Blog | Wednesday, April 16, 2014

QD: News Every Day--3 guidelines to help clinicians manage cancer survivor's care

Three evidence-based clinical practice guidelines were created to guide clinicians as they manage cancer survivors symptoms of neuropathy, fatigue and depression, and anxiety.

The American Society of Clinical Oncology released the guidelines as the first in a planned series of physicians and patient materials.

The first guideline, Prevention and Management of Chemotherapy-induced Peripheral Neuropathy in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline, provides evidence-based recommendations for the prevention and treatment of chemotherapy-based peripheral neuropathy (CPIN), which affects an estimated 30% to 40% of people treated with chemotherapy. The guideline, based on a literature search that found 48 randomized clinical trials for management of CIPN, identifies drugs that may be helpful in diminishing the symptoms, but it does not recommend any agents for prevention.

“There is no clear panacea for neuropathy,” Gary H. Lyman, MD, MPH, FACP, co-chair of the ASCO Survivorship Guidelines Advisory Group, said in a press release. “Some of the drugs used for prevention or treatment of neuropathy may cause side effects or interfere with other drugs. We want to be clear that if there is no evidence of benefit from those drugs, it’s probably best not to take them.”

Key guideline recommendations are:
• Due to lack of high-quality, consistent evidence, no established agents are recommended for the prevention of CIPN in people with cancer undergoing treatment with neurotoxic agents;
• Specifically, the following agents should not be offered for prevention of CIPN: acetyl-L-carnitine, amifostine, amitriptyline, CaMg, dietyldithio-carbamate, glutathione, nimodipine, Org 2766, all-trans retinoic acid, rhuLIF, and vitamin E;
• Clinicians may offer duloxetine to patients experiencing CIPN; and
• While there is no strong evidence of benefit from for use of tricyclic antidepressants, gabapentin, and a topical gel containing baclofen, amitriptyline, and ketamine, it may be reasonable to try those agents in select patients.

Physicians cannot predict who will develop CIPN, how severe the symptoms will be, and how long they will last. If CIPN is recognized early, symptoms and risk of permanent nerve damage can be decreased by selecting treatments that don’t have neuropathy as a side effect. Physicians are urged to talk to their patients about the potential for CIPN prior to starting therapy and to monitor for symptoms of CIPN during the course of therapy.

The second guideline, Screening, Assessment and Management of Fatigue in Adult Survivors of Cancer: an American Society of Clinical Oncology Clinical Practice Guideline Adaptation, recommends that all survivors be evaluated for symptoms of fatigue upon completion of primary treatment and be offered management strategies. It was based on a formal systematic review of clinical practice guideline databases and relevant medical literature, and the adaptation is based on a Pan-Canadian guideline on fatigue and 2 National Comprehensive Cancer Network guidelines on cancer-related fatigue and survivorship.

Key guideline recommendations are:
• All patients should be screened for fatigue from the point of diagnosis onward;
• Health care providers should assess fatigue history, disease status, and treatable contributing factors;
• All patients should be educated about differences between normal and cancer-related fatigue, causes of fatigue, and contributing factors. Patients should be offered strategies to manage fatigue, including physical activity, psychosocial interventions (e.g., cognitive and behavioral therapies, psycho-educational therapies), and mind-body interventions (e.g., yoga, acupuncture).

The third guideline, Screening, Assessment and Care of Anxiety and Depressive Symptoms in Adults with Cancer: an American Society of Clinical Oncology Clinical Practice Guideline Adaptation, emphasizes that health care providers have a vital role to play in mitigating the negative emotional and behavioral side effects of cancer. It was based on a formal systematic review of clinical practice guideline databases and relevant medical literature. The adaptation is based on a Pan-Canadian practice guideline on depression and anxiety in adults with cancer.

All people who have been treated for cancer be evaluated for symptoms of depression and anxiety, the guideline states. Supportive care services should be offered to all; those who display moderate or severe symptoms of anxiety and depression should be referred for appropriate interventions.

Additional recommendations are:
• Health care providers should periodically evaluate all survivors for symptoms of depression and anxiety;
• Assessment should be performed using validated, published measures and procedures;
• Supportive care services (e.g., education about normalcy of stress in the context of cancer, signs and symptoms of distress, stress reduction strategies, fatigue management) should be offered to all survivors; and
• Psychological, psychosocial, and psychiatric interventions should be offered to survivors with moderate or severe symptoms of depression or anxiety.

“Doctors sometimes don’t give these symptoms much attention because they think it’s normal that their patients are a little anxious or depressed about their disease,” said Dr. Lyman. “But it’s important to keep an eye on the symptoms and step in when they start to interfere with the patients’ quality of life.”

In addition to the guidelines, patient information website has updated information for survivors that is based on ASCO’s latest recommendations for managing side effects and managing emotions.