A pan-Canadian practice guideline and algorithm: screening, assessment, and supportive care of adults with cancer-related fatigue

PURPOSE

The purpose of the present systematic review was to develop a practice guideline to inform health care providers about screening, assessment, and effective management of cancer-related fatigue (crf) in adults.

METHODS

The internationally endorsed adapte methodology was used to develop a practice guideline for pan-Canadian use. A systematic search of the literature identified a broad range of evidence: clinical practice guidelines, systematic reviews, and other guidance documents on the screening, assessment, and management of crf. The search included medline, embase, cinahl, the Cochrane Library, and other guideline and data sources to December 2009.

RESULTS

Two clinical practice guidelines were identified for adaptation. Seven guidance documents and four systematic reviews also provided supplementary evidence to inform guideline recommendations. Health professionals across Canada provided expert feedback on the adapted recommendations in the practice guideline and algorithm through a participatory external review process.

CONCLUSIONS

Practice guidelines can facilitate the adoption of evidence-based assessment and interventions for adult cancer patients experiencing fatigue. Development of an algorithm to guide decision-making in practice may also foster the uptake of a guideline into routine care.

Does NSCLC patient-rated performance status predict survival more accurately than physician ratings?

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Background: The Eastern Cooperative Oncology Group (ECOG) score is a well known predictor of survival, which impacts on treatment decisions. Patient (pt) rated activity level, using the Patient Generated Subjective Global Assessment (PG-SGA) scale, is identical in criteria to the ECOG scale used by physicians. We compared the patient rated activity level (Pt-PS) to physician rated PS (MD-PS), at baseline, and evaluated survival with respect to the 2 PS ratings. Methods: Pts with newly diagnosed advanced NSCLC (stages 3–4) completed a PG-SGA self rated questionnaire, which was then compared to the physician-generated ECOG score recorded prior to any treatment using a Wilcoxon signed rank test. Pts were treated with standard chemotherapy. Survival analysis was performed using a Kaplan Meier analysis and Cox regression. Results: 92 pts (M: F-48:44) with a mean age of 65 years (39–83) were included. 67 (73%) presented with stage 4 disease. 62 (67%) had an MD-PS of 0–1, whereas only 51 (55%) had a Pt-PS of 0 -1. MD-PS 3–4 was seen in 9 (10%), compared to 28 (30%) by Pt-PS. Pt-PS was significantly different from MD-PS in 48% of scores (p=0.003). When scores were not congruent, 29/44 (66%) pts evaluated themselves as having a worse PS than the physician. Survival analysis demonstrated that stage and functional status irrespective of method of reporting was predictive of survival (p=0.01 for MD-PS and p=0.001 for Pt-PS). However, when comparing median survival by method of performance status evaluation, Pt-PS was associated with superior stratification of survival than MD-PS ( table 1 ). Conclusions: Pt-PS and MD-PS are not congruent almost 50% of the time. Pt-PS allows for better stratification of survival and should be further evaluated in prospective trials.

No significant financial relationships to disclose.

[Table: see text]

Do most newly diagnosed advanced NSCLC patients need nutritional intervention?

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Background: Depletion of nutritional reserves and significant weight loss are commonly noted in patients (pts) with non-small cell lung cancer (NSCLC). The Patient Generated Subjective Global Assessment (PG-SGA) is a nutritional screening tool for cancer pts, recommended by the Oncology Network of Dietitians of Canada and the American Dietetic Association. The PG-SGA categorizes total scores into 4 ranges for nutritional triage: 0–1 requires no intervention, 2–3 requires education, 4 - 8 requires intervention by a dietitian, and =9 requires urgent symptom control and nutrition intervention. (Ottery, 2000). Methods: We determined the prevalence of malnutrition in 92 newly diagnosed advanced NSCLC pts (stages 3 / 4) in an outpatient clinic who had completed a baseline PG-SGA. We also investigated the association between CRP (an inflammatory marker which correlates with poor prognosis) and the PG-SGA. PG-SGA score was based on the sum of 4 subscales: symptoms, weight history, food intake and functional status. Results: 92 pts (M 48, F 44) aged 65 ±11 years were studied. 21 (23%) pts had a PG-SGA score of 0–3, 23 (25%) 4–8, and 48 (52%) of 9 or greater. The most common symptoms accounting for a high PG-SGA score were: no appetite 37 (40%), pain 27 (29%), constipation 26 (28%), feeling full 24 (26%), dry mouth 22 (24%) and taste changes 19 (21%). 51 (55%) pts lost 0–4.9% of their body weight in the past month, 17 (19%) had a weight loss of 5–9.9% and 24 (26%) had a weight loss =10 %. In pts with a PG-SGA score of 0–3 the median CRP was 7.0 mg/L (range: 0.7–66.0), in those with a score of 4–8 the median CRP was 41.8 mg/L (0.8–266.1) and in those with a score of =9 the median CRP was 18.5 mg/L (0.3–219.0) (p=0.02). Conclusion: At time of diagnosis, 77% of advanced NSCLC pts were in need of nutritional intervention; 52% required urgent intervention. The PG-SGA is a simple screening tool which should be incorporated into patient care in outpatient oncology clinics.

No significant financial relationships to disclose.

Circulation time end points. A quantitative comparison of saccharin and radioiodinated albumin as indicators

Ideal measurements are both simple and precise. The subjective circulation time has provided more simplicity than precision to three generations of physicians attempting to analyze cardiac function. Other more complex and less available measurements have displaced the circulation time from its prior vogue, probably because of the wide ranges of normal circulation time values. Yet, no other bedside measurement of cardiac function reflects both cardiac output and central blood volume with a single result.

The peripheral arrival characteristics of radioisotope-labeled albumin are described in 15 normal subjects and in 13 patients with heart failure. These circulation-times are compared with the taste end point of the saccharin indicator simultaneously injected.

Taste threshold, a variable not dependent on cardiac status, determines a significant proportion of the circulation time in both normal and failing circulations.

The wide availability of instruments which measure radioactivity, dye density, or thermal change as a function of time could reinvest the circulation time with a new precision, in return for a modest loss of simplicity. Bypass of the noncardiac variable taste threshold may be added to the other well-described advantages of an objective circulation-time measurement by use of the time of half-peak concentration as the end point in recording the circulation time.