Use of Dexamethasone for Severe Fatigue in the Advanced Cancer Population: A Brief Report

Background

Fatigue is a common and distressing symptom for palliative care patients. Although the current literature emphasizes nonpharmacological management, dexamethasone is reportedly used in clinical practice. This study helps to characterize its use, efficacy, and adverse effects in a real-world setting.

Objective

To improve the evidence base by exploring the use, efficacy, and side effect profile of dexamethasone for fatigue management.

Methods

This international multisite prospective observational case series assessed the benefit and adverse effects of dexamethasone at baseline (T0) and at five to seven days postbaseline (T1). Fatigue scores were assessed using the symptom assessment scale (SAS) and visual analogue fatigue scale (VAFS). Adverse events were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE). The related samples Wilcoxon signed-rank test was used to compare before and after scores.

Results

All 18 patients (male-female, 11:7) had advanced metastatic cancer with most in the deteriorating palliative care phase (56%). The most common dose of dexamethasone was 4 mg daily orally. At T1 (n = 12), improvement was seen in all measures of fatigue; the median SAS scores decreased from 7 to 5.5 (p = 0.007), the median VAFS scores increased from 3 to 5 (p = 0.126), and the median NCI-CTCAE fatigue scores were reduced from 3 to 2.5 (p = 0.18). Dexamethasone was well tolerated; one participant experienced grade 3 delirium.

Conclusion

The small number of participants recruited for this study suggests that dexamethasone is not widely used specifically for fatigue. Our results suggest an improvement in fatigue scores from T0 to T1.

Cancer-related fatigue measures in palliative care: A psychometric systematic review

INTRODUCTION

In palliative care, the prevention and relief of fatigue are regarded as crucial goals in patients with cancer.

METHODS

A systematic review was carried out according to the COnsensus-based Standards for the selection of health status Measurement INstruments methodology. Searches were conducted in Medline (through PubMed), Web of Science, Open Gray, Scielo, Cochrane, CINAHL and EMBASE. All instruments found in each study were assessed using the COnsensus-based Standards for the selection of health status Measurement INstruments checklist and Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

A total of 5598 articles were identified in the different databases. In total, 57 studies describing 19 instruments were included in this study. The main properties evaluated were internal consistency, cross-cultural validity, hypotheses testing and responsiveness. All studies were evaluated with the Strobe scale with a score greater than 6 points.

CONCLUSIONS

According to the quality methodological results, Edmonton Symptom Assessment System, Problems and Needs in Palliative Care Questionnaire, European Organisation for Research and Treatment of Cancer Quality of Life 15-item Questionnaire for Palliative Care and Palliative Care Quality of Life Instrument are the recommended instruments used for assessing cancer-related fatigue in palliative care. PROPESRO registration number: CRD42020206783.

The Level of Distress From Fatigue Reported in the Final Two Months of Life by a Palliative Care Population: An Australian National Prospective, Consecutive Case Series

CONTEXT

Fatigue is the most commonly reported symptom in life-limiting illnesses, although not much is known about the distress it causes patients as they approach death.

OBJECTIVES

To map the trajectory of distress from fatigue reported by an Australian palliative care population in the last 60 days leading up to death.

METHODS

A prospective, longitudinal, consecutive cohort study using national data from the Australian Palliative Care Outcomes Collaboration between July 1, 2013, and December 31, 2018. Patients were included if they had at least one measurement of fatigue on a 0-10 numerical rating scale in the 60 days before death. Descriptive statistics were used to analyse patients by diagnostic cohort and functional status.

RESULTS

A total of 116,604 patients from 203 specialist palliative care services were analyzed, providing 501,104 data points. Distress from fatigue affected up to 80% of patients referred to palliative care, with the majority experiencing moderate or severe distress. Malignant and nonmalignant diagnoses were equally affected, with the neurological cohort showing the greatest variability. The degree of distress correlated with a patient's functional level; it worsened as a patient's function declined until a patient became bedbound when the reporting of distress reduced.

CONCLUSIONS

Distress from fatigue is high in this cohort of patients. Interventions to reduce this distress need to be a research priority.

Fatigue in Cancer Patients in Palliative Care-A Review on Pharmacological Interventions

Simple Summary

Cancer related fatigue is a common and distressing symptom for patients with cancer during and after primary treatment, and also in the palliative phase of the disease trajectory. This review focuses on the pharmacological treatment of cancer related fatigue in patients with advanced or metastatic cancer. There are few high-quality studies performed in this setting, but both methylphenidate and corticosteroids might be used to relieve fatigue.

Abstract

Fatigue is one of the most distressing symptoms experienced by cancer patients. The suggested biological mechanism for cancer related fatigue (CRF) includes immune activation triggered by tumor tissue or by anticancer treatment but other mechanisms have also been proposed. Previous large meta-analysis of interventions on fatigue focuses mostly on patients early in the disease trajectory, with only one tenth of included studies performed in palliative cohorts. The aim of this narrative review is therefore to present a background on CRF with focus on the palliative setting. A summary of recent randomized, controlled trials on pharmacological interventions on CRF in palliative care is presented, including studies on psychostimulants, corticosteroids, testosterone and melatonin. Interestingly, in several of these studies there was a positive and similar effect on fatigue in both the intervention and the placebo arm—indicating an important placebo effect for any pharmacological treatment. In addition, studies on dietary supplements and on pharmacological complementary medicines are discussed. To conclude, the evidence is still weak for using pharmacological treatments on CRF in palliative care patients—although methylphenidate and corticosteroids might be considered.

How Confident Are We at Assessing and Managing Fatigue in Palliative Care Patients? A Multicenter Survey Exploring the Current Attitudes of Palliative Care Professionals

Background: Fatigue is a common and significant problem for palliative care (PC) patients, affecting up to 80% of patients. Health care professionals (HCPs) commonly underestimate its significance and lack the confidence in how to manage it, resulting in poor quality of life. It is currently not known how PC professionals manage fatigue in clinical practice or what the barriers to implementation are. Objective: To determine the current attitudes of HCPs toward fatigue management in patients with a life-limiting illness. Design/Setting: An electronic survey, created on REDCap, was distributed to all staff working directly with PC patients in both the community and inpatient setting within the Sydney Local Health District. The study duration was for four weeks (May 1-30, 2018). Results: Participants recognized that fatigue is common, but only 58.5% recognized that severe fatigue is more distressing than pain. A total of 77.2% of participants do not find fatigue an easy symptom to manage and less than half (46.9%) feel confident assessing and managing it. There was no consistent systematic approach to management although exercise, education, and pacing/energy conservation were recognized as important interventions. Themes identified as potential barriers to management included lack of resources, poor patient and staff understanding, and patient/disease factors. Conclusions: HCPs lack confidence in assessing fatigue and completing an individualized management plan; the approaches adopted are highly variable. This justifies the need for further education, as well as further research assessing the efficacy of a multimodal intervention and a guideline to assist in management.

Cancer in patients with schizophrenia: What is the next step?

People with schizophrenia, who constitute approximately 0.3-1% of the general population, have a nearly 20% shorter life expectancy than the general population. The incidence of varied types of cancers in patients with schizophrenia is controversial. The majority of previous research has demonstrated that patients who have schizophrenia and cancer have early mortality compared to the general population with cancer. The causes of early mortality in patients with schizophrenia and cancer might be attributed to a lower cancer screening rate and lack of effective treatment, including: (i) patient factors, such as poor lifestyle, passive attitude toward treatment, or comorbidity; (ii) physician factors, such as physician bias, which may decrease the delivery of care for individuals with mental disorders; and (iii) hospital administration factors, such as stigma and discrimination. Additional studies on patients with schizophrenia and cancer are warranted and should include the following: a comprehensive review of previous studies; a focus on differentiating the specific types of cancer; and methods for improvement. To decrease the early mortality of patients with schizophrenia, the following measures are proposed: (i) enhance early detection and early treatment, such as increasing the cancer screening rate for patients with schizophrenia; (ii) provide effective, timely treatment and rehabilitation; (iii) improve patients' psychiatric symptoms and cognitive impairment; (iv) promote healthy behavior in the general population and emphasize healthy lifestyles in vulnerable populations; and (v) remove the stigma of schizophrenia. To reduce disparities in physical health, public health strategies and welfare policies must continue to focus on this group of patients.

Genomic Variants Associated With Cancer-Related Fatigue: A Systematic Review

BACKGROUND

Cancer-related fatigue (CRF) is the most common stressful side effect caused by cancer and cancer treatments. Although CRF causes a significant burden to quality of life, no pharmacologic interventions are available because the mechanism remains unknown.

OBJECTIVES

This systematic review analyzed the genomic variants that have been found to be associated with CRF.

METHODS

A search for peer-reviewed articles through PubMed, EBSCOhost, and DePaul WorldCat Libraries Worldwide yielded 16 published studies.

FINDINGS

The majority of genomic variants demonstrated that the inflammatory and immune response pathways, including the neuro-proinflammatory cytokine pathway, have statistically significant associations with CRF. Additional genomic studies are still needed to validate the findings in this systematic review. The exact biologic underpinnings that contribute to the development of CRF remain unknown.