Supportive Treatments for Patients with Cancer

Anemia diagnosis and therapy in malignant diseases: implementation of guidelines-a representative study

PURPOSE

Anemia in cancer should be diagnosed and treated according to guideline recommendations. The implementation of ESMO and German guidelines and their effect on anemia correction was analyzed.

METHODS

This retrospective epidemiological study, representative for Germany, analyzed data on anemia management of cancer patients with anemia ≥ grade 2. The Guideline Adherence Score (GLAD) for diagnosis (GLAD-D) and therapy (GLAD-T) was defined as follows: 2 points for complete, 1 point for partial, 0 point for no adherence.

RESULTS

Data were analyzed for 1046 patients. Hb levels at diagnosis of anemia were 8-10 g/dL in 899 (85.9%) patients, 7-8 g/dL in 92 (8.7%), and < 7 g/dL (5.0%) in 52. Transferrin saturation was determined in 19% of patients. Four hundred fifty-six patients received RBC (43.6%), 198 (18.9%) iron replacement, 106 (10.1%) ESA, and 60 (5.7%) vitamin B12 replacement. 60.6% of patients receiving iron replacement were treated intravenously and 39.4% were treated orally. Two hundred eighty-eight (36.6%) of 785 patients receiving transfusions had no guideline-directed indication. GLAD-D was 2 in 310 patients (29.6%), 1 in 168 (16.1%), and 0 in 568 (54.3%). GLAD-T was 2 in 270 patients (25.8%), 1 in 320 patients (30.6%), and 0 in 456 patients (43.6%). Higher GLAD-D significantly correlated with higher GLAD-T (τB = 0.176, p < 0.001). GLAD-T 2 was significantly associated with greater Hb increase than GLAD-T 0/1 (p < 0.001) at 28 days (10.2 vs. 9.7 g/dL) and at 2 months (10.4 vs. 9.9 g/dL).

CONCLUSIONS

Anemia assessment is inadequate, transfusion rates too high, and iron and ESA therapy too infrequent.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05190263, date: 2022-01-13.

Contributing and limiting factors to guideline-adherent therapy in senior and elderly breast cancer patients: a questionnaire-based cross-sectional study using clinical and cancer registry data in Germany

PURPOSE

Elderly cancer patients are less likely to be treated in accordance with evidence-based guideline recommendations. This study examines patient-related factors associated with deviations from guideline recommendations.

METHODS

Using medical documentation and cancer registry data, we investigated the treatment courses of female breast cancer patients aged 50 and older in Germany regarding compliance with German guidelines. Participants completed a questionnaire querying factors hypothesized to be associated with guideline adherence. We conducted univariate analyses to explore the data and select variables for multivariate logistic regression to estimate adjusted odds ratios.

RESULTS

Of 1150 participants, 206 (17.9%) were treated in deviation from guideline recommendations. Patients 70 years and older were more likely to be treated deviating from guideline recommendations than patients 50-69 years old (OR: 2.07; 95% CI: 1.52-2.80). Patients aged 50-69 years who reported that quality of life guided their treatment decision were more likely to be treated in deviation from guideline recommendations (AOR: 2.08; 95% CI: 1.11-3.92) than the elderly. In older patients, higher age was associated with an increased chance of receiving guideline-discordant care (AOR: 1.06; 95% CI: 1.01-1.11), as was depression diagnosed prior to cancer (AOR: 1.84; 95% CI: 1.00-3.40).

CONCLUSION

Reasons for deviations from guideline recommendations in breast cancer patients differ by age. In decision-making concerning elderly patients, particular attention should be paid to those with pre-existing depressive disorders. Adequately addressing their needs and concerns could prevent inappropriate deviations from guideline recommendations.

The Prevention and Treatment of Nausea and Vomiting During Tumor Therapy

BACKGROUND

Nausea and vomiting are common and distressing side effects of tumor therapy. Despite prophylaxis, 40-50% of patients suffer from nausea, and 20-30% from vomiting. Antiemetic prophylaxis and treatment are therefore of great importance for improving patients' quality of life and preventing sequelae such as tumor cachexia.

METHODS

The recommendations presented here are based on international and national guidelines, updated with publications retrieved by a selective search in the PubMed and Cochrane Library databases, with special attention to randomized controlled trials and meta-analyses that have appeared in the past 5 years since the German clinical practice guideline on supportive therapy was published.

RESULTS

Risk-adjusted prevention and treatment is based on the identification of treatment-related and patient-specific risk factors, including female sex and younger age. Parenteral tumor therapy is divided into four risk classes (minimal, low, moderate, high), and oral tumor therapy into two (minimal/low, moderate/high). In radiotherapy, the radiation field is of decisive importance. The antiemetic drugs most commonly used are 5-HT3-RA, NK1-RA, and dexamethasone; olanzapine has proven beneficial as an add-on or rescue drug. The use of steroids in patients being treated with drug combinations including checkpoint inhibitors is discussed controversially because of the potentially reduced therapeutic response. Benzodiazepines, dimenhydrinate, and cannabinoids can be used as backup antiemetics. Acupuncture/acupressure, ginger, and progressive muscle relaxation are pos - sible alternative methods.

CONCLUSION

Detailed, effective, risk profile-adapted algorithms for the prevention and treatment of nausea and vomiting are now available for patients undergoing classic chemotherapy regimens or combined radiotherapy and chemotherapy. Optimal symptom control for patients undergoing oral tumor therapy over multiple days in the outpatient setting remains a challenge.

Analgesic effects of medicinal plants and phytochemicals on chemotherapy-induced neuropathic pain through glial modulation

Chemotherapy-induced peripheral neuropathy (CIPN) frequently occurs in cancer patients. This side effect lowers the quality of life of patients and may cause the patients to abandon chemotherapy. Several medications (e.g., duloxetine and gabapentin) are recommended as remedies to treat CIPN; however, usage of these drugs is limited because of low efficacy or side effects such as dizziness, nausea, somnolence, and vomiting. From ancient East Asia, the decoction of medicinal herbal formulas or single herbs have been used to treat pain and could serve as alternative therapeutic option. Recently, the analgesic potency of medicinal plants and their phytochemicals on CIPN has been reported, and a majority of their effects have been shown to be mediated by glial modulation. In this review, we summarize the analgesic efficacy of medicinal plants and their phytochemicals, and discuss their possible mechanisms focusing on glial modulation in animal studies.

Antibiotic Prophylaxis or Granulocyte-Colony Stimulating Factor Support in Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplantation

We compare, in this manuscript, antibiotic prophylaxis versus granulocyte-colony stimulating factor (G-CSF) support as anti-infective strategies, in patients with multiple myeloma (MM), undergoing high-dose therapy followed by autologous stem cell transplantation (HDT/ASCT). At our institution, antibiotic prophylaxis after HDT/ASCT in MM was stopped in January 2017 and replaced by G-CSF support in March 2017. Consecutive MM patients who received HDT/ASCT between March 2016 and July 2018 were included in this single-center retrospective analysis. In total, 298 patients and 353 individual cases of HDT/ASCT were evaluated. In multivariate analyses, G-CSF support was associated with a significantly shortened duration of severe leukopenia < 1/nL (p < 0.001, hazard ratio (HR) = 16.22), and hospitalization (estimate = -0.19, p < 0.001) compared to antibiotic prophylaxis. Rates of febrile neutropenia, need of antimicrobial therapy, transfer to intensive care unit, and death, were similar between the two groups. Furthermore, antibiotic prophylaxis was associated with a significantly increased risk for the development of multidrug resistant bacteria especially vancomycin-resistant Enterococcus faecium compared to G-CSF support (odds ratio (OR) = 17.38, p = 0.01). Stop of antibiotic prophylaxis as an anti-infective strategy was associated with a reduction in overall resistance rates of bacterial isolates. These results indicate that G-CSF support should be the preferred option in MM patients undergoing HDT/ASCT.

A retrospective study of patient-tailored FOLFIRINOX as a first-line chemotherapy for patients with advanced biliary tract cancer

BACKGROUND

FOLFIRINOX is a pillar first-line regimen in the treatment of pancreatic cancer. Historically, biliary tract cancer (BTC) and pancreatic cancer have been treated similarly with gemcitabine alone or combined with a platinum compound. With growing evidence supporting the role of fluoropyrimidines in the treatment of BTC, we aimed at assessing the outcomes of patients (pts) with BTC on frontline FOLFIRINOX.

METHODS

We retrospectively analyzed data of all our consecutive patients with locally advanced (LA) or metastatic (M) BTC who were registered to receive FOLFIRINOX as a first-line therapy between 12/2013 and 11/2017 at Paul Brousse university hospital. The main endpoints were Overall Survival (OS), Time-to-Progression (TTP), best Objective Response Rate (ORR), Disease Control rate (DCR), secondary macroscopically-complete resection (res) and incidence of severe (grade 3-4) toxicity (tox).

RESULTS

There were 17 male (40%) and 25 female (60%) pts. aged 36 to 84 years (median: 67). They had PS of 0 (55%) or 1 (45%), and intrahepatic cholangiocarcinoma (CCA) (21 pts., 50%), gallbladder carcinoma (8 pts., 19%), perihilar CCA (7 pts., 17%), distal CCA (4 pts., 10%) and ampulloma (2 pts., 5%). BTC was LA or M in 10 (24%) and 32 pts. (76%) respectively. Biliary stent was placed in 14 pts. (33%). A median of 10 courses was given with median treatment duration of 6 months. There were no untoward toxicity issues, with no febrile neutropenia, emergency admission for toxicity or toxic death. We observed 12 partial responses (29%) and 19 disease stabilisations (45%). Six patients (14%) underwent secondary R0-R1 resection. Median TTP was 8 months [95%CL, 6-10] and median OS was 15 months [13-17]. Patients undergoing secondary resection displayed a 3-y disease-free rate of 83%.

CONCLUSIONS

First-line FOLFIRINOX offers promising results in patients with LA and M-BTC. It deserves prospective evaluation to further improve outcomes for advanced BTC.

Patient-Related Risk Factors for Chemotherapy-Induced Nausea and Vomiting: A Systematic Review

Background

Studies have reported that patient-related factors significantly impact the risk of Chemotherapy-Induced Nausea and Vomiting (CINV). The objective of this study was to analyze those risk factors of CINV through a systematic literature review.

Methods

We searched MEDLINE to identify articles that addressed patient-related risk factors of CINV through clinical studies.

Results

A total of 49 articles were selected for this study. A total of 28 patient-related risk-factors that significantly impact the risk of CINV were documented. Three factors are demographically related, 17 factors are intrinsic in nature and innate to patient's physiology or influenced by physiology, and eight factors are extrinsic in nature. At least five studies identified seven risk factors with notable summary odds ratio: history of nausea/vomiting (odds ratio: 3.13, 95% CI 2.40–4.07, p < 0.05), female sex (odds ratio: 2.79, 95% CI 2.26–3.44, p < 0.05), expectancy of CINV (odds ratio: 2.61, 95%CI 1.69–4.02, p < 0.05), younger age (odds ratio: 2.59, 95% CI 2.18–3.07, p < 0.05), anxiety (odds ratio: 2.57, 95% CI 1.94–3.40, p < 0.05), history of morning sickness (odds ratio: 1.97, 95% CI 1.46–2.65, p < 0.05), and low alcohol intake (odds ratio: 1.94, 95% CI 1.68–2.24, p < 0.05).

Conclusions

Oncologists can use these factors prior to the initiation of a chemotherapy regimen to identify patients at risk for CINV, in order to focus on more comprehensive antiemetic treatment options for those high-risk patients. This may enable better outcomes and avoid complications.

Hematopoietic Growth Factors in the Management of Anemia and Febrile Neutropenia

Chemotherapy-induced anemia (CIA) in cancer patients correlates with poor performance status and decreased quality of life. Currently recommended causal therapies are erythropoiesis-stimulating agents (epoetins), iron substitution, or a combination of both. Guidelines recommend considering red blood cell (RBC) transfusions for symptomatic anemia at a hemoglobin (Hb) level of <8 g/dl. Granulocyte colony-stimulating factor (G-CSF) is recommended if the risk of febrile neutropenia (FN) following from the chosen chemotherapy protocol is ≥20%. If a chemotherapy is planned that induces a moderate FN risk (10-20%), the individual overall FN risk should be assessed prior to each chemotherapy cycle, taking into account patient- or tumor-related risk factors. G-CSF is required when risk factors such as age ≥ 65 years, advanced disease or relevant comorbidity, or previous neutropenia complications are present. Neutropenia that required a shift in chemotherapy is also an indication for G-CSF prophylaxis in subsequent cycles, in order to maintain the planned dose intensity. The use of G-CSF improves patient survival and reduces the rate of neutropenia complications.

Kidney cancer survivorship care: Patient experiences in a Canadian setting

INTRODUCTION

The incidence of kidney cancer (KCa) in Canada is rising. Despite this, there is a shortage of research assessing KCa care experiences. This study aims to explore the current experiences of KCa survivors related to treatment and management, information provision, and barriers to care.

METHODS

A cross-sectional, descriptive study of KCa patients was conducted online and through various cancer centers across Canada. English- and French-speaking adults who received a KCa diagnosis and were currently undergoing treatment or had completed treatment in Canada were eligible to participate.

RESULTS

In total, 368 surveys were completed. Ten percent of respondents had not yet received treatment, 29% were receiving treatment, and 56% had completed treatment. Most respondents (72%) had localized KCa (stage 0-3) at diagnosis. Sixty-one percent of respondents reported that their doctors discussed various treatment options with them and 24% reported discussing applicable clinical trials. Most (85%) respondents received information about their KCa and 36% discussed where to get information about their disease and support. The most commonly reported barriers to care were side effects (26%), system delays (26%), not having access to certain treatments (25%), and financial burden (24%). More participants in Central Region and Quebec (p=0.004) and rural/suburban (p=0.014) areas reported lacking access to certain treatments and KCa experts.

CONCLUSIONS

This was the first large-scale study to explore access to care experiences of Canadian KCa survivors. Results show examples of good patient-centered care and provide new practical information that can inform efforts to improve patient-centered care for KCa patients.

Oligomeric Enteral Nutrition in Undernutrition, due to Oncology Treatment-Related Diarrhea. Systematic Review and Proposal of An Algorithm of Action

Oncology treatment-related diarrhea and malnutrition appear together in oncological patients because of the disease itself, or the treatments that are administered for it. Therefore it is essential to carry out a nutritional treatment. Enteral nutrition formulas, containing peptides and medium chain triglycerides, can facilitate absorption in cases of malabsorption. There are few references to the use of enteral nutrition in the clinical society guidelines of patient management with oncology treatment-related diarrhea (OTRD). A bibliographic review of the studies with oligomeric enteral nutrition in OTRD found only nine studies with chemotherapy (all with the same oligomeric formula in which oral mucositis improves, while the rest of the outcomes show different results), and eight studies with radiotherapy (with different products and very heterogeneous results). We hereby present our action algorithm to supplement the diet of OTRD patients with an oligomeric enteral nutrition formula. The first step is the nutritional assessment, followed by the assessment of the functional capacity of the patient’s intestine. With these two aspects evaluated, the therapeutic possibilities available vary in degrees of complexity: These will range from the usual dietary recommendations, to supplementation with oral oligomeric enteral nutrition, along with complete enteral nutrition with oligomeric formula, and up to potentially total parenteral nutrition.

Physical and Psychological Impairments Associated with Mucositis after Oral Cancer Treatment and Their Impact on Quality of Life

BACKGROUND

Posttherapeutic mucositis is a common secondary effect of oral cancer treatment. Mucositis affects the oral mucosa, which leads to specific physical impairments in oral function and a negative impact on quality of life.

OBJECTIVE

To evaluate the impairments associated with oral mucositis and their impact on posttherapeutic quality of life.

METHODS

A retrospective analysis was conducted on 1,652 patients treated for oral cancer during the multicenter rehabilitation study of the German-Austrian-Swiss Cooperative Group on Tumors of the Maxillofacial Region (DÖSAK), which included 43 clinics from Germany, Austria, and Switzerland. The analysis was based on questionnaires filled out by patients following treatment.

RESULTS

Approximately 10% of 1,652 patients included in our study had physical or psychological impairments due to increased posttreatment oral mucositis; this was mainly due to adjuvant radiotherapy or radiochemotherapy administered. Oral mucositis was significantly associated with specific physical impairments, especially xerostomia and pain (p = 0.000), which required supportive care and analgesia (p = 0.000). Additionally, impaired ingestion and speech significantly led to psychological disorders such as public avoidance behavior and social isolation (p = 0.001). Depressive coping of disease (p = 0.001) and concomitant depressive tendencies (p = 0.004) were highly associated with mucositis, which was accompanied by diminished general condition (p = 0.001), bleak future prospects (p = 0.006), and a reduction in quality of life (p = 0.002).

CONCLUSION

Minimizing mucositis-related impairments should be a main effort in oral cancer treatment to optimize patient outcome and improve quality of life after therapy.

Prevention and Management of Chemotherapy-Induced Polyneuropathy

Chemotherapy-induced peripheral neurotoxicity (CIPN) is a severe and common side effect caused by a variety of antineoplastic agents. Approximately 30-40% of patients treated with agents such as taxanes, vinca alkaloids, or platinum derivatives will develop CIPN. CIPN presents predominantly as a sensory axonal neuro(no)pathy with occasional motor and autonomic dysfunction exhibiting considerable variability of clinical symptoms ranging from mild tingling sensation to severe neuropathic pain. Typical symptoms include numbness ("minus symptom"), weakness, and abnormal gait as well as paresthesia and pain ("positive symptoms"). As CIPN symptoms potentially lead to long-term morbidity and can even aggravate after cessation of therapy, patients' quality of life can be tremendously affected. In view of improved breast cancer survival outcomes, the late effects of CIPN are an unmet need in these patients. Therefore, early detection and assessment of first symptoms is important to effectively prevent severe CIPN. Therapeutic options for patients with CIPN are still limited, and pharmacological treatment focuses primarily on reduction or relief of neuropathic pain. CIPN is usually acutely managed by dose reduction or discontinuation of causative chemotherapy, potentially compromising treatment outcome. Currently, there is no causative proven therapy for the prevention of CIPN.

G-CSF guideline adherence in Germany, an update with a retrospective and representative sample survey

Background

Current guidelines (GL) recommend neutropenia prophylaxis with G-CSF after chemotherapy (CTX) for patients with high (≥ 20%), or, if additional risk factors are present, intermediate (≥ 10–20%) risk of febrile neutropenia. The first sample survey in 2012 (NP1) showed lack of GL adherence. The aim of this second sample survey was to evaluate if GL adherence and implementation have improved.

Methods

The sample size represented 1.0% of the incidences of lung and 1.1% of breast cancer in Germany in 2010. Data of patients with a febrile neutropenia (FN) risk ≥ 10% who had received at least 2 cycles of chemotherapy between October 2014 and September 2015 was surveyed retrospectively.

Results

Data from 573 lung cancer (LC) and 801 breast cancer (BC) patients was collected from 109 hospitals and 83 oncology practices with 222 physicians participating. Compared with the NP1 survey, GL adherence increased in LC and FN high-risk (HR) chemotherapy from 15.4 to 47.8% (p < 0.001), and in FN intermediate-risk (IR) chemotherapy from 38.8 to 44.3% (p = 0.003). In BC and FN-HR chemotherapy, GL adherence was unchanged: 85.6% vs. 85.1% (p = 0.73) but increased in FN-IR from 49.3 to 57.8% (p < 0.001). In all IR CTX cycles, there are also no significant differences in GL adherence between the first (51.3%) and subsequent cycles (51.1%; p = 0.948). In LC patients treated in certified or comprehensive cancer centers, the GL adherence in FN-HR chemotherapy was 53.0% vs. 44.9% in other centers (p = 0.295); in FN-IR chemotherapy, it was 45.1% vs. 43.8% (p = 0.750). In BC with FN-HR chemotherapy, GL adherence in certified or comprehensive centers was 85.4% vs. 84.7% in other institutions (p = 0.869); in FN-IR chemotherapy, it was 60.2% vs. 55.0% (p = 0.139). GL adherence in FN-HR chemotherapy and in FN-IR chemotherapy differed between pulmonologists and hematologist-oncologists (FN-HR: 25.0% vs. 43.6%, p < 0.001; 38.1% vs. 48.6%, p < 0.001). Comparing gynecologists with hematologist-oncologists, GL adherence in FN-HR chemotherapy was 86.2% vs. 82.5%. In FN-IR chemotherapy, GL adherence by gynecologists and hematologist-oncologists was 58.6% and 55.6%, respectively (p = 0.288; p = 0.424). Classification and regression tree analysis split pulmonologists and other specialists, with the latter adhering more to GL (p < 0.001). Hematologist-oncologists and gynecologists with more than 2 years of professional training in medical cancer therapy adhered more closely to GL than others (68.7% vs. 46.2%, p < 0.001). Pulmonologists attending ≥ 2 national congresses annually adhered more to guidelines than other pulmonologists (44.8% vs. 24.3%, p < 0.001).

Conclusions

Adherence to G-CSF GL in Germany has increased but is still insufficient. Certified and comprehensive cancer centers show a higher rate of GL implementation. In GL adherence, there is still a disparity between cancer types and between oncology treatment specialists.