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Porter AB. Neurologic Complications of Cancer Treatment. Continuum (Minneap Minn) 2023; 29:903-922. [PMID: 37341335 DOI: 10.1212/con.0000000000001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE Advances in cancer treatment have led to extended survival and increased risk of neurologic complications in an aging population. This review summarizes potential neurologic complications in patients who have undergone treatment for neurologic and systemic malignancies. LATEST DEVELOPMENTS Radiation and cytotoxic chemotherapy along with other targeted therapies continue to be the mainstay of cancer treatment. These advances in cancer care have led to improved outcomes and increased the need to understand the spectrum of neurologic complications that may arise from treatment. While radiation and older therapies including cytotoxic chemotherapies have side effect profiles that are widely known and well understood, this article serves as a review of the more commonly associated neurologic complications of both traditional and newer treatments being offered to this patient population. ESSENTIAL POINTS Neurotoxicity is a common complication of cancer-directed treatment. In general, neurologic complications of radiation therapy are more common in central nervous system malignancies, and neurologic complications of chemotherapy are more common in non-neurologic malignancies. Attempts at prevention, early detection, and intervention remain paramount in the reduction of neurologic morbidity.
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Felger JC. Increased Inflammation and Treatment of Depression: From Resistance to Reuse, Repurposing, and Redesign. ADVANCES IN NEUROBIOLOGY 2023; 30:387-416. [PMID: 36928859 DOI: 10.1007/978-3-031-21054-9_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Based on mounting clinical and translational evidence demonstrating the impact of exogenously administered inflammatory stimuli on the brain and behavior, increased endogenous inflammation has received attention as one pathophysiologic process contributing to psychiatric illnesses and particularly depression. Increased endogenous inflammation is observed in a significant proportion of depressed patients and has been associated with reduced responsiveness to standard antidepressant therapies. This chapter presents recent evidence that inflammation affects neurotransmitters and neurocircuits to contribute to specific depressive symptoms including anhedonia, motor slowing, and anxiety, which may preferentially improve after anti-cytokine therapies in patients with evidence of increased inflammation. Existing and novel pharmacological strategies that target inflammation or its downstream effects on the brain and behavior will be discussed in the context of a need for intelligent trial design in order to meaningfully translate these concepts and develop more precise therapies for depressed patients with increased inflammation.
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Abstract
Background Cancer-related fatigue (CRF) is one of the most prevalent, debilitating symptoms affecting a majority of patients with cancer worldwide. It can lead to poor compliance with anticancer therapy and discontinuation of treatment. Current management strategies for CRF center around activity and exercise; however, these strategies can be challenging for many patients undergoing active treatment. Ginseng has been shown to improve CRF and may provide benefit for patients suffering from CRF. Methods A systematic review was completed by searching PubMed and Scopus databases. Results 115 search results were reduced to a final sample of five articles after applying inclusion and exclusion criteria. Published results suggest that 2,000 mg of American ginseng once daily improves symptoms of CRF. Minimal side effects or drug interactions are observed. Additional research is needed to further evaluate the role of ginseng for CRF. Conclusion There are data to support the use of American ginseng to treat CRF. Large-scale randomized controlled trials are needed to validate these findings and determine optimal dosage and duration of therapy.
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Affiliation(s)
- Emily A Lemke
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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4
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Brown AL, Sok P, Taylor O, Woodhouse JP, Bernhardt MB, Raghubar KP, Kahalley LS, Lupo PJ, Hockenberry MJ, Scheurer ME. Cerebrospinal Fluid Metabolomic Profiles Associated With Fatigue During Treatment for Pediatric Acute Lymphoblastic Leukemia. J Pain Symptom Manage 2021; 61:464-473. [PMID: 32889041 PMCID: PMC7914130 DOI: 10.1016/j.jpainsymman.2020.08.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/22/2020] [Accepted: 08/24/2020] [Indexed: 12/21/2022]
Abstract
CONTEXT Cancer-related fatigue (CRF) is one of the most distressing and persistent symptoms reported during pediatric acute lymphoblastic leukemia (ALL) therapy; however, information on the pathways underlying CRF severity is limited. OBJECTIVES We conducted global metabolomics profiling of cerebrospinal fluid (CSF) samples to provide insight into the underlying mechanisms of CRF. METHODS Fatigue in pediatric ALL patients (2012-2017) was assessed during postinduction therapy approximately six months after diagnosis. Postinduction CSF was collected from 171 participants, comprising discovery (n = 86) and replication (n = 85) cohorts. We also conducted secondary validation using diagnostic CSF from 48 replication cohort participants. CSF metabolomic profiling was performed using gas chromatography-mass spectrometry (MS) and liquid chromatography-MS/MS. Kendall's rank correlation was used to evaluate associations between metabolite abundance and CRF. False discovery rate was used to account for multiple comparisons. RESULTS Participants were 56% males and 59% Hispanic with a mean age at diagnosis of 8.5 years. A total of 274 CSF-derived metabolites were common to the discovery and replication cohorts. Eight metabolites were significantly associated with fatigue in the discovery cohort (P < 0.05), of which three were significant in the replication cohort, including false discovery rate-corrected associations with gamma-glutamylglutamine (Pcombined = 6.2E-6) and asparagine (Pcombined = 3.5E-4). Notably, the abundance of gamma-glutamylglutamine in diagnostic CSF samples was also significantly associated with fatigue (P = 0.0062). CONCLUSION The metabolites identified in our assessment have been implicated in neurotransmitter transportation and glutathione recycling, suggesting that glutamatergic pathways or oxidative stress may contribute to ALL-associated CRF. This information could inform targeted therapies for reducing CRF in at-risk individuals.
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Affiliation(s)
- Austin L Brown
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.
| | - Pagna Sok
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Olga Taylor
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - John P Woodhouse
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - M Brooke Bernhardt
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Lisa S Kahalley
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Philip J Lupo
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Michael E Scheurer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Pedersen L, Lund L, Petersen MA, Sjogren P, Groenvold M. Methylphenidate as Needed for Fatigue in Patients With Advanced Cancer. A Prospective, Double-Blind, and Placebo-Controlled Study. J Pain Symptom Manage 2020; 60:992-1002. [PMID: 32464260 DOI: 10.1016/j.jpainsymman.2020.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 11/12/2022]
Abstract
CONTEXT Cancer-related fatigue is a highly prevalent symptom with a strong negative impact on patients' daily life. OBJECTIVES To evaluate the efficacy of methylphenidate as needed for the management of fatigue in patients with advanced cancer. METHODS A prospective, controlled, double-blind, and paired design, where the patient was her and/or his own control. Patients with advanced cancer with a tiredness score of ≥50 on a 0-100 visual analogue scale (VAS) were included. Patients were given 10 placebo and 10 methylphenidate tablets numbered 1-20 packed in blocks of four with two active and two placebo tablets (randomly arranged). Patients taking minimum three tablets were regarded evaluable. Primary effect parameters were mean differences in VAS for tiredness after two and five hours. With 28 evaluable patients, the study had a power of 0.90 to detect a mean difference of 15 between active and placebo. RESULTS Thirty-eight patients were enrolled to get 28 evaluable patients. Mean tiredness score before taking the tablets was 75 for placebo and 72 for methylphenidate on VAS (0-100). Mean changes (decrease) for methylphenidate after two and five hours were 20 and 17, respectively, and eight and five for placebo. Comparing mean differences, a significant decrease for methylphenidate compared with placebo was observed after two hours (P = 0.004) and five hours (P = 0.001), respectively. CONCLUSION In this controlled and double-blind study in patients with advanced cancer, methylphenidate as needed was significantly more effective than placebo in relieving fatigue after two and five hours.
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Affiliation(s)
- Lise Pedersen
- Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Line Lund
- Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Morten A Petersen
- Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Per Sjogren
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Section of Palliative Medicine, Department of Oncology, Rigshospitalet - Copenhagen University Hospital, Copenhagen, Denmark
| | - Mogens Groenvold
- Department of Palliative Medicine, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark; Section of Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Henson LA, Maddocks M, Evans C, Davidson M, Hicks S, Higginson IJ. Palliative Care and the Management of Common Distressing Symptoms in Advanced Cancer: Pain, Breathlessness, Nausea and Vomiting, and Fatigue. J Clin Oncol 2020; 38:905-914. [PMID: 32023162 PMCID: PMC7082153 DOI: 10.1200/jco.19.00470] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2019] [Indexed: 12/27/2022] Open
Abstract
Good symptom management in oncology is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages. With population growth and aging, the proportion of patients with multiple symptoms-both related and unrelated to their cancer-is anticipated to increase, supporting calls for a more routine and integrated approach to symptom management. This article presents a summary of the literature for the use of symptom assessment tools and reviews the management of four common and distressing symptoms commonly experienced by people with advanced cancer: pain, breathlessness, nausea and vomiting, and fatigue. We also discuss the role of palliative care in supporting a holistic approach to symptom management throughout the cancer trajectory.
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Affiliation(s)
- Lesley A. Henson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Catherine Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Martin Davidson
- King’s College Hospital National Health Service Foundation Trust, Denmark Hill, London, United Kingdom
| | - Stephanie Hicks
- King’s College Hospital National Health Service Foundation Trust, Denmark Hill, London, United Kingdom
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
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8
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Abstract
Approximately one third of depressed patients fail to respond to currently available antidepressant therapies. Therefore, new conceptual frameworks are needed to identify pathophysiologic pathways and neurobiological targets for the development of novel treatment strategies. In this regard, recent evidence suggests that inflammation may contribute to symptoms relevant to a number of psychiatric disorders and particularly depression. Numerous studies (including meta-analyses) have found elevated peripheral and central inflammatory cytokines and acute phase proteins in depression. Chronic exposure to increased inflammation is thought to drive changes in neurotransmitters and neurocircuits that lead to depressive symptoms and that may also interfere with or circumvent the efficacy of antidepressants. Indeed, patients with high inflammation have been shown to exhibit poor response to conventional antidepressant therapies. Recent developments in our ability to understand and measure the effects of inflammation on the brain in patients have opened new doors for the testing of novel treatment strategies that target the immune system or its consequences on neurotransmitter systems. Such recent developments in the field of behavioral immunology and their translational implications for the treatment of depression are discussed herein.
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Zhou ES, Hall KT, Michaud AL, Blackmon JE, Partridge AH, Recklitis CJ. Open-label placebo reduces fatigue in cancer survivors: a randomized trial. Support Care Cancer 2018; 27:2179-2187. [DOI: 10.1007/s00520-018-4477-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/17/2018] [Indexed: 12/17/2022]
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10
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Felger JC. Imaging the Role of Inflammation in Mood and Anxiety-related Disorders. Curr Neuropharmacol 2018; 16:533-558. [PMID: 29173175 PMCID: PMC5997866 DOI: 10.2174/1570159x15666171123201142] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 10/23/2017] [Accepted: 11/21/2017] [Indexed: 02/08/2023] Open
Abstract
Background Studies investigating the impact of a variety of inflammatory stimuli on the brain and behavior have reported evidence that inflammation and release of inflammatory cytokines affect circuitry relevant to both reward and threat sensitivity to contribute to behavioral change. Of relevance to mood and anxiety-related disorders, biomarkers of inflammation such as inflammatory cytokines and acute-phase proteins are reliably elevated in a significant proportion of patients with major depressive disorder (MDD), bipolar disorder, anxiety disorders and post-traumatic stress disorder (PTSD). Methods This review summarized clinical and translational work demonstrating the impact of peripheral inflammation on brain regions and neurotransmitter systems relevant to both reward and threat sensitivity, with a focus on neuroimaging studies involving administration of inflammatory stimuli. Recent translation of these findings to further understand the role of inflammation in mood and anxiety-related disorders is also discussed. Results Inflammation was consistently found to affect basal ganglia and cortical reward and motor circuits to drive reduced motivation and motor activity, as well as anxiety-related brain regions including amygdala, insula and anterior cingulate cortex, which may result from cytokine effects on monoamines and glutamate. Similar relationships between inflammation and altered neurocircuitry have been observed in MDD patients with increased peripheral inflammatory markers, and such work is on the horizon for anxiety disorders and PTSD. Conclusion Neuroimaging effects of inflammation on reward and threat circuitry may be used as biomarkers of inflammation for future development of novel therapeutic strategies to better treat mood and anxiety-related disorders in patients with high inflammation.
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Affiliation(s)
- Jennifer C Felger
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States.,Winship Cancer Institute, Emory University, Atlanta, GA, United States
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Grossberg AJ, Vichaya EG, Christian DL, Molkentine JM, Vermeer DW, Gross PS, Vermeer PD, Lee JH, Dantzer R. Tumor-Associated Fatigue in Cancer Patients Develops Independently of IL1 Signaling. Cancer Res 2017; 78:695-705. [PMID: 29217760 DOI: 10.1158/0008-5472.can-17-2168] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/20/2017] [Accepted: 11/27/2017] [Indexed: 12/19/2022]
Abstract
Fatigue is the most common symptom of cancer at diagnosis, yet causes and effective treatments remain elusive. As tumors can be highly inflammatory, it is generally accepted that inflammation mediates cancer-related fatigue. However, evidence to support this assertion is mostly correlational. In this study, we directly tested the hypothesis that fatigue results from propagation of tumor-induced inflammation to the brain and activation of the central proinflammatory cytokine, IL1. The heterotopic syngeneic murine head and neck cancer model (mEER) caused systemic inflammation and increased expression of Il1b in the brain while inducing fatigue-like behaviors characterized by decreased voluntary wheel running and exploratory activity. Expression of Il1b in the brain was not associated with any alterations in motivation, measured by responding in a progressive ratio schedule of food reinforcement, depression-like behaviors, or energy balance. Decreased wheel running occurred prior to Il1b detection in the brain, when systemic inflammation was minimal. Furthermore, mice null for two components of IL1β signaling, the type 1 IL1 receptor or the receptor adapter protein MyD88, were not protected from tumor-induced decreases in wheel running, despite attenuated cytokine action and expression. Behavioral and inflammatory analysis of four additional syngeneic tumor models revealed that tumors can induce fatigue regardless of their systemic or central nervous system inflammatory potential. Together, our results show that brain IL1 signaling is not necessary for tumor-related fatigue, dissociating this type of cancer sequela from systemic cytokine expression.Significance: These findings challenge the current understanding of fatigue in cancer patients, the most common and debilitating sequela associated with malignancy. Cancer Res; 78(3); 695-705. ©2017 AACR.
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Affiliation(s)
- Aaron J Grossberg
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas. .,Department of Symptom Research, MD Anderson Cancer Center, Houston, Texas
| | | | - Diana L Christian
- Department of Symptom Research, MD Anderson Cancer Center, Houston, Texas
| | - Jessica M Molkentine
- Department of Experimental Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Daniel W Vermeer
- Cancer Biology Research Center, Sanford Research, Sioux Falls, South Dakota
| | - Phillip S Gross
- Department of Symptom Research, MD Anderson Cancer Center, Houston, Texas
| | - Paola D Vermeer
- Cancer Biology Research Center, Sanford Research, Sioux Falls, South Dakota
| | - John H Lee
- Cancer Biology Research Center, Sanford Research, Sioux Falls, South Dakota
| | - Robert Dantzer
- Department of Symptom Research, MD Anderson Cancer Center, Houston, Texas
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Kolak A, Kamińska M, Wysokińska E, Surdyka D, Kieszko D, Pakieła M, Burdan F. The problem of fatigue in patients suffering from neoplastic disease. Contemp Oncol (Pozn) 2017; 21:131-135. [PMID: 28947882 PMCID: PMC5611502 DOI: 10.5114/wo.2017.68621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 12/20/2016] [Indexed: 12/12/2022] Open
Abstract
Modern therapeutic management of patients with cancer is associated with many adverse side effects, including fatigue defined as weariness, burnout, lassitude, malaise, apathy, impatience, and/or inability to perform daily activities. It occurs frequently before the diagnosis of cancer and may persist for a long time after the end of cancer therapy. It is a common problem that occurs regardless of the type of cancer and applied therapeutic procedure. The appearance of this symptom significantly affects the quality of life of patients and often reduces the effectiveness of implemented treatment. The symptom of fatigue occurs among approximately 80% of patients treated with chemotherapy and/or radiotherapy, as well as among more than 75% of patients with metastatic disease. Causes of fatigue include metabolic and immune system disorders as well as increased level of tumour necrosis factor α (TNF-α). Recent studies also indicate a significant contribution of other cytokines, especially pro-inflammatory ones, i.e. interleukin-1 (IL-1), interleukin-6 (IL-6), soluble tumour necrosis factor receptor type II (sTNF type II) and C-reactive protein (CRP). A patient reporting fatigue should be properly diagnosed and thoroughly interviewed by doctors. Patients are mostly treated non-pharmacologically (by means of physical exercise and psychotherapy) and pharmacologically (by applying methylphenidate and methylprednisolone). What is also extremely important is proper education of the patient and their closest family/friends on the symptoms, which significantly reduces anxiety and stress. On the other hand therapeutic management hinders the subjectivity of feeling and lack of standardised scales to rate symptoms.
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Affiliation(s)
- Agnieszka Kolak
- St. John of Dukla Lublin Region Cancer Centre, Lublin, Poland
| | | | | | - Dariusz Surdyka
- St. John of Dukla Lublin Region Cancer Centre, Lublin, Poland
| | - Dariusz Kieszko
- St. John of Dukla Lublin Region Cancer Centre, Lublin, Poland
| | - Magdalena Pakieła
- Department of Social Nursing, Warsaw Medical University, Warsaw, Poland
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Abstract
Chronotherapeutics aim at treating illnesses according to the endogenous biologic rhythms, which moderate xenobiotic metabolism and cellular drug response. The molecular clocks present in individual cells involve approximately fifteen clock genes interconnected in regulatory feedback loops. They are coordinated by the suprachiasmatic nuclei, a hypothalamic pacemaker, which also adjusts the circadian rhythms to environmental cycles. As a result, many mechanisms of diseases and drug effects are controlled by the circadian timing system. Thus, the tolerability of nearly 500 medications varies by up to fivefold according to circadian scheduling, both in experimental models and/or patients. Moreover, treatment itself disrupted, maintained, or improved the circadian timing system as a function of drug timing. Improved patient outcomes on circadian-based treatments (chronotherapy) have been demonstrated in randomized clinical trials, especially for cancer and inflammatory diseases. However, recent technological advances have highlighted large interpatient differences in circadian functions resulting in significant variability in chronotherapy response. Such findings advocate for the advancement of personalized chronotherapeutics through interdisciplinary systems approaches. Thus, the combination of mathematical, statistical, technological, experimental, and clinical expertise is now shaping the development of dedicated devices and diagnostic and delivery algorithms enabling treatment individualization. In particular, multiscale systems chronopharmacology approaches currently combine mathematical modeling based on cellular and whole-body physiology to preclinical and clinical investigations toward the design of patient-tailored chronotherapies. We review recent systems research works aiming to the individualization of disease treatment, with emphasis on both cancer management and circadian timing system–resetting strategies for improving chronic disease control and patient outcomes.
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Affiliation(s)
- Annabelle Ballesta
- Warwick Medical School (A.B., P.F.I., R.D., F.A.L.) and Warwick Mathematics Institute (A.B., D.A.R.), University of Warwick, Coventry, United Kingdom; Warwick Systems Biology and Infectious Disease Epidemiological Research Centre, Senate House, Coventry, United Kingdom (A.B., P.F.I., R.D., D.A.R., F.A.L.); INSERM-Warwick European Associated Laboratory "Personalising Cancer Chronotherapy through Systems Medicine" (C2SysMed), Unité mixte de Recherche Scientifique 935, Centre National de Recherche Scientifique Campus, Villejuif, France (A.B., P.F.I., R.D., D.A.R., F.A.L.); and Queen Elisabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Cancer Unit, Edgbaston Birmingham, United Kingdom (P.F.I., F.A.L.)
| | - Pasquale F Innominato
- Warwick Medical School (A.B., P.F.I., R.D., F.A.L.) and Warwick Mathematics Institute (A.B., D.A.R.), University of Warwick, Coventry, United Kingdom; Warwick Systems Biology and Infectious Disease Epidemiological Research Centre, Senate House, Coventry, United Kingdom (A.B., P.F.I., R.D., D.A.R., F.A.L.); INSERM-Warwick European Associated Laboratory "Personalising Cancer Chronotherapy through Systems Medicine" (C2SysMed), Unité mixte de Recherche Scientifique 935, Centre National de Recherche Scientifique Campus, Villejuif, France (A.B., P.F.I., R.D., D.A.R., F.A.L.); and Queen Elisabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Cancer Unit, Edgbaston Birmingham, United Kingdom (P.F.I., F.A.L.)
| | - Robert Dallmann
- Warwick Medical School (A.B., P.F.I., R.D., F.A.L.) and Warwick Mathematics Institute (A.B., D.A.R.), University of Warwick, Coventry, United Kingdom; Warwick Systems Biology and Infectious Disease Epidemiological Research Centre, Senate House, Coventry, United Kingdom (A.B., P.F.I., R.D., D.A.R., F.A.L.); INSERM-Warwick European Associated Laboratory "Personalising Cancer Chronotherapy through Systems Medicine" (C2SysMed), Unité mixte de Recherche Scientifique 935, Centre National de Recherche Scientifique Campus, Villejuif, France (A.B., P.F.I., R.D., D.A.R., F.A.L.); and Queen Elisabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Cancer Unit, Edgbaston Birmingham, United Kingdom (P.F.I., F.A.L.)
| | - David A Rand
- Warwick Medical School (A.B., P.F.I., R.D., F.A.L.) and Warwick Mathematics Institute (A.B., D.A.R.), University of Warwick, Coventry, United Kingdom; Warwick Systems Biology and Infectious Disease Epidemiological Research Centre, Senate House, Coventry, United Kingdom (A.B., P.F.I., R.D., D.A.R., F.A.L.); INSERM-Warwick European Associated Laboratory "Personalising Cancer Chronotherapy through Systems Medicine" (C2SysMed), Unité mixte de Recherche Scientifique 935, Centre National de Recherche Scientifique Campus, Villejuif, France (A.B., P.F.I., R.D., D.A.R., F.A.L.); and Queen Elisabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Cancer Unit, Edgbaston Birmingham, United Kingdom (P.F.I., F.A.L.)
| | - Francis A Lévi
- Warwick Medical School (A.B., P.F.I., R.D., F.A.L.) and Warwick Mathematics Institute (A.B., D.A.R.), University of Warwick, Coventry, United Kingdom; Warwick Systems Biology and Infectious Disease Epidemiological Research Centre, Senate House, Coventry, United Kingdom (A.B., P.F.I., R.D., D.A.R., F.A.L.); INSERM-Warwick European Associated Laboratory "Personalising Cancer Chronotherapy through Systems Medicine" (C2SysMed), Unité mixte de Recherche Scientifique 935, Centre National de Recherche Scientifique Campus, Villejuif, France (A.B., P.F.I., R.D., D.A.R., F.A.L.); and Queen Elisabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Cancer Unit, Edgbaston Birmingham, United Kingdom (P.F.I., F.A.L.)
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Felger JC, Treadway MT. Inflammation Effects on Motivation and Motor Activity: Role of Dopamine. Neuropsychopharmacology 2017; 42:216-241. [PMID: 27480574 PMCID: PMC5143486 DOI: 10.1038/npp.2016.143] [Citation(s) in RCA: 252] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 07/13/2016] [Accepted: 07/27/2016] [Indexed: 01/18/2023]
Abstract
Motivational and motor deficits are common in patients with depression and other psychiatric disorders, and are related to symptoms of anhedonia and motor retardation. These deficits in motivation and motor function are associated with alterations in corticostriatal neurocircuitry, which may reflect abnormalities in mesolimbic and mesostriatal dopamine (DA). One pathophysiologic pathway that may drive changes in DAergic corticostriatal circuitry is inflammation. Biomarkers of inflammation such as inflammatory cytokines and acute-phase proteins are reliably elevated in a significant proportion of psychiatric patients. A variety of inflammatory stimuli have been found to preferentially target basal ganglia function to lead to impaired motivation and motor activity. Findings have included inflammation-associated reductions in ventral striatal neural responses to reward anticipation, decreased DA and DA metabolites in cerebrospinal fluid, and decreased availability, and release of striatal DA, all of which correlated with symptoms of reduced motivation and/or motor retardation. Importantly, inflammation-associated symptoms are often difficult to treat, and evidence suggests that inflammation may decrease DA synthesis and availability, thus circumventing the efficacy of standard pharmacotherapies. This review will highlight the impact of administration of inflammatory stimuli on the brain in relation to motivation and motor function. Recent data demonstrating similar relationships between increased inflammation and altered DAergic corticostriatal circuitry and behavior in patients with major depressive disorder will also be presented. Finally, we will discuss the mechanisms by which inflammation affects DA neurotransmission and relevance to novel therapeutic strategies to treat reduced motivation and motor symptoms in patients with high inflammation.
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Affiliation(s)
- Jennifer C Felger
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Michael T Treadway
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Winship Cancer Institute, Emory University, Atlanta, GA, USA
- Department of Psychology, Emory University, Atlanta, GA, USA
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15
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Lacouture ME, Dréno B, Ascierto PA, Dummer R, Basset-Seguin N, Fife K, Ernst S, Licitra L, Neves RI, Peris K, Puig S, Sokolof J, Sekulic A, Hauschild A, Kunstfeld R. Characterization and Management of Hedgehog Pathway Inhibitor-Related Adverse Events in Patients With Advanced Basal Cell Carcinoma. Oncologist 2016; 21:1218-1229. [PMID: 27511905 PMCID: PMC5061532 DOI: 10.1634/theoncologist.2016-0186] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 06/09/2016] [Indexed: 12/14/2022] Open
Abstract
Abnormal activation of hedgehog pathway signaling is a key driver in the pathogenesis of basal cell carcinoma (BCC). Vismodegib, a first-in-class small-molecule inhibitor of hedgehog pathway signaling, is approved by regulatory authorities for the treatment of adults who have metastatic BCC or locally advanced BCC that has recurred after surgery, or who are not candidates for surgery and who are not candidates for radiation. A second inhibitor, sonidegib, was also recently approved for the same patient group with locally advanced BCC. Adverse events (AEs) commonly observed in hedgehog pathway inhibitor (HPI)-treated patients include muscle spasms, ageusia/dysgeusia, alopecia, weight loss, and asthenia (fatigue). These AEs are thought to be mechanistically related to inhibition of the hedgehog pathway in normal tissue. Although the severity of the majority of AEs associated with HPIs is grade 1-2, the long-term nature of these AEs can lead to decreased quality of life, treatment interruption, and in some cases discontinuation, all of which might affect clinical outcome. The incidence, clinical presentation, putative mechanisms, and management strategies for AEs related to HPIs in advanced BCC are described. These observations represent the first step toward the development of mechanism-based preventive and management strategies. Knowledge of these AEs will allow health care professionals to provide appropriate counseling and supportive care interventions, all of which will contribute to improved quality of life and optimal benefit from therapy. IMPLICATIONS FOR PRACTICE The hedgehog pathway inhibitors (HPIs) vismodegib and sonidegib represent a therapeutic breakthrough for patients with advanced basal cell carcinoma. However, the nature of the low-grade adverse events (AEs) commonly observed in HPI-treated patients, including muscle spasms, ageusia/dysgeusia, alopecia, weight loss, and fatigue, can impact clinical outcomes as a result of decreased quality of life and treatment discontinuation. The incidence, clinical presentation, putative mechanisms, and management strategies for AEs related to administration of HPIs are described, with the goal of enabling health care professionals to provide appropriate counseling and supportive care interventions to their patients.
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Affiliation(s)
| | - Brigitte Dréno
- Department of Dermatology, Hôtel Dieu University Hospital, Nantes, France
| | | | | | | | - Kate Fife
- Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Scott Ernst
- Western University London Regional Cancer Program, London, Ontario, Canada
| | | | - Rogerio I Neves
- Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | | | - Susana Puig
- Dermatology Department, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomédiques August Pi I Sunyer, Barcelona, Spain
| | - Jonas Sokolof
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Axel Hauschild
- Department of Dermatology, University of Kiel, Kiel, Germany
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16
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Aapro M, Scotte F, Bouillet T, Currow D, Vigano A. A Practical Approach to Fatigue Management in Colorectal Cancer. Clin Colorectal Cancer 2016; 16:275-285. [PMID: 29066018 DOI: 10.1016/j.clcc.2016.04.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 04/08/2016] [Accepted: 04/27/2016] [Indexed: 01/06/2023]
Abstract
Cancer-related fatigue is serious and complex, as well as one of the most common symptoms experienced by patients with colorectal cancer, with the potential to compromise quality of life, activities of daily living, and ultimately survival. There is a lack of consensus about the definition of cancer-related fatigue; however, definitions have been put forward by the European Association for Palliative Care (EAPC) and the National Comprehensive Cancer Network (NCCN). Numerous cancer- and treatment-related factors can contribute to fatigue, including disease progression, comorbidities, medical complications such as anemia, side effects of other medications, and a number of physical and psychologic factors. This underlines the importance of tackling factors that may contribute to fatigue before reducing the dose of treatment. NCCN guidelines and the EAPC have proposed approaches to managing fatigue in cancer patients; however, relatively few therapeutic agents have been demonstrated to reduce fatigue in randomized controlled trials. It is recognized that physical activity produces many beneficial physiologic modifications to markers of physical performance that can help to counteract various causes of fatigue. In appropriately managed and monitored patients with colorectal cancer, emerging evidence indicates that exercise programs may have a favorable influence on cancer-related fatigue, quality of life, and clinical outcomes, and therefore may help patients tolerate chemotherapy. This review assesses fatigue in patients with colorectal cancer and proposes updates to a treatment algorithm that may help clinicians manage this common problem.
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Affiliation(s)
- Matti Aapro
- Multidisciplinary Oncology Institute, Clinique de Genolier, Genolier, Switzerland.
| | - Florian Scotte
- Oncology Department, Georges Pompidou European Hospital, Paris, France
| | - Thierry Bouillet
- Oncology Department, University Hospital Avicenne, Bobigny, France
| | - David Currow
- Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - Antonio Vigano
- McGill Nutrition and Performance Laboratory and Division of Supportive and Palliative Care, McGill University Health Centre, Montreal, Canada
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17
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Nelson DV, Esty ML. Neurotherapy As a Catalyst in the Treatment of Fatigue in Breast Cancer Survivorship. Explore (NY) 2016; 12:246-9. [PMID: 27234465 DOI: 10.1016/j.explore.2016.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Indexed: 01/04/2023]
Abstract
Pharmacologic and non-pharmacologic treatments for cancer-related fatigue (CRF) have produced mixed and often disappointing results. Treatment using the Flexyx Neurotherapy System (FNS), a novel variant of electroencephalograph biofeedback that involves minutely pulsed electromagnetic (EM) stimulation of brainwave functioning, was explored to determine utility for alleviating CRF in a 45-year-old woman who had debilitating fatigue with onset during chemotherapy for stage II infiltrating right breast cancer, who had been free of signs of disease for over five years, and who had been struggling to increase her activity level and engage in regular exercise without benefit. FNS was administered in 10 weekly sessions. Alleviation of fatigue and other potentially interrelated symptoms (cognitive clouding, sleep disturbance, pain, and negative mood/emotions) and overall greater activity level was sustained at six-month follow-up. Very low energy EM brainwave stimulation therapies such as FNS may contribute to an enlivening of drive to engage in greater energized activity.
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Affiliation(s)
- David V Nelson
- Department of Psychology and Philosophy, Sam Houston State University, Box 2447, Huntsville, TX 77341.
| | - Mary Lee Esty
- Brain Wellness and Biofeedback Center of Washington, Bethesda, MD
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18
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Conley CC, Kamen CS, Heckler CE, Janelsins MC, Morrow GR, Peppone LJ, Scalzo AJ, Gross H, Dakhil S, Mustian KM, Palesh OG. Modafinil Moderates the Relationship Between Cancer-Related Fatigue and Depression in 541 Patients Receiving Chemotherapy. J Clin Psychopharmacol 2016; 36:82-5. [PMID: 26658264 PMCID: PMC4689625 DOI: 10.1097/jcp.0000000000000442] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to examine the effect of modafinil on depression via a secondary data analysis of a randomized clinical trial of modafinil for fatigue in cancer patients. The primary aim is to elucidate factors that contributed to the effectiveness of modafinil in the parent trial. METHODS Five hundred forty-one cancer patients receiving chemotherapy and experiencing fatigue (Brief Fatigue Inventory [BFI] item 3 of ≥3) were randomized to receive 200 mg modafinil (n = 260) or placebo (n = 281) daily from baseline (cycle 2) to posttest (cycle 4). Patients completed the Center for Epidemiological Studies-Depression Scale (CES-D) and Profile of Mood States depression-dejection subscale at baseline and posttest. We used linear regression to address the hypothesis that modafinil would be associated with reduced depression, particularly in those experiencing severe fatigue (BFI ≥7). RESULTS Modafinil did not have a significant effect on depression, even for those patients with severe fatigue. However, for subjects with severe fatigue (BFI ≥7), those receiving modafinil had lower depression scores than did control subjects. Modafinil significantly moderated the relationship between baseline fatigue and CES-D total scores (P = 0.04) and was marginally significant as a moderator for the relationship between baseline fatigue and Profile of Mood States depression-dejection subscale scores (P = 0.07). Modafinil also significantly moderated the relationship between baseline fatigue and CES-D positive affect subscale scores (P = 0.003), but not CES-D somatic, negative affect, or interpersonal subscale scores. CONCLUSIONS Modafinil differentially impacts depression based on a patient's level of fatigue and reduced depressive symptoms only in those with extreme fatigue. This effect may be driven by increases in positive affective symptoms. These results have significant implications for intervention; in patients with high levels of fatigue, modafinil might also reduce depression. Future randomized clinical trials are needed to confirm these results.
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Affiliation(s)
| | | | | | | | | | | | | | - Howard Gross
- Dayton Community Clinical Oncology Program, Dayton, OH
| | - Shaker Dakhil
- Wichita Community Clinical Oncology Program, Wichita, KS
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19
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Alexander K, Goldberg J, Korc-Grodzicki B. Palliative Care and Symptom Management in Older Patients with Cancer. Clin Geriatr Med 2015; 32:45-62. [PMID: 26614860 DOI: 10.1016/j.cger.2015.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Older patients with cancer are best served by a multidisciplinary approach with palliative care (PC) playing an integral role. PC focuses on symptom control irrespective of its cause and should not be associated only with terminal care. It provides an additional layer of support in the care of patients with cancer with an emphasis on quality of life. This article discusses the evaluation and management of pain and other common nonpain symptoms that occur in elderly patients with cancer, as well as end-of-life care.
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Affiliation(s)
- Koshy Alexander
- Geriatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 205, New York, NY 10065, USA; Department of Medicine, Weill Cornell Medical College, 425 East 61st Street, New York, NY 10065, USA.
| | - Jessica Goldberg
- Palliative Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Beatriz Korc-Grodzicki
- Geriatrics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 205, New York, NY 10065, USA; Department of Medicine, Weill Cornell Medical College, 425 East 61st Street, New York, NY 10065, USA
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20
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Krishnamoorthy SK, Relias V, Sebastian S, Jayaraman V, Saif MW. Management of regorafenib-related toxicities: a review. Therap Adv Gastroenterol 2015; 8:285-97. [PMID: 26327919 PMCID: PMC4530428 DOI: 10.1177/1756283x15580743] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Regorafenib (Stivarga, BAY 73-4506; Bayer Pharma AG, Berlin, Germany) is an oral multikinase inhibitor that targets the angiogenic tumor microenvironment and oncogenic kinases including vascular endothelial growth factor receptor 2 (VEGFR2), VEGFR1, VEGFR3, fibroblast growth factor receptor 1 (FGFR1), RAF, KIT, RET and BRAF. Its antiangiogenic effect is greater than that of its related drug, sorafenib. Regorafenib has been approved by the US Food and Drug Administration (FDA) for the treatment of metastatic colorectal cancer (mCRC) in patients who have failed treatment with fluoropyrimidine, oxaliplatin and irinotecan based chemotherapy, an anti-VEGF therapy and, if KRAS wild type, an anti-EGFR therapy. The FDA based this approval on data from the CORRECT trial, which showed the efficacy of regorafenib compared with placebo. The most common grade 3-4 adverse reactions with the drug are hand foot skin reactions (HFSR), diarrhea, hypertension and fatigue. This review discusses the efficacy data, and the incidence and management of regorafenib's toxicities.
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Affiliation(s)
| | - Valerie Relias
- Division of Hematology/Oncology and Experimental Therapeutics, Tufts Medical Center, Boston, MA, USA
| | | | | | - Muhammad Wasif Saif
- Department of Medicine and Cancer Center, Tufts Medical Center, 800 Washington Street Box 245, Boston, MA 02111, USA
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21
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Mitchell SA, Hoffman AJ, Clark JC, DeGennaro RM, Poirier P, Robinson CB, Weisbrod BL. Putting evidence into practice: an update of evidence-based interventions for cancer-related fatigue during and following treatment. Clin J Oncol Nurs 2015; 18 Suppl:38-58. [PMID: 25427608 DOI: 10.1188/14.cjon.s3.38-58] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cancer-related fatigue (CRF) has deleterious effects on physical, social, cognitive, and vocational functioning, and causes emotional and spiritual distress for patients and their families; however, it remains under-recognized and undertreated. This article critically reviews and integrates the available empirical evidence supporting the efficacy of pharmacologic and nonpharmacologic treatment approaches to CRF, highlighting new evidence since 2007 and 2009 Putting Evidence Into Practice publications. Interventions that are recommended for practice or likely to be effective in improving fatigue outcomes include exercise; screening for treatable risk factors; management of concurrent symptoms; yoga; structured rehabilitation; Wisconsin ginseng; cognitive-behavioral therapies for insomnia, pain, and depression; mindfulness-based stress reduction; and psychoeducational interventions such as anticipatory guidance, psychosocial support, and energy conservation and activity management. This information can be applied to improve the management of CRF, inform health policy and program development, shape the design of clinical trials of new therapies for CRF, and drive basic and translational research.
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Affiliation(s)
- Sandra A Mitchell
- Division of Cancer Control and Population Sciences, National Cancer Center, Bethesda, MD
| | - Amy J Hoffman
- College of Nursing, Michigan State University, East Lansing
| | - Jane C Clark
- Georgia Center for Oncology Research and Education in Atlanta
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22
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Abstract
An aging population and advances in diagnostics and treatment have resulted in a rapidly growing population of people impacted by cancer. People live longer after a cancer diagnosis and tolerate more aggressive treatments than in the past. Younger patients struggle with diversions from the normal developmental milestones in career and relationships, while older patients deal with the dual challenges of aging and cancer. Cancer's transition from likely death to survival has increased interest in its impact on psychosocial issues and quality of life, rather than just longevity. In this article, the authors review the psychiatric diagnosis and management of the mental health issues most often encountered in oncology. Oncology treatment teams, including oncologists, nurses, social workers, and other ancillary staff, are often on the front lines of addressing psychiatric distress and clinical syndromes when psychiatrists are not easily available. The purpose of this review article is to highlight opportunities for nonpsychiatrists to improve identification and treatment of psychosocial distress and psychiatric syndromes and to request formal psychiatric consultation in appropriate situations. Psychotherapeutic, psychopharmacologic, cognitive, and behavioral-oriented interventions, as well as supportive interventions, are discussed for treating patients who are facing challenges during active cancer treatment, survivorship, and at the end of life. This review is not exhaustive but highlights the more common psychosomatic medicine and palliative care scenarios that impact cancer patient care. The importance of recognizing and addressing burnout and compassion fatigue in multidisciplinary professionals who care for those treated for cancer is also discussed given the secondary impact this can have on patient care.
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Affiliation(s)
- Reema D Mehta
- Fellow, Psychosomatic Medicine Psycho-Oncology, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center/New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| | - Andrew J Roth
- Attending Psychiatrist, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center/New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
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23
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Carr AC, Vissers MCM, Cook JS. The effect of intravenous vitamin C on cancer- and chemotherapy-related fatigue and quality of life. Front Oncol 2014; 4:283. [PMID: 25360419 PMCID: PMC4199254 DOI: 10.3389/fonc.2014.00283] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Accepted: 09/29/2014] [Indexed: 12/30/2022] Open
Abstract
Cancer patients commonly experience a number of symptoms of disease progression and the side-effects of radiation therapy and adjuvant chemotherapy, which adversely impact on their quality of life (QOL). Fatigue is one of the most common and debilitating symptom reported by cancer patients and can affect QOL more than pain. Several recent studies have indicated that intravenous (IV) vitamin C alleviates a number of cancer- and chemotherapy-related symptoms, such as fatigue, insomnia, loss of appetite, nausea, and pain. Improvements in physical, role, cognitive, emotional, and social functioning, as well as an improvement in overall health, were also observed. In this mini review, we briefly cover the methods commonly used to assess health-related QOL in cancer patients, and describe the few recent studies examining the effects of IV vitamin C on cancer- and chemotherapy-related QOL. We discuss potential mechanisms that might explain an improvement in QOL and also considerations for future studies.
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Affiliation(s)
- Anitra C Carr
- Department of Pathology, Centre for Free Radical Research, University of Otago , Christchurch , New Zealand
| | - Margreet C M Vissers
- Department of Pathology, Centre for Free Radical Research, University of Otago , Christchurch , New Zealand
| | - John S Cook
- New Brighton Health Care , Christchurch , New Zealand
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24
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Yeh CT, Wang LS. Potential pathophysiological mechanism of cancer-related fatigue and current management. FORMOSAN JOURNAL OF SURGERY 2014. [DOI: 10.1016/j.fjs.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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