Efficacy and safety of bupropion in cancer-related fatigue, a randomized double blind placebo controlled clinical trial

5-EPIFAT trial protocol: a multi-center, randomized, placebo-controlled trial of the efficacy of pharmacotherapy for fatigue using methylphenidate, bupropion, ginseng, and amantadine in advanced cancer patients on active treatment

BACKGROUND

Cancer-related fatigue (CRF) is still undertreated in most patients, as evidence for pharmacological treatments is limited and conflicting. Also, the efficacy of the pharmacological agents relative to each other is still unclear. Therefore, medications that may potentially contribute to improving CRF will be investigated in this head-to-head trial. Our main objective is to compare the efficacy of methylphenidate vs. bupropion vs. ginseng vs. amantadine vs. placebo in patients with advanced cancer.

METHODS

The 5-EPIFAT study is a 5-arm, randomized, multi-blind, placebo-controlled, multicenter trial that will use a parallel-group design with an equal allocation ratio comparing the efficacy and safety of four medications (Methylphenidate vs. Bupropion vs. Ginseng vs. Amantadine) versus placebo for management of CRF. We will recruit 255 adult patients with advanced cancer who experience fatigue intensity ≥ 4 based on a 0-10 scale. The study period includes a 4-week intervention and a 4-week follow-up with repeated measurements over time. The primary outcome is the cancer-related fatigue level over time, which will be measured by the functional assessment of chronic illness therapy-fatigue (FACIT-F) scale. To evaluate safety, the secondary outcome is the symptomatic adverse events, which will be assessed using the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events in cancer clinical trials (PRO-CTCAE). Also, a subgroup analysis based on a decision tree-based machine learning algorithm will be employed for the clinical prediction of different agents in homogeneous subgroups.

DISCUSSION

The findings of the 5-EPIFAT trial could be helpful to guide clinical decision-making, personalization treatment approach, design of future trials, as well as the development of CRF management guidelines.

TRIAL REGISTRATION

IRCT.ir IRCT20150302021307N6. Registered on 13 May 2023.

Cancer-related fatigue-pharmacological interventions: systematic review and network meta-analysis

INTRODUCTION

Cancer-related fatigue (CRF) is a very common symptom in patients with cancer, and one of the five areas of highest priority in cancer research. There is currently no consensus on pharmacologic interventions for treating CRF. The aim of this systematic review is to provide more clarity on which pharmacologic interventions may be most promising, for future clinical trials. The network meta-analysis provides the ability to compare multiple agents when no direct head-to-head trials of all agents have been performed.

METHODS

Medline (PubMed), EMBASE and Cochrane Central Register of Controlled Trials were searched up until 5 March 2021. Studies were included if they reported on a pharmacologic intervention for CRF. Standardised mean differences and corresponding 95% CIs were computed using a random-effects maximum-likelihood model.

RESULTS

This review reports on 18 studies and 2604 patients, the most comprehensive review of pharmacologic interventions for CRF at the time of this publication. Methylphenidate, modafinil and paroxetine were superior to placebo. Methylphenidate and modafinil were equivalent to one another. Paroxetine was superior to modafinil.

CONCLUSION

Paroxetine should be further studied in future trials. As well, more safety data are needed on pharmacologic interventions.

Psychological Aspects of Breast Cancer

Breast cancer is the most commonly diagnosed cancer in women. Associated psychological symptoms include stress, adjustment difficulties, anxiety, depression, impaired cognitive function, sleep disturbances, altered body image, sexual dysfunction, and diminished overall well-being. Distress screening and assessment identifies women who will benefit from therapeutic interventions. Addressing these symptoms improves compliance with treatment and outcomes including disease-related outcomes, psychological symptoms, and quality of life. The most effective treatments include teaching coping skills such as expressing emotion, along with other structured cognitive behavioral, interpersonal, and mindfulness approaches. Patients should be provided these psychosocial supports throughout their cancer journey.

Cancer and Non-cancer Fatigue Treated With Bupropion: A Systematic Review

CONTEXT

Fatigue is a predominant and distressing symptom in cancer and non-cancer conditions for which there is a paucity of recommendations for pharmacological interventions. Bupropion is a novel treatment whose efficacy and safety in the treatment of fatigue are unknown.

OBJECTIVES

This study aimed to systematically assess the evidence on the efficacy and safety of bupropion in the treatment of fatigue in people with cancer and non-cancer conditions.

METHODS

PubMed, EMBASE, and Ovid Medline databases were searched up to July 26, 2022. Studies were included if they reported bupropion as an intervention for cancer and non-cancer-related fatigue and used an objective scale to assess symptom outcomes. Experimental and quasi-experimental studies in adult patients published in English were included.

RESULTS

This review reports on seven studies (three randomized studies, three non-randomized studies, and one case series) that enrolled a total of 584 patients. Bupropion was tested in five studies for treating cancer-related fatigue and in two studies for treating fatigue in non-cancer conditions. The reviewed studies were heterogeneous in relation to the scales used to assess fatigue. Six out of seven studies reported that bupropion significantly reduced the fatigue burden without causing major adverse effects. These positive results must be taken with caution caused by the small sample sizes and low quality of the studies reviewed.

CONCLUSION

Bupropion may prove to be an effective and safe intervention for fatigue in cancer and non-cancer conditions. A high-quality randomized trial is warranted to test current preliminary results.

Correlates of Cancer-Related Fatigue among Colorectal Cancer Patients Undergoing Postoperative Adjuvant Therapy Based on the Theory of Unpleasant Symptoms

BACKGROUND

Cancer-related fatigue (CRF) is a common and burdensome symptom in cancer patients that is influenced by multiple factors. Identifying factors associated with CRF may help in developing tailored interventions for fatigue management. This study aimed to examine the correlates of CRF among colorectal cancer patients undergoing postoperative adjuvant therapy based on the theory of unpleasant symptoms.

METHODS

A cross-sectional study was implemented, and finally, a sample of 363 participants from one tertiary general hospital and one tertiary cancer hospital was purposively recruited. Data were collected using the general information questionnaire, cancer fatigue scale, the distress disclosure index, Herth hope index, and perceived social support scale. Univariate analysis and multiple linear regression analysis were performed to determine the correlates of CRF.

RESULTS

The mean score of CRF among colorectal cancer patients was 21.61 (SD = 6.16, 95% CI 20.98-22.25), and the fatigue degree rating was "moderate". The multiple linear regression model revealed that 49.1% of the variance in CRF was explained by hope, sleep disorder, internal family support, self-disclosure, pain, and time since operation.

CONCLUSIONS

Our study identified several significant, modifiable factors (self-disclosure, hope, internal family support, pain, and sleep disorder) associated with CRF. Understanding these correlates and developing targeted psychosocial interventions may be associated with the improvement of CRF in patients with colorectal cancer.

A New Approach to Understanding Cancer-Related Fatigue: Leveraging the 3P Model to Facilitate Risk Prediction and Clinical Care

Simple Summary

For the growing number of cancer survivors worldwide, fatigue presents a major hurdle to function and quality of life. Treatment options for cancer-related fatigue are still emerging, and our current understanding of its etiology is limited. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. We propose that the 3P model may be leveraged—particularly using metabolomics, the microbiome, and inflammation in conjunction with behavioral science—to better understand the pathophysiology of cancer-related fatigue.

Abstract

A major gap impeding development of new treatments for cancer-related fatigue is an inadequate understanding of the complex biological, clinical, demographic, and lifestyle mechanisms underlying fatigue. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. This model framework outlined herein, which incorporates the emerging field of metabolomics, may help to frame a more in-depth analysis of the etiology of cancer-related fatigue as well as a broader and more personalized set of approaches to the clinical treatment of fatigue in oncology care. Included within this review paper is an in-depth description of the proposed biological mechanisms of cancer-related fatigue, as well as a presentation of the 3P model’s application to this phenomenon. We conclude that a clinical focus on organization risk stratification and treatment around the 3P model may be warranted, and future research may benefit from expanding the 3P model to understand fatigue not only in oncology, but also across a variety of chronic conditions.

Cancer-Related Fatigue – Clinical Evaluation Scales and Interventions: A Systematic Review

Background:

Cancer-related fatigue (CRF) is one of the most frequent and prevalent symptoms expressed by cancer patients and cancer survivors. It is a multifactorial phenomenon that causes a direct detrimental impact on quality of life.

Objectives:

This systematic review aims to identify different clinical evaluation scales and interventions available for fatigue associated with cancer.

Materials and Methods:

A methodology of the systematic literature review was carried out. Two separate databases PubMed and Google Scholar searches were performed using different MeSH terms.

Results:

A total of 2611 research articles were screened and identified 10 unidimensional scales (four with one item scales and six with numerous item scales) and 13 multidimensional scales which are available for the screening and clinical evaluation of fatigue. Reviews have also revealed non-pharmacological interventions such as exercise, complementary therapies, nutritional and psychoeducational interventions, sleep therapy, energy therapy, bright white light, restorative therapies upcoming anthroposophical medicine, and various pharmacological agents effective in managing CRF.

Conclusion:

Clinical evaluation of fatigue and its management is crucial for improving the quality of life. Yet, more rigorous research studies with higher statistical power need to be conducted on these interventions to generate adequate evidences for managing the CRF.

Use of Contrave, Naltrexone with Bupropion, Bupropion, or Naltrexone and Major Adverse Cardiovascular Events: A Systematic Literature Review

Naltrexone/Bupropion extended release (ER; Contrave) is an extended-release, fixed-dose combination medication of naltrexone (8 mg) and bupropion (90 mg) for patients with obesity or overweight with at least one weight-related comorbidity. Obese and overweight patients with or without comorbidities are at increased cardiovascular (CV) risk. Due to the increased CV risk profile in this patient population, this systematic literature review was conducted to assess human studies reporting major adverse CV events (MACE) and other CV events. A priori eligibility criteria included clinical studies (randomized and observational) published from January 1, 2012, to September 30, 2021, with data comparing users of naltrexone/bupropion ER, naltrexone with bupropion, bupropion without naltrexone, or naltrexone without bupropion versus comparator groups (placebo or other treatments), and with sufficient information to determine the frequency of MACE or other CV adverse events by treatment group. Among 2539 English-language articles identified, 70 articles met the eligibility criteria: seven studies of naltrexone/bupropion ER or naltrexone with bupropion, 32 studies of bupropion, and 31 studies of naltrexone. No studies reported an increased risk of MACE among users of naltrexone/bupropion ER, naltrexone with bupropion, or bupropion or naltrexone individually compared with nonusers. One-half of the available studies (n = 35) reported no (zero) CV events and the other half (n = 35) reported that a non-zero frequency of CV events occurred. Four studies reported data on MACE, including three studies of bupropion and one study of naltrexone/bupropion ER. For composite MACE and its components, the difference in proportions between naltrexone/bupropion ER-, bupropion-, or naltrexone-treated patients compared with active comparators or placebo-treated patients did not exceed 2.5%. In conclusion, the available human evidence does not indicate an increased risk of CV events or MACE following use of naltrexone/bupropion ER, naltrexone with bupropion, or the individual components.

Circulating markers of NADH-reductive stress correlate with mitochondrial disease severity

Mitochondrial disorders represent a large collection of rare syndromes that are difficult to manage both because we do not fully understand biochemical pathogenesis and because we currently lack facile markers of severity. The m.3243A>G variant is the most common heteroplasmic mitochondrial DNA mutation and underlies a spectrum of diseases, notably mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes (MELAS). To identify robust circulating markers of m.3243A>G disease, we first performed discovery proteomics, targeted metabolomics, and untargeted metabolomics on plasma from a deeply phenotyped cohort (102 patients, 32 controls). In a validation phase, we measured concentrations of prioritized metabolites in an independent cohort using distinct methods. We validated 20 analytes (1 protein, 19 metabolites) that distinguish patients with MELAS from controls. The collection includes classic (lactate, alanine) and more recently identified (GDF-15, α-hydroxybutyrate) mitochondrial markers. By mining untargeted mass-spectra we uncovered 3 less well-studied metabolite families: N-lactoyl-amino acids, β-hydroxy acylcarnitines, and β-hydroxy fatty acids. Many of these 20 analytes correlate strongly with established measures of severity, including Karnofsky status, and mechanistically, nearly all markers are attributable to an elevated NADH/NAD+ ratio, or NADH-reductive stress. Our work defines a panel of organelle function tests related to NADH-reductive stress that should enable classification and monitoring of mitochondrial disease.

Recent trends in the management of depression in persons with cancer

PURPOSE OF REVIEW

Depression is a prevalent comorbidity in cancer that significantly increases the risk for numerous negative health outcomes. This review updates the current evidence base for management of depression in cancer, highlighting new research directions based on the inflammatory hypothesis of depression.

RECENT FINDINGS

Research on pharmacotherapy and psychotherapy for depression in cancer has shown mixed efficacy partly because of methodological issues arising from the phenomenology of depression in cancer. After decades of stagnancy, more recent high-quality clinical trials are beginning to provide an evidence base to guide treatment. Inflammatory cytokine-associated depression is a subtype of depression that may have particular relevance in cancer, opening new avenues to explore therapeutic targets and biobehavioral impacts of interventions, which may improve cancer outcomes.

SUMMARY

The continuum of severity in cancer-related depression is important to consider in management approaches. Choice of treatment should be personalized to the patient and their symptom profile as there is currently insufficient evidence to recommend any particular medication or psychotherapy over another. Psychological interventions should be considered first line for mild-to-moderate depression, and pharmacological treatment added for more severe depression, which can be optimally delivered within a collaborative care model.

VIDEO ABSTRACT

http://links.lww.com/YCO/A62.

An update on cancer-related fatigue in older adults: A narrative review

Up to 70% of older adults report fatigue after a cancer diagnosis. For many of these patients, cancer-related fatigue (CRF) persists for years after cancer treatment and is associated with significant disability. Despite this, little has been written on the diagnosis and management of CRF in older adults. To address this gap, we performed a narrative review of the literature on CRF in older adults and used literature from the general population when evidence was lacking to provide guidance to clinical providers on how to tailor care to this population. We recommend evidence-based options for evaluating CRF and address their limitations in the assessment of older adults. We also provide guidance and a treatment algorithm on evaluating CRF using the Comprehensive Geriatrics Assessment. Lastly, we present evidence for the use of non-pharmacologic and pharmacologic therapies in the management of CRF in older adults.

Pharmacological Interventions for the Management of Cancer-Related Fatigue Among Cancer Survivors: Systematic Review and Meta-Analysis

OBJECTIVE

Current guidelines have different recommendations on applying pharmacological interventions for managing cancer-related fatigue (CRF) among cancer survivors. This systematic review aims to synthesize clinical evidence on pharmacological interventions for managing CRF.

METHODS

Five databases were searched for potential randomized controlled trials (RCTs) from their inception until October 2020. RCTs assessing the effect of pharmacological treatments for CRF among cancer survivors were considered eligible. Clinical significance was determined by comparing the estimated effect with that of minimal important difference (MID). The risk of bias of each included RCT was appraised using the Cochrane risk of bias tool for randomized trials 2. Data were synthesized using random-effect pairwise meta-analyses.

RESULTS

A total of 15 RCTs (1238 participants) were included. The majority presented some concerns of bias arising from the randomization process and selection of the reported results. Meta-analysis showed that psychostimulant and wakefulness agents had statistically significant while clinically insignificant effects on the treatment of CRF (pooled weighted mean difference [WMD]: 2.8, 95% confidence interval [CI]: 0.2-5.4, I2: 0%, 3 RCTs, MID: 3.0-6.0). Three natural products, including Renshen Yangrong Tang (mean difference [MD]: -16.1, 95% CI: -8.9 to -23.3, MID: -17.3 to -11.4), Tualang honey (MD: 11.2, 95% CI: 7.1-15.3, MID: 3.0-6.0), and Shenmai injection plus Peptisorb (MD: -1.6, 95% CI: -2.1 to -1.1, MID: -1.1 to -0.8) demonstrated statistically and clinically significant effect in reducing CRF.

CONCLUSIONS

Existing evidence showed promising effects of 3 natural products in reducing CRF among cancer survivors. The results from this study need to be further confirmed with well-designed and adequately powered RCTs that use validated instruments for the measurement of CRF.