BY SARAH DIGIULIO
The American Society of Clinical Oncology has released three new evidence-based clinical practice guidelines on the prevention and management of symptoms that affect cancer survivors: neuropathy, fatigue and depression, and anxiety. The Society notes that these are the first three in a planned series of guidelines on survivorship care, and all are now available online ahead of print in the Journal of Clinical Oncology (specific citations below).
The topics came from a comprehensive list of many topics in cancer survivorship care, which was developed by the ASCO Survivorship Guideline Advisory Group, Gary Lyman, MD, MPH, FASCO, FRCP(Edin), Co-Chair of that committee, explained via email. The topics were then ranked in terms of importance and need in a survey, which included experts on the Guideline Advisory Committee and others.
“These three topics were at the top of the list and were considered a good starting point for developing what will become a large ASCO portfolio of survivorship guidelines,” he said, adding that he was not able to say when future guidelines would be released, but they are in the works. Lyman also serves as Co-Director of the Hutchinson Institute for Cancer Outcomes Research in the Public Health Sciences and Clinical Research Divisions at Fred Hutchinson Cancer Research Center, as well as Professor of Medicine and Medical Oncology at the University of Washington School of Medicine.
Chemotherapy-Induced Peripheral Neuropathy
The first guideline provides recommendations for prevention and treatment of chemotherapy-induced peripheral neuropathy (CIPN) (doi: 10.1200/JCO.2013.54.0914). The guideline is based on evidence from 48 randomized controlled trials for the treatment of CIPN with primary outcomes being the incidence and severity of neuropathy as measured by neurophysiologic changes, patient-reported outcomes, and quality of life.
Key recommendations are:
- Based on a lack of high-quality, consistent evidence, no established agents are recommended for the prevention of chemotherapy-induced peripheral neuropathy in patients with cancer undergoing treatment with neurotoxic agents—but the following agents may be offered for prevention: acetyl-L-carnitine, amifostine, amitriptyline, calcium and magnesium (CaMg), dietyldithio-carbamate, glutathione, nimodipine, Org 2766, all-trans retinoic acid, recombinant human leukemia inhibitory factor (rhuLIF), and vitamin E;
- Venlafaxine is not recommended for routine use in clinical practice for prevention of CIPN (due to a lack of strong enough data to support its utility); and no recommendations can be made on the use of N-acetylcysteine, carbamazepine, glutamate, glutathione (GSH) for patients receiving cisplatin or oxaliplatin-based chemotherapy, goshajinkigan, omega-3 fatty acids, or oxycarbazepine for the prevention of CIPN;
- Clinicians may offer duloxetine to patients experiencing CIPN;
- No recommendations can be made at this time regarding the use of acetyl-l-carnitine (ALC), tricyclic antidepressants, gabapentin, or the topical gel treatment containing baclofen, amitriptyline, and ketamine—although the guideline notes that some of those agents may be tried in some patients who meet the criteria specified in the guideline.
The guideline was developed by an ASCO Expert Panel that was co-chaired by Dawn L. Hershman, MD, Associate Professor of Medicine in the Division of Hematology/Oncology at Columbia University Medical Center, and Charles L. Loprinzi, MD, Professor of Oncology at Mayo Clinic.
The second guideline provides recommendations on screening, assessment, and treatment approaches for adult cancer survivors experiencing fatigue (doi: 10.1200/JCO.2013.52.4611). The document notes that the guideline is based on an adaptation of a Pan-Canadian guideline on fatigue and two National Comprehensive Cancer Network guidelines on cancer-related fatigue and survivorship.
The guideline was written using the method created by the ADAPTE Collaboration (an international group of researchers, guideline developers, and guideline implementers), and development of the guideline was led by an ASCO Expert Panel co-chaired by Julienne E. Bower, PhD, Assistant Professor of Psychiatry and Biobehavioral Sciences Health Psychology at David Geffen School of Medicine at UCLA, and Paul Jacobsen, PhD, Associate Center Director of the Division of Population Science at Moffitt Cancer Center.
The key recommendations are categorized in three areas:
- Screening: All patients should be screened by health care providers for fatigue from the point of diagnosis onward, including following completion of primary treatment, then as clinically indicated and at least annually (and should be documented using a quantitative or semi-quantitative assessment);
- Assessment: Health care providers should assess fatigue history, disease status, and treatable contributing factors in cancer patients; and
- Treatment and Care Options: All patients should be offered education about fatigue following treatment (including the difference between normal and cancer-related fatigue, persistence of fatigue after treatment, and causes and contributing factors); patients should be offered advice on general strategies that help manage fatigue; and if treated for fatigue, patients should be followed and re-evaluated on a regular basis to determine whether treatment is effective or needs to be reassessed.
The fatigue guideline also recommends that clinicians encourage physical activity for cancer patients post-treatment as a way to help reduce cancer-related fatigue), and the guidelines make recommendations for psychosocial, mind-body, and pharmacological interventions that may be effective for reducing the condition.
Anxiety & Depression
The third new ASCO guideline provides recommendations on screening, assessment, and care of psychosocial distress—including depression and anxiety—in adults with cancer (doi: 10.1200/JCO.2013.53.4495). The guideline is based on an adaptation of the Pan-Canadian Guideline on Screening, Assessment, and Care of Psychosocial Distress (Depression, Anxiety) in Adults with Cancer, also using the ADAPTE method.
The ASCO Expert Panel who developed the guideline was co-chaired by Barbara L. Andersen, PhD, Professor at Ohio State University Comprehensive Cancer Center—Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, and Julia Howe Rowland, PhD, Director of the Office of Cancer Survivorship at the National Cancer Institute.
Key recommendations are:
- All patients with cancer and cancer survivors should be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care (and assessment should be performed using validated measures;
- Supportive care services (e.g., education about normalcy of stress in the context of cancer, signs and symptoms of distress, stress reduction strategies, and fatigue management) should be offered to all survivors;
- Depending on the levels of symptoms reported, more specific treatment pathways are recommended in the guideline—and the guideline notes that failure to identify and treat anxiety and depression in the context of cancer increases the risk for poor quality of life, and potentially increased disease-related morbidity and mortality;
- Health care providers should assess follow-through on referrals and compliance with treatment recommendations (as the guideline notes, it is common for patients with symptoms of depression and/or anxiety to disregard such recommendations); and
- Health care practitioners implementing the recommendations should first identify the available resources in their institutions and community for the treatment of depressive and anxiety symptoms (availability and accessibility of supportive care services being important in preventing or reducing the severity of these symptoms).