SELECTION CRITERIA Studies were included in the review if they assessed megestrol acetate compared to placebo or other drug treatments in randomized controlled trials of patients with a clinical diagnosis of anorexia-cachexia related to cancer, AIDS or another underlying pathology. DATA COLLECTION AND ANALYSIS Data extraction was conducted by two independent authors, and methodological quality evaluated. Quantitative analyses were performed using appetite and quality of life as a dichotomous variable, and weight gain was analysed as continuous and dichotomous variables. Studies with more than 50% of patients lost to follow-up were excluded from the analysis. MAIN RESULTS Thirty trials met the inclusion criteria (4123 patients). Twenty-one trials compared MA at different doses with placebo; four compared different doses of MA versus other drugs; two compared MA with other drugs and placebo; and three compared different doses of MA. For all patient conditions, meta-analysis showed a benefit of MA compared with placebo, particularly with regard to appetite improvement and weight gain in cancer patients. Analysing quality of life, clinical and statistical heterogeneity was found and discussed. There was insufficient information to define the optimal dose of MA. AUTHORS' CONCLUSIONS This review demonstrates that MA improves appetite and weight gain in patients with cancer. No overall conclusion about quality of life (QOL) could be drawn due to heterogeneity. The small number of patients, methodological shortcomings and poor reporting have not allowed us to recommend megestrol acetate in AIDS patients or with other underlying pathologies.
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Affiliation(s)
- E G Berenstein
- Epidemiology Department, Alejandro Posadas National Hospital, Alvea 1097, 1714 Buenos Aires, Argentina
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Abstract
PURPOSE Hepatocellular carcinoma (HCC) is generally considered as a sex hormone-dependent tumor, and hormonal therapy has been proposed as a strategy for the treatment of HCC. The aim of the study is to investigate the effect of megestrol acetate, a synthetic progesteronal agent, on growth of HepG2 cells in vitro and in vivo. EXPERIMENTAL DESIGN Cell growth in vitro was assessed by a colormetric method, and cell growth in vivo was assessed by tumor volumetrics. RESULTS Megestrol acetate was shown to inhibit the growth of HepG2 cells in vitro in dose- and time-dependent manners with an IC (50) of 260 microm (24-h incubation). The growth of HepG2 cell-transplanted tumors in nude mice was also inhibited by i.p. injection of megestrol acetate (10 mg/kg/day). The tumor volumes of the megestrol acetate-treated group regressed to 59% of controls by week 6 and to 41% of controls by week 13. Apoptosis following G(1) arrest was observed in megestrol acetate-treated cells and may be a mechanism through which megestrol acetate inhibits HepG2 cells. Megestrol acetate was also demonstrated to have a beneficial effect on the weight gain of tumor-bearing nude mice, and the mean weight of the megestrol acetate-treated animals was higher than that of controls from week 4 of the treatment period, and the differences were statistically significant in week 5 and 6 (P < 0.05, compared with controls). No significant survival advantage was, however, demonstrated in the treatment group. CONCLUSIONS This study showed that megestrol acetate inhibited the growth of HepG2 cells grown in vitro and in vivo. These data provide useful information for clinical study of megestrol acetate for the treatment of HCC.
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Affiliation(s)
- Kai Zhang
- Department of Experimental Surgery and Department of General Surgery, Singapore General Hospital, Singapore.
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Tassinari D, Maltoni M, Sartori S, Fantini M, Poggi B, Ravaioli A. Outcome research in palliative care: could it represent a new dimension of clinical research or clinical practice? Support Care Cancer 2004; 13:176-81. [PMID: 15580363 DOI: 10.1007/s00520-004-0683-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2003] [Accepted: 07/27/2004] [Indexed: 02/04/2023]
Abstract
Outcome research is a new dimension of clinical research, and all fields of clinical medicine are involved in this kind of analysis. Overall survival and quality of life are the main outcomes identified in clinical oncology. The former must be the main outcome whenever possible; the latter has to be the main outcome when an improvement of overall survival cannot be expected. It follows that quality of life is the main outcome of palliative care, in which the patient instead of the disease represents the target of the clinical approach. In our critical paper, we review the meaning of clinical outcomes in palliative care, classifying the outcomes as main and surrogate outcomes, and the results of the trials as indexes of activity and efficacy of a treatment. We also review the main randomized clinical trials on the treatment of cancer cachexia, trying to define the role of the treatments in cachexia-related symptom control and quality of life improvement. Strictly related to outcome analysis is the dimension of pharmacoeconomic evaluation. The models of the different designs of pharmacoeconomic analysis are revisited in an attempt to conjugate the pharmacoeconomic evaluation with the particular dimension of palliative care.
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Pascual López A, Roqué i Figuls M, Urrútia Cuchi G, Berenstein EG, Almenar Pasies B, Balcells Alegre M, Herdman M. Systematic review of megestrol acetate in the treatment of anorexia-cachexia syndrome. J Pain Symptom Manage 2004; 27:360-9. [PMID: 15050664 DOI: 10.1016/j.jpainsymman.2003.09.007] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2003] [Indexed: 11/18/2022]
Abstract
This study aimed to assess the efficacy and safety of megestrol acetate (MA) in anorexia-cachexia syndrome (ACS). Literature and relevant databases were searched for randomized controlled trials of MA to treat ACS in patients with cancer, AIDS, or other pathologies. Data were extracted by two independent reviewers, and meta-analyses were performed where possible. Twenty-six studies were included (n=3,887). Compared to placebo, MA increased appetite in oncology patients [RR=2.31 (95% CI 1.52-3.59)], led to weight gain [RR=1.88 (95% CI 1.43-2.47)] and improved HRQOL [RR=1.52 (95% CI 1.00-2.30)]. In AIDS patients, it increased weight [RR=2.16 (95% CI 1.45-3.21)]. MA showed significant benefits over dronabinol in improving appetite, but no statistically significant advantages over other drugs for treating ACS were observed. There were no appreciable differences between lower (<800 mg/day) and higher (>800 mg/day) doses of MA. Few serious adverse events were recorded. MA is an effective and safe treatment for ACS in cancer and AIDS patients, particularly in terms of improvement in appetite and weight gain.
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Abstract
BACKGROUND Previous studies have suggested that placebo treatment can have positive effects on a variety of disorders and disease-related symptoms. However, the methodology used to collect and interpret the data may not have been ideal, because the studies were not double-blinded or the endpoints were not properly validated. The purpose of the present study was to determine the probability of improvement in symptoms or quality of life and tumor response in cancer patients treated with placebos in randomized controlled trials. We hypothesized that administration of placebos would improve symptom control and quality of life but would not lead to tumor response. METHODS We reviewed reports of randomized controlled trials in which there was a placebo arm (37 trials) or a best supportive care (BSC) arm (10 trials). RESULTS In trials that assessed average responses for patients in the placebo arm, improvements in average levels of pain were reported in two of six trials and in appetite, in one of seven trials. No improvements in average levels of weight gain (six trials), in quality of life (as assessed by patients; 10 trials), or in performance status (as assessed by physicians; nine trials) were reported. In trials that assessed response to a placebo in individual patients, 0%-21% of patients showed reduced pain or decreased analgesic intake, 8%-27% of patients showed appetite improvement, 7%-17% of patients showed weight gain, and 6%-14% of patients showed improvement in performance status. Quality of life for individual patients was not reported in any trial. Tumor response assessed by World Health Organization criteria was observed in 10 (2.7%) of 375 patients (seven trials total). Response as assessed by a serum marker was observed in 1 (1.7%) of 60 patients (two trials total). The probability of symptom improvement in patients receiving BSC was generally similar to that in patients receiving placebo, although no improvement in pain and only one tumor response among 191 patients (five trials) were reported. CONCLUSION In randomized double-blinded, placebo-controlled trials, presumably with minimum sources of bias, placebos are sometimes associated with improved control of symptoms such as pain and appetite but rarely with positive tumor response. Substantial improvements in symptoms and quality of life are unlikely to be due to placebo effects.
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Affiliation(s)
- Gisèle Chvetzoff
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France
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Abstract
Anorexia and weight loss represent a major cause of morbidity and mortality. At present in the United States two effective anorectic agents are commonly used, namely, megestrol acetate and dronabinol. These two agents are compared in Table 1. In persons with a large excess cytokine production. megestrol acetate should be tried at a does of 800 mg per day for no longer than 3 months. Megestrol acetate should be administered with testosterone in men. It should be avoided in persons who are bed-bound because of the risk of deep vein thrombosis. Dronabinol should be used for most anorectic patients. Dronabinol should initially be given in a low dose (2.5 mg) in the evening. The dose should be increased to 5 mg per day if no improvement in appetite is seen after 2 to 4 weeks. Dronabinol can be continued indefinitely. It seems to have a particularly good profile for persons with anorexia who are at the end of life. In persons with depression and anorexia. mirtazapine seems to be the antidepressant of choice. In addition, the use of taste enhancers can be considered in persons who complain that the food does not taste good. The appropriate use of anabolic agents in older persons with weight loss is controversial. Certainly all older men who are losing weight should have bioavailable testosterone measured and, if the testosterone level is low, should receive testosterone replacement therapy. Women who are losing weight may benefit from the use of low-dose testosterone (eg, Estratest). Anabolic agents, such as oxandrolone, should be reserved for those who have profound cachexia. An approach to the management of anorexia and weight loss in older persons is given in Fig. 1. Thomas et al have provided a more complex algorithm the management of weight loss in nursing home residents.
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Affiliation(s)
- John E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 South Grand Boulevard M238, Saint Louis, MO 63104, USA.
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Maltoni M, Nanni O, Scarpi E, Rossi D, Serra P, Amadori D. High-dose progestins for the treatment of cancer anorexia-cachexia syndrome: a systematic review of randomised clinical trials. Ann Oncol 2001; 12:289-300. [PMID: 11332139 DOI: 10.1023/a:1011156811739] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The aim of the present study was to summarise evidence from scientific studies on cancer anorexia-cachexia syndrome in order to assess and highlight the efficacy of high-dose progestins (megestrol acetate and medroxyprogesterone acetate) compared with placebo in patients with hormone-independent tumors. MATERIALS AND METHODS A systematic review of published randomised clinical trials was carried out by an extensive electronic and hand search through databases, relevant journals and books, congress, proceedings, reference lists, without any language or year of publication restriction. The research was conducted by two independent operators who collected the data in a form specifically designed for this review. Among the several possible outcomes, appetite and body weight were chosen. RESULTS Fifteen randomised clinical trials (more than 2000 patients) were retrieved for the review. There was a statistically significant advantage for high-dose progestins as regards improved appetite: pooled odds ratio (OR) = 4.23, 95% confidence interval (CI): 2.53-7.04. Although the effect of high-dose progestins on body weight was less impressive, statistical significance was also reached for this outcome: pooled OR = 2.66, 95% CI: 1.80-3.92. Treatment morbidity was very low, due to the brief period of the treatment in most of the studies. CONCLUSIONS The effects of high-dose progestins on appetite and body weight were clearly demonstrated. However, further studies are undoubtedly warranted to investigate other aspects of progestin activity, especially as regards dosage, duration and timing with best therapeutic index.
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Affiliation(s)
- M Maltoni
- Department of Medical Oncology, Pierantoni Hospital, Forli, Italy.
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Langer CJ, Hoffman JP, Ottery FD. Clinical significance of weight loss in cancer patients: rationale for the use of anabolic agents in the treatment of cancer-related cachexia. Nutrition 2001; 17:S1-20. [PMID: 11428126 DOI: 10.1016/s0899-9007(01)80001-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- C J Langer
- Fox Chase Cancer Center, Philadelphia, Pa., USA
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Affiliation(s)
- A Jatoi
- Division of Medical Oncology and Department of Biostatistics, Mayo Clinic, Rochester, USA
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