A predictive model of inflammatory markers and patient-reported symptoms for cachexia in newly diagnosed pancreatic cancer patients

BACKGROUND

Cachexia is a frequent manifestation of pancreatic cancer, can limit a patient's ability to take chemotherapy, and is associated with shortened survival. We developed a model to predict the early onset of cachexia in advanced pancreatic cancer patients.

METHODS

Patients with newly diagnosed, untreated metastatic or locally advanced pancreatic cancer were included. Serum cytokines were drawn prior to therapy. Patient symptoms were recorded using the M.D. Anderson Symptom Inventory (MDASI). Our primary endpoint was either 10% weight loss or death within 60 days of the start of therapy.

RESULTS

Twenty-seven of 89 patients met the primary endpoint (either having lost 10% of body weight or having died within 60 days of the start of treatment). In a univariate analysis, smoking, history symptoms of pain and difficulty swallowing, high levels of MK, CXCL-16, IL-6, TNF-a, and low IL-1b all correlated with this endpoint. We used recursive partition to fit a regression tree model, selecting four of 26 variables (CXCL-16, IL-1b, pain, swallowing difficulty) as important in predicting cachexia. From these, a model of two cytokines (CXCL-16 > 5.135 ng/ml and IL-1b < 0.08 ng/ml) demonstrated a better sensitivity and specificity for this outcome (0.70 and 0.86, respectively) than any individual cytokine or tumor marker.

CONCLUSIONS

Cachexia is frequent in pancreatic cancer; one in three patients met our endpoint of 10% weight loss or death within 60 days. Inflammatory cytokines are better than conventional tumor markers at predicting this outcome. Recursive partitioning analysis suggests that a model of CXCL-16 and IL-1B may offer a better ability than individual cytokines to predict this outcome.

Siltuximab (CNTO 328) with lenalidomide, bortezomib and dexamethasone in newly-diagnosed, previously untreated multiple myeloma: an open-label phase I trial

The safety and efficacy of siltuximab (CNTO 328) was tested in combination with lenalidomide, bortezomib and dexamethasone (RVD) in patients with newly-diagnosed, previously untreated symptomatic multiple myeloma. Fourteen patients were enrolled in the study, eleven of whom qualified to receive therapy. A majority of patients (81.8%) completed the minimal number or more of the four required cycles, while two patients completed only three cycles. The maximum tolerated dose (MTD) of siltuximab with RVD was dose level −1 (siltuximab: 8.3 mg/kg; bortezomib: 1.3 mg/m²; lenalidomide: 25 mg; dexamethasone: 20 mg). Serious adverse events were grade 3 pneumonia and grade 4 thrombocytopenia, and no deaths occurred during the study or with follow-up (median follow-up 28.1 months). An overall response rate, after 3–4 cycles of therapy, of 90.9% (95% confidence interval (CI): 58.7%, 99.8%) (9.1% complete response (95% CI: 0.2%, 41.3%), 45.5% very good partial response (95% CI: 16.7%, 76.6%) and 36.4% partial response (95% CI: 10.9%, 69.2%)) was seen. Two patients withdrew consent, and nine patients (81.8%) opted for autologous stem cell transplantation.

Abstract P3-10-01: Burden of symptoms associated with development of metastatic bone disease in patients with breast cancer

Background: Bone is the most common site of distant metastasis in advanced breast cancer patients (pts). Development of bone metastases (mets) is associated with substantial morbidity including skeletal complications, decreased quality of life, increased pain, and shortened lifespan. Pt burden of symptoms associated with bone mets has been assessed in tumor types other than breast or in metastatic disease not specific to bone. This study characterizes patterns of pt-reported symptoms over time among breast cancer pts with bone mets.

Methods: The Oncology Services Comprehensive Electronic Records (OSCER) database was used to retrospectively identify women with breast cancer who developed bone mets during their care and had ≥1 ACORN Patient Care Monitor (PCM) assessment. The PCM summarizes symptoms on an 11-point scale (0 = not a problem to 10 = as bad as possible). Moderate/severe symptoms were defined by a PCM score ≥4. PCM items relevant to metastatic disease (fatigue, physical pain, trouble sleeping, numbness/tingling, anxious, loss of interest in others) were assessed. A generalized linear mixed model was used to evaluate symptom progression before and after bone mets diagnosis (dx). Kaplan-Meier methods were used to estimate time to development of and proportion of pts with moderate/severe symptoms after bone mets dx.

Results: 1105 pts with breast cancer and bone mets were included. In general, the proportion of pts with moderate/severe symptom burden increased in the months (mos) before bone mets dx (Table 1). The odds (risk) of pts experiencing moderate/severe symptom burden increased in the mos leading up to bone mets dx, with a 9% increase per mo for both fatigue and physical pain, and a 19% increase per mo for numbness/tingling (P&lt;0.001 for all). Non-significant changes were observed in the risk of pts experiencing trouble sleeping (3%), anxiousness (0%), or loss of interest in others (16%). After bone mets dx, the cumulative proportion of pts with moderate/severe symptom burden increased with time (Table 2). Median time to moderate/severe symptoms after bone mets dx was 1.4 mos for fatigue, 1.9 mos for physical pain, 3.9 mos for trouble sleeping, 9.3 mos for numbness/tingling, 20.6 mos for anxious, and was not reached for loss of interest in others.

Table 1. Unadjusted proportion of pts with moderate/severe symptom burden before or at time of bone mets dxSymptom12 mos before dx6 mos before dxAt bone mets dxFatigue35%37%52%Physical pain29%34%47%Trouble sleeping22%25%28%Numbness/tingling16%18%19%Anxious14%16%23%Loss of interest in others4%6%6%

Conclusions: These data from a large number of breast cancer pts treated at community oncology practices show that pts experience increasing symptom burden for a substantial period of time before bone mets dx. Most pts continue to experience burdensome symptoms after bone mets dx. These findings reinforce the need for multiple symptoms to be proactively monitored and managed in these pts.

Table 2. KM estimate: cumulative proportion of pts with moderate/severe symptom burden after bone mets dxSymptom2 mos after dx12 mos after dxFatigue58%82%Physical pain51%74%Trouble sleeping39%64%Numbness/tingling26%53%Anxious27%46%Loss of interest in others9%22%

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-10-01.

Effect of abiraterone acetate on fatigue in patients with metastatic castration-resistant prostate cancer after docetaxel chemotherapy

BACKGROUND

Fatigue is a common, debilitating side-effect of prostate cancer and its treatment. Patient-reported fatigue was evaluated as part of COU-AA-301, a randomized, placebo-controlled, phase III trial of abiraterone acetate and prednisone versus placebo and prednisone in metastatic castration-resistant prostate cancer (mCRPC) patients after docetaxel chemotherapy. This is the first phase III study in advanced prostate cancer to evaluate fatigue outcomes using a validated fatigue-specific instrument.

PATIENTS AND METHODS

The Brief Fatigue Inventory (BFI) questionnaire was used to measure patient-reported fatigue intensity and fatigue interference with activities of daily life. All analyses were conducted using prespecified responder definitions of clinically meaningful changes.

RESULTS

A total of 797 patients were randomized to abiraterone acetate and prednisone, and 398 were randomized to placebo and prednisone. Compared with prednisone alone, in patients with clinically significant fatigue at baseline, abiraterone acetate and prednisone significantly increased the proportion of patients reporting improvement in fatigue intensity (58.1% versus 40.3%, P = 0.0001), improved fatigue interference (55.0% versus 38.0%, P = 0.0075), and accelerated improvement in fatigue intensity (median 59 days versus 194 days, P = 0.0155).

CONCLUSIONS

In patients with mCRPC progressing after docetaxel chemotherapy, abiraterone acetate and prednisone yielded clinically meaningful improvements in patient-reported fatigue compared with prednisone alone.

Identifying head and neck cancer patients at risk for high symptom burden during treatment

6066

Background: Treatment for head and neck cancer (HNC) is well known to be associated with high levels of toxicity and symptom burden, but patients vary in the severity of treatment related symptom burden. The pre-treatment identification of patient characteristics most at risk for high treatment related symptom levels would be helpful for clinical and trial symptom intervention planning. Methods: 134 patients with HNC participated in the study. Patients completed the M. D. Anderson Symptom Assessment Inventory - Head and Neck module (MDASI-HN) prior to radiotherapy (RT) or chemoradiotherapy (CRT) and again six weeks after treatment began. Cluster analysis was used to identify those who were highly symptomatic due to their disease prior to treatment and those who became highly symptomatic due to treatment. We used validated MDASI-HN score ranges to define symptom severity with scores 5–6 defined as ‘moderate‘ and 7 or more as ‘severe.’ Logistic regression was used to determine which baseline symptoms may predict group membership of highly symptomatic patients at the end of therapy. Results: 18% (22/120) of HNC patients were symptomatic prior to therapy. This subset of patients reported moderate levels of pain, fatigue, sleep disturbance, feeling sad and emotional distress. At six weeks after beginning treatment, 59% (73/124) of patients were highly symptomatic. The cluster of symptoms at this point included moderate levels of pain, fatigue, nausea, mouth sores and excessive mucus and severe levels of poor appetite, dry mouth, difficulty chewing and loss of taste for food. Approximately 54% (50/92) of patients who were not symptomatic at the beginning of treatment became symptomatic at the end of treatment. Patients with moderate to severe pain before beginning treatment are 4 times more likely to be severely symptomatic at the end of treatment (p < 0.009). Conclusions: As expected, only a minority of patients with HNC were highly symptomatic prior to therapy, while the majority of patients had high levels of symptoms toward the end of therapy. Patients with moderate to severe pain before beginning treatment are more likely to be have greater symptom burden at the end of treatment, so may benefit from more intensive symptom interventions.

No significant financial relationships to disclose.

Measuring the symptom burden of head and neck cancer patients undergoing concurrent chemotherapy and radiation therapy using area under the curve

6067

Background: Patients with head and neck cancer (HNC) experience a significant treatment-related symptom burden during therapy that presents management challenges for both patients and treatment staff. Typical symptom measurement approaches have failed to capture the extent of this symptom burden over the course of therapy. We evaluated frequent symptom measurement summarized as area under the curve (AUC) as a way of portraying treatment related symptom burden in HNC patients, and explored this method for comparing symptoms produced by treatments that were expected to produce different levels of symptom impact. Methods: The M. D. Anderson Symptom Inventory - Head and Neck module - was administered at baseline and weekly for 10 weeks following the start of treatment to patients undergoing radiation therapy (XRT) as a single modality therapy (N = 49) and a second group receiving chemoradiotherapy CXRT (N = 53). We expected that treatment-related symptom burden would be greater for those patients receiving CXRT. A single value (AUC) was calculated based on the core symptoms reported by both groups of patients. Results: AUC comparisons for mean symptom severity for core symptom items demonstrated the expected greater symptom burden associated with CXRT (170.6 vs 120.9, p < 0.008). The AUC for symptom interference, as measured by the MDASI-HN, was also greater for the CXRT group (p < 0.002). AUCs for individual symptoms, such as fatigue (p < 0.002), sleep disturbance (p < 0.05) and lack of appetite (p < 0.02), were also significantly larger for the CXRT group. Conclusions: The AUC of individual and combined symptoms during cancer therapy present a useful summary of treatment related symptoms that can be used to compare treatment-related symptom burden between different treatment strategies used for the same disease.

No significant financial relationships to disclose.

Survey of disease and treatment-related symptoms in outpatients with invasive cancer of the breast, prostate, lung, or colon/rectum (E2Z02, the SOAPP study)

9619

Background: The full spectrum and impact of symptoms experienced by ambulatory patients (pts) in medical oncology clinics throughout their care trajectory is poorly understood. Methods: This large prospective study by the Eastern Cooperative Oncology Group (ECOG) enrolled pts with invasive cancer of the breast, prostate, colon/rectum or lung regardless of phase of care or stage of disease. The study was conducted between 3/06 and 5/08 at multiple academic (n=7) and community (n=32) medical oncology clinics. Pre-defined sampling algorithms were used to reduce selection bias. At baseline and again 4 weeks later, pts completed a 25-item measure of symptoms and functional interference (M.D. Anderson Symptom Inventory-ECOG). Patients’ providers simultaneously prioritized their symptoms. Results: 3124 patients were enrolled (90% from community clinics) and 3077 were analyzable with 1524 breast (50%), 715 colorectal (23%), 518 lung (17%), and 320 prostate (10%) pts. The most prevalent moderate-to-severe symptoms of the full cohort at baseline (B) and follow-up (F) were: fatigue (B34% to F32%), disturbed sleep (B27% to F21%), drowsiness (B22% to F21%), hair loss (B20% to F19%), pain (B19% to F18%), dry mouth (B19% to F15%), and numbness/tingling (B19% to F17%). At baseline, 40% of the cohort had at least 3 moderate-to-severe symptoms and 36% had this attribute at follow-up. Clinician perception of symptoms was strongly correlated with patient symptom survey results regardless of disease site, race, or ethnicity. Of the 849 pts receiving anti-cancer treatment for metastatic disease, half had 2 or more metastatic sites with 75% receiving cytotoxic chemotherapy. Clinicians judged lung cancer patients’ symptoms to be the most difficult to manage (p<0.01). Conclusions: Non-pain symptoms, particularly fatigue and sleep disturbance, are a major source of symptom distress in ambulatory medical oncology practice. Overall, symptom burden remains substantial and difficult to resolve. These data will help guide future interventional studies.

No significant financial relationships to disclose.

The utility of the MDASI-BT in assessing symptoms in patients with brain metastases

2052

Background: Symptom occurrence has been shown to predict treatment course and survival in patients with solid tumors. The M. D. Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT) was recently validated in patients with primary brain. This study evaluated the reliability and validity of the MDASI-BT as well as symptom severity and prevalence in patients with brain metastases. Methods: Patients diagnosed with systemic cancer with brain metastases participated in this cross-sectional study. Data collection included demographic and clinical factors, and the MDASI-BT (0–10 scale). The average for the 22 symptoms and 6 interference items scores the MDASI-BT was computed. Construct validity was assessed using confirmatory factor analysis, and known-group validity was evaluated by detecting group differences due to disease severity and performance status. For reliability, Cronbach’s alpha values were computed for each subscale. Results: A sample of 124 patients participated, of which 53.2% females. Participants were primarily white (79.8%) and married (78.2%), with a variety of solid tumor malignancies represented. Factor analysis revealed six underlying constructs including affective, cognitive, focal neurologic deficit, constitutional, gastrointestinal, and interference with life. This solution explained 68.4% of the variance, and satisfied Harman’s criteria for model fit. Known-group validity was established for the MDASI-BT using the Karnofsky performance status (KPS). Mean symptom scores were 1.2 and 2.6, and mean interference were 1.8 and 4.3, for patients with good (90–100) and poor KPS (80 and below) respectively (p<0.001). These subscales were also sensitive to opioid analgesic use with group differences of 1.5 and 2.2 (p<0.001). Cronbach’s alpha was 0.9 for each of the two subscales. Fatigue, sleep disturbance, drowsiness, distress, and dry mouth were the most severe symptoms. Conclusions: The MDASI-BT demonstrated validity and reliability in patients with brain metastases and can be used to identify symptom occurrence related to the tumor and therapies.

No significant financial relationships to disclose.

Prevalence and temporal patterns of persistence of symptoms in 165 rectal cancer patients receiving preoperative chemoradiation therapy

19580

Background: The symptom burden during preoperative chemoradiation therapy for rectal cancer (CRT) has not been objectively characterized previously. The severity and temporal patterns of patient self-reported symptoms during CRT were assessed using the MD Anderson Symptom Inventory (MDASI). Methods: 165 consecutive patients with T3/T4/N+ rectal cancer received 45–55 Gy in 25–30 fractions concurrently with capecitabine chemotherapy. No additional intervention beyond standard supportive care was triggered by the MDASI score severity. The mean symptom scores were grouped into three time points; weeks 0–1 (“baseline”), 2–3 (“early treatment”), and 4–6 (“late treatment”) of CRT. Lowess curves were used to demonstrate the severity and pattern of individual symptoms. Linear mixed models were used to assess changes in symptom severity. Repeated measures analyses compared the mean severity of the reported symptoms at the three time points. Results: The median number of data points per patient was 3.0 (range, 1–6), for a total of 533 data points. Lowess curves demonstrated increasing symptom severity during CRT, which was confirmed by the linear mixed models analysis for each symptom (p<0.05). Using repeated measures with the three time points, these symptoms, except fatigue, showed statistically significant differences in mean severity ( Table 1 ). High baseline fatigue levels blunted statistical power to detect differences during CRT. Despite normal hemoglobin levels, fatigue remained the most severe symptom. Placed in context, the mean symptom levels remained mild throughout CRT. Conclusions: CRT was associated with a high prevalence of and progressive increase in symptom burden during therapy although the functional impact was limited. All symptoms followed clinically recognized patterns. The linear mixed model, a more sensitive measure of these trends, is recommended for prospective studies of interventions for symptom control

[Table: see text]

No significant financial relationships to disclose.

Utility of the of the M. D. Anderson Symptom Assessment Inventory (MDASI) for symptom evaluation during chemoradiation (CRT) in patients with gastrointestinal malignancies

6613

Background: Symptom assessment has become an important therapeutic endpoint in clinical trials. Measures that evaluate symptoms during CRT are needed for evaluation of clinical benefit in developing therapeutics and in monitoring quality improvement in clinical practice. Methods: 330 patients with gastrointestinal malignancies (Liver/Biliary:44; Colon:45; Rectal:197; Gastric:44) were evaluated during CRT with the self-reported MDASI-GI. All patients received 45–56Gy of radiation (1.8Gy/fraction); 78% received between 45–50.4Gy. In all cases fluoropyrimidine (oral or intravenous) was given concurrently during radiation. Lowess curves were used to describe the severity and pattern of each symptom evaluated. ANOVA was used to compare the mean severity of symptoms by tumor type. Follow-up evaluations were performed with a t-test using a Bonferroni corrected level of significance [p< 0.002]. Results: Relationships among symptoms were examined using 1,020 symptom measurements (Liver/Biliary:141; Colon:132; Rectal:613; Gastric:134 observations). Lowess curves showed almost parallel steep increases in pain and poor appetite between weeks 2–4 of CRT. Fatigue was most profound in Liver/Biliary and Rectal cancers. As expected, no significant differences in dyspnea were found among these cancers. CRT for Rectal cancer produced the worst symptom burden with significantly more pain, skin pain, and diarrhea. Consistent with clinical findings, poor appetite, nausea and vomiting were statistically more common during CRT for Gastric cancer. Conclusions: The MDASI is a brief and easy to use symptom measure in the clinical setting and is sensitive to treatment-related symptom changes during CRT in abdominopelvic malignancies.

[Table: see text]

A phase II trial of pemetrexed (P) in patients (pts) with performance status (PS) 2 and 3 as first- and second-line treatment for advanced non-small cell lung cancer (NSCLC)

18149

P (Alimta) is approved as second-line therapy in pts with advanced NSCLC. In a phase III trial comparing P with docetaxel (D), median survival was 8.3 mos (P) vs 7.9 mos (D); P had a more favorable safety profile than D (Hanna, 2004). There are few data on pts with PS 3, and ASCO 2003 guidelines recommend that chemotherapy be reserved for pts with PS 0, 1 and possibly 2. Since P is well tolerated, PS3 pts may tolerate and benefit from it. In this trial, we treated 20 pts with stage IIIb/IV NSCLC and PS 2–3 who were chemo-naive or had received 1 prior regimen. Pts received P 500 mg/m2 IV D1 Q 3 wks. All pts received folic acid, vitamin B12 and dexamethasone prophylaxis. Serial blood samples were obtained to monitor inflammatory cytokines, and symptoms were monitored using the validated MDASI instrument. All pts were assessable for toxicity-symptoms, and 17 pts were evaluable for response (assessed after first cycle). Pt characteristics: 8 pts were PS 3 (4/8 first line) and 12 pts were PS 2 (6/12 first line). Median age was 69 for PS3 and 68 for PS2. 5/8 PS3 pts and 6/12 PS2 pts were men. 2/8 PS3 pts and 4/12 PS2 pts had stage IIIb. 4/8 PS3 pts and 6/12 PS2 pts were chemo-naive. Grade 3–4 toxicities for PS3/PS2 cohorts were: neutropenia 0/1 pt, anemia 1/2, fatigue 2/0, pneumonia 1/1, hypotension 1/1, neutropenic fever 0/1, atrial fibrillation 1/1. Response rates (RR) in PS3 pts were minor response (MR) 1/8, stable disease (SD) 5/8, progressive disease (PD) 2/8; RR in PS2 pts were partial response (PR) 1/12, MR 2/12, SD 3/12, PD 3/12, inevaluable 3/12. RR by line of therapy: first-line 6/10 SD, 2/10 PD, 2/10 inevaluable, and second-line, 1/10 PR, 2/10 MR, 3/10 SD, 3/10 PD, and 1/10 inevaluable. Reasons for PS3 pts coming off study were progression (4/8), constitutional toxicity (3/8), fatal pulmonary emboli (1/8); PS2 pts came off study due to progression (5/12), constitutional toxicity (2/12), and pneumonia (1/12). 4/12 PS2 pts are still on study. These preliminary data suggest that single-agent P is well-tolerated and has a promising RR in poor PS pts. Total planned accrual is 30 PS3 and 45 PS2 pts. Survival, symptom, cytokine data will be presented.

[Table: see text]

The adequacy of pain treatment in advance stage non-small cell lung cancer: A longitudinal study

17016

Background: Pain is a prevalent symptom in advance stage non-small- cell lung cancer (NSCLC). Previous studies have shown these patients to be at risk for inadequate pain management. This longitudinal study evaluated pain and analgesic management in this patient population. Patients were treated at a major tertiary cancer center. Methods: Data from 102 patients receiving chemotherapy were used. Their pain was assessed weekly using the pain item from the M.D. Anderson Symptom Inventory, administered through an interactive voice response system. Analgesic orders were collected three times every two cycles of chemotherapy across 18 weeks (T1, T2 and T3). Adequacy of pain management was evaluated by the Pain Management Index (PMI). Chi-square tests were used to test for differences in proportions. Results: This analysis was based on all available data, as sensitivity analyses of pain trajectory by dropout as a function of time did not show differences. At baseline, 60% of 102 patients reported pain (ratings of 1 or greater on a 0- 10 scale) with the following distributions: 39% mild, 14% moderate and 7% severe. The proportions of patients with moderate to severe pain were 21%, 15%, 17% and 20% at baseline, T1, T2 and T3, respectively. The proportion of patients with moderate to severe pain did not increase over time. According to the PMI, there were 21%, 18%, 15% and 21% of patients who were inadequately treated at baseline, T1, T2 and T3, respectively. The percentages of patient receiving orders for strong opioids were 19%, 25%, 26% and 41% at baseline, T1, T2 and T3, respectively. Conclusions: About 80% of patients seen in a major tertiary cancer center were adequately treated for pain, while about 20% of patients experienced moderate to severe pain. Both these percentages were seen over time and did not significantly change during the course of their cancer treatment. These may be accounted for by a significant increase in the prescription orders for strong opioids by twice as much during the latter stage of their treatment.

No significant financial relationships to disclose.

Symptom burden and survival outcome: 3 cycles versus 6 cycles of chemotherapy in advanced NSCLC

17054

Background: Improving survival and quality of life is the primary treatment goal for patient with advanced NSCLC receiving palliative chemotherapy. The optimal treatment duration remains to be determined, and there are few studies that examine longitudinal symptom burden in this population. Methods: We prospectively collected self-reported symptom data from advanced stage NSCLC patients receiving chemotherapy. Symptom data was collected weekly utilizing the MD Anderson Symptom Inventory (15 symptoms) pre chemotherapy until therapy discontinuation or up to 26 weeks. Principal components analysis of symptoms measures with a Varimax rotation were used to identify symptom clusters. A piecewise linear mixed-effect regression model was used to estimate the changes over time in symptom severity, and Cox modeling was used for data analysis. Results: Data from 102 subjects were available for analysis. Chemotherapy was primarily discontinued because of tumor progression or a decline in the patient's functional status. Seventy patients received only 2 cycles of chemotherapy, while 46 and 29 patients received 4 and 6 cycles of chemotherapy, respectively. Four clusters of symptoms were identified prior to therapy, including: general symptoms (such as pain, fatigue, sleeping disturbance), GI distress (nausea, vomiting, lack of appetite & constipation), affective symptoms (sadness & distress) and specific disease related symptoms (coughing & shortness of breath). In patients who received = 3 cycles of chemotherapy, a rapid increased in symptom severity was observed, compared to those who received > 3 cycles (P<.05). Patients who received =3 cycles of chemotherapy demonstrated shorter survival compared to those who received > 3 of chemotherapy (HR=9.9, CI=4–22.7, P<.001). Conclusion: Patients with advanced NSCLC who received more than 3 cycles of chemotherapy demonstrated more stable symptom burden and longer survival compared to those who received = 3 cycles of chemotherapy.

No significant financial relationships to disclose.

Baseline and temporal patterns of fatigue predict pathological response in patients treated with preoperative chemoradiation therapy (CRT) for rectal cancer

14522

Background: We investigated whether symptom burden before and during preoperative chemoradiation therapy (CRT) for rectal cancer predicts for pathological response, a surrogate for treatment outcome. Methods: Fifty-four patients with T3/T4/N+ rectal cancers were treated on a Phase II trial using preoperative capecitabine and concomitant boost radiotherapy. Most patients had T3 tumors (94%) and hemoglobin > 12 (85%). Symptom burden was prospectively assessed prior to (baseline) and weekly during CRT by a patient self-reported questionnaire, the MD Anderson Symptom Inventory (MDASI). Survival probabilities were estimated non-parametrically using Kaplan-Meier’s product limit method. Lowess curves were plotted for symptom burden across time. Logistic regression was used to determine whether symptom burden levels predicted for pathological response. Results: Among 51 patients evaluable for pathological response, 9 patients (18%) achieved pCR, and 26 patients (51%) had TDS. The actuarial rates of local control (LC), disease-free survival (DFS), and overall survival (OS) at 2 years were 93%, 76%, and 98%, respectively. Patients with TDS had lower levels of fatigue at baseline and at completion (week 5) of CRT compared to those without TDS (p = 0.03 for both). A similar trend was not observed for other symptom burden parameters of pain, sleep disturbance, appetite, nausea, or feeling of sadness. Evaluation of the potential effect of symptom burden on pCR, LC, DFS, or OS was not possible because of the low number of events during the 2-year median follow-up. Conclusions: Lower levels of fatigue at baseline and completion of CRT were significant predictors of pathological response, as gauged by TDS. Unlike studies that have documented improved quality of life among responders, our study demonstrates the converse, i.e. fatigue, a measure of symptom burden, independently predicted for tumor response. This provocative finding could potentially be used to stratify patients into prognostic groups, influence treatment decisions, and/or modify treatment. An evaluation of changes in cytokine profile during CRT is ongoing to determine the molecular basis of this phenomenon.

No significant financial relationships to disclose.

Validation of the M. D. Anderson symptom inventory (MDASI-BT)

1546

Background: The occurrence of symptoms has been shown to predict treatment course and survival in a number of solid tumor patients. Primary brain tumor patients are unique in the neurologic symptoms that occur. Currently, no instrument exists that measures both neurologic and cancer-related symptoms. Methods: Patients diagnosed with Primary Brain Tumors (PBT) participated in this study. Data collection tools included a patient completed demographic data sheet, an investigator completed clinician checklist, and the core M.D. Anderson Symptom Inventory to which 18 neurologic symptoms were added (M.D. Anderson Symptom Inventory-Brain Tumor Module, MDASI-BT). The study evaluated the reliability and validity of the MDASI-BT in primary brain tumor patients. Results: 201 patients participated in this study. Mean symptom severity of items as well as cluster analysis was used to reduce the number of total items to 22. Regression analysis showed more than half (56%) of the variability in symptom severity was explained by the 9 remaining brain tumor items. Factor analysis was then performed to determine the underlying constructs being evaluated by the remaining items. The 22 item MDASI-BT measures six underlying constructs including affective, cognitive, focal neurologic deficit, constitutional, generalized symptom, and a gastrointestinal related factor. The internal consistency (reliability) of the sets of items comprising the six factors and also the interference scale were .87, .82, .72, .81, .69, .67 and .91 respectively). Test-retest reliability was good in a subset of 19 patients completing the instrument at two points in time. The MDASI-BT was sensitive to disease severity based on Karnofsky performance status (KPS) based on mean symptom severity (1.7 versus 3.8, p < .001) and mean symptom interference (2.2 versus 6.1, p < .001). Conclusions: The 22 item MDASI-BT demonstrated validity and reliability in patients with PBT. This instrument can be used to describe symptom occurrence throughout the disease trajectory and to evaluate interventions designed for symptom management.

[Table: see text]

Validation of the M.D. Anderson Symptom Inventory Brain Tumor Module (MDASI-BT)

BACKGROUND

Symptom occurrence has been shown to predict treatment course and survival in patients with solid tumors. Primary brain tumor (PBT) patients are unique in the occurrence of neurologic symptoms. Currently, no instrument exists that measures both neurologic and cancer-related symptoms.

METHODS

Patients diagnosed with PBT participated in this study. Data was collected at one point in time and included demographic and clinical factors, and the M.D. Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT). The study evaluated the reliability and validity of the MDASI-BT in primary brain tumor patients.

RESULTS

Two hundred and one patients participated in this study. Mean symptom severity of items as well as cluster analysis was used to reduce the number of total items to 22 (13 core, 9 brain tumor items). Regression analysis showed more than half (56%) of the variability in symptom severity was explained by brain module items. The MDASI-BT measures six underlying constructs including affective, cognitive, focal neurologic deficit, constitutional, generalized symptom, and a gastrointestinal related factor. The internal consistency (reliability) of the instrument was 0.91. The MDASI-BT was sensitive to disease severity based on performance status (P<0.001), tumor recurrence (P<0.01), and mean symptom interference (P<0.001).

CONCLUSIONS

The 22 item MDASI-BT demonstrated validity and reliability in patients with PBT. This instrument can be used to identify symptom occurrence throughout the disease trajectory and to evaluate interventions designed for symptom management.

Greek brief pain inventory: validation and utility in cancer pain

OBJECTIVE

The Brief Pain Inventory (BPI) is a pain assessment tool. It has been translated into and validated in several languages. The purpose of this study was the translation into and validation of the BPI in Greek. Moreover, we wanted to detect cultural and social differences, if any, of pain interference in patients' lives.

METHODS

The translation and validation of the inventory took place at the Areteion Hospital. The final validation sample consisted of 220 cancer patients (123 males, 97 females, age range 21-87 years, mean age 61.3). Primary cancer locations were lung 25.6%, gastrointestinal tract 25.6%, breast 11.5%, prostate 7.07%, gynecological cancers 9.6% and others 20.57%. The patients themselves completed the majority of the Greek BPI (G-BPI) papers. The pain management index (PMI) was also calculated in order to assess the adequacy of pain treatment. Assessing the reliability and the validity made the actual validation of the G-BPI.

RESULTS

Pain severity and pain management: 147 patients reported severe pain, 48 patients moderate, and 25 patients mild pain (mean average pain 6.22). From these patients only 21 were found on strong and 33 on weak opioid treatment, while 166 patients were found on no opioid analgesic treatment. In agreement with these data is the PMI which was positive only for 9 patients, while 44 patients had PMI = 0 and all the others had negative PMI scores. Reliability and Validity of the G-BPI: Coefficient alphas were 0.849 for the interference items and 0.887 for the severity items. Additionally, the factor analysis of the G-BPI items results in a two-factor solution, that satisfies the criteria of reproducibility, interpretability and confirmatory setting.

CONCLUSION

This study shows the efficacy of the G-BPI for the assessment of pain severity as well as the pain management in Greece, and therefore its utility in improving the analgesic treatment outcome in Greek patients.

NCCN Practice Guidelines for Cancer Pain

The overall approach to pain management encompassed in these guidelines is comprehensive. It is based on objective pain assessments, utilizes both pharmacologic and nonpharmacologic interventions, and requires continual reevaluation of the patient. The NCCN Cancer Pain Practice Guidelines Panel believes that cancer pain can be well controlled in the vast majority of patients if the algorithms presented are systematically applied, carefully monitored, and tailored to the needs of the individual patient.

NCCN Practice Guidelines for Cancer-Related Fatigue

These guidelines propose a treatment algorithm in which patients are evaluated regularly for fatigue, using a brief screening instrument, and are treated as indicated by their fatigue level. The algorithm's goal is to identify and treat all patients with fatigue that causes distress or interferes with daily activities or functioning. Management of fatigue begins with primary oncology team members who perform the initial screening and either provide basic education and counseling or expand the initial screening to a more focused evaluation for moderate or higher levels of fatigue. At this point the patient is assessed for the five primary factors known to be associated with fatigue: pain, emotional distress, sleep disturbance, anemia, and hypothyroidism. If any of these conditions are present, it should be treated according to practice guidelines, and the patient's fatigue should be reevaluated regularly. If none of the primary factors is present or the fatigue is unresolved, a more comprehensive assessment is indicated--with referral to other care providers as appropriate. The comprehensive assessment should include a thorough review of systems, review of medications, assessment of comorbidities, nutritional/metabolic evaluation, and assessment of activity level. Management of fatigue is cause-specific when conditions known to cause fatigue can be identified and treated. When specific causes, such as infection, fluid and electrolyte imbalances, or cardiac dysfunction, cannot be identified and corrected, nonpharmacologic and pharmacologic treatment of the fatigue should be considered. Nonpharmacologic interventions may include a moderate exercise program to improve functional capacity and activity tolerance, restorative therapies to decrease cognitive alterations and improve mood state, and nutritional and sleep interventions for patients with disturbances in eating or sleeping. Pharmacologic therapy may include drugs such as antidepressants for depression or erythropoietin for anemia. A few clinical reports of the use of corticosteroids and psychostimulants suggest the need for further research on these agents as a potential treatment modalities in managing fatigue. Basic to these interventions, the effective management of cancer-related fatigue involves an informed and supportive oncology care team that assesses patients' fatigue levels regularly and systematically and incorporates education and counseling regarding strategies for coping with fatigue (Johnson, 1999), as well as using institutional fatigue management experts for referral of patients with unresolved fatigue.

Pain management guidelines: implications for managed care--a roundtable discussion

One of the most important concerns of patients with cancer, particularly those with metastatic disease, is "Will I be in constant pain?" This is a similar concern voiced by patients with late-stage human immunodeficiency virus infection. The management of chronic pain has enormous implications on a patient's ability to function and on his or her quality of life. In June 1996, Medical Interface convened a panel of experts in Chicago to discuss pain management therapies, guidelines, and how these issues will affect, and be affected by, the managed care environment.

Physiologic and psychobehavioral research in oncology

A major thrust in research in psychosocial oncology is the study of the interaction of psychologic and physiologic variables. This discussion reviews the current status and future directions of such research. Areas addressed include pain, nausea and vomiting with chemotherapy, sexuality, effects of cancer on psychologic and neuropsychologic function, impact of psychologic factors on cancer and its treatment, and psychoneuroimmunology. In addition, specific recommendations for strategies to facilitate research in these areas of psychosocial oncology are proposed.

The Indians have many terms for it: stuttering among the Bannock-Shoshoni

This report follows by 23 years correspondence between Wendell Johnson and Sven Liljeblad in which Liljeblad pointed out that among North American "nonstuttering" Indians there were Indians who stuttered. He also reported several terms that referred to stuttering. An unpublished study reported by Frank confirmed Liljeblad's claims. Since we must rely on published reports, it is important to get these findings into print for future scholars. Though these findings in no way refute the claimed importance of linguistics and cultural variables as contributing to the development of stuttering, they do call to question evidence supporting the view that stuttering is a diagnosogenic disorder. Historical and sociological issues related to these contradictory findings are similar to those discussed by Freeman.

Biofeedback in urology using urodynamics: preliminary observations

Biofeedback training aided by urodynamic instrumentation produced significant clinical improvement in 4 of 8 urological patients. The display of electromyographic activity of the periurethral striated muscles was facilitated by the use of a new intraurethral catheter with 5 surface mounted electrodes. This modality of treatment seems worth considering for selected patients with urinary retention or urinary incontinence.

Movement disorders as a complication of acute hemiplegia of childhood

We evaluate three cases of acute hemiplegia in childhood complicated by tremor and/or choreoathetosis. Each patient experienced the abrupt onset of hemiplegia thought to be localized to an insult involving the middle cerebral distribution without associated seizure, trauma, loss of consciousness or demonstrable cardiac, hematological or neoplastic causes. All three patients recovered most, if not all, strength on the affected side, but each was left with a disorder of movement involving the previously hemiplegic upper extremity. These disorders included resting and intention tremors, as well as choreoathetosis. Anticholinergic drugs failed in treating two patients, but biofeedback techniques were quite successful in one of the two patients so treated.