The importance of quality-of-life management in patients with advanced pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) carries a poor prognosis, and as such, a focus on quality of life is vital. This review will discuss various aspects of quality of life in patients with PDAC and their treatment. Pancreatic exocrine and endocrine insufficiency may result in issues related to nutrition, and pain and fatigue are other common symptoms, and may be managed with pharmaceutical or nonpharmaceutical methods. It has also been reported that low mood is a particular problem for patients with PDAC compared to patients with other cancers; however, the data supporting this is inconsistent. Data regarding improvements in quality of life in patients with PDAC receiving chemotherapy is also reviewed, which in some cases suggests a benefit to chemotherapy, particularly in the presence of a radiological response. Furthermore, the importance of early palliative care is discussed and the benefits reported including improved quality of life and mood, reduced aggressive interventions at the end of life and improved survival. Areas for future development may include increased use of quality of life as a trial outcome and the use of patient-reported outcomes to improve symptomatic care of patients, and particularly in those receiving active systemic treatment.

Cancer-related fatigue: a review

Cancer-related fatigue is the most prevalent cancer symptom, reported in 50%-90% of patients and severely impacts quality of life and functional capacity. The condition remains underreported and often goes untreated. Guidelines suggest screening for fatigue at the initial visit, when the diagnosis of advanced disease is made, and at each chemotherapy session, as well as the identification of treatable contributing factors such as anemia, hypothyroidism, depression and sleep disorders. Brief assessment tools such as the Brief Fatigue Inventory or the Visual Analog Scale may be appropriate in the initial scoring of fatigue severity, but the initial approach to treatment usually requires a more comprehensive assessment, education, and the determination of an individualized treatment plan. Patients with moderate or severe fatigue may benefit from both pharmacological and non-pharmacological interventions, whereas mild fatigue that does not interfere with quality of life can be treated with non-pharmacological measures alone. Non-pharmacological measures that have shown to be promising include cognitive-behavioral interventions such as energy conservation and activity management (ECAM), exercise and perhaps sleep therapy. Many other modalities may be beneficial and can be used on an individual basis, but there is insufficient evidence to promote any single treatment. Pharmacological therapies that have shown to be promising include the psycho-stimulants methylphenidate and dexmethylphenidate, modafinil (in severely fatigued patients only), and erythropoietin-stimulating agents in patients with chemotherapy-associated anemia and hemoglobin levels < 10 g/dL. Recently, our group reported impressive results with the use of the dry extract of Guarana (Paullinia cupana), with no significant side effects and at low cost, for the treatment of physical and mental cancer-related fatigue.

Efficacy and Safety of Modafinil in the Treatment of Cancer-Related Fatigue

Objective:

To review the efficacy and safety of modafinil in the treatment of cancer-related fatigue (CRF).

Data Souces:

Literature was accessed via MEDLINE (1950–week 3, November 2008), International Pharmaceutical Abstracts, and Google Scholar using the terms modafinil, cancer, and fatigue. Reference citations from articles identified were reviewed.

Study Selection and Data Extraction:

All English-language publications identified were analyzed for significance. Studies relevant to the objective were used, including 2 prospective open-label studies, one randomized double-blind, dose-controlled trial with an open-label extension, and one Phase 3 randomized, placebo-controlled, double-blind trial.

Data Synthesis:

Fatigue is a nearly universal adverse effect of cancer and its treatment that is unrelated to physical exertion, is not relieved by sleep or rest, and negatively affects quality of life. Modafinil is a central nervous system stimulant with minimal toxicity and a low propensity for abuse. Clinical data demonstrate that modafinil significantly reduces fatigue in patients who have received cancer treatment or are currently undergoing chemotherapy. Additional benefits include improvement in cognitive function, mood, general activity, walking ability, normal work ability, relations with other people, and enjoyment of life. Limitations of the available data include open-label design in 3 of the 4 studies; the absence of numerical results of fatigue assessments in the abstract of 1 trial, preventing the determination of clinical significance; and the full inclusion/exclusion criteria, which were not included in the published abstracts. These limitations leave readers without a clear picture of the study populations. Finally, different patient populations at different points in treatment with varying durations of therapy were used, which makes extrapolation of data to the general population challenging.

Conclusions:

Further randomized placebo-controlled trials are necessary to amass evidence for the effective and safe use of modafinil for CRF; however, if traditional therapies have failed or are intolerable, modafinil can be considered a treatment option.

From the podium to the patient: bringing the 2008 ASCO meeting to the clinic

Around 4,800 abstracts on preclinical and clinical research in different oncology areas were presented and discussed by oncology clinicians and scientists at the 44th American Society of Clinical Oncology meeting, the largest international forum in the field. As expected, the meeting provided valuable insights into future developments as well as enlightening clinicians regarding current controversies. This manuscript is an opinion-based review of the studies presented at the meeting, focusing on findings from randomized phase III trials and translational researches that, in the authors' opinion, are most likely to modify clinical practice or help scientists in designing future translational and clinical studies.