Fatigue in gynaecological cancer patients: a pilot study

Surgical Oncology: Evolution of Postoperative Fatigue and Factors Related to Its Severity

BACKGROUND

Fatigue has been reported by many patients undergoing surgery and is associated with a negative prognosis. The factors associated with postoperative fatigue and its evolution during the postoperative period are unclear. Adequate fatigue measurement instruments are necessary to obtain reliable evaluations and to direct effective care to control fatigue in this patient population.

OBJECTIVES

This article describes the evolution of postoperative fatigue in patients with cancer as well as related factors.

METHODS

A review of the literature using the CINAHL® and PubMed databases was undertaken.

FINDINGS

The prevalence of moderate and severe fatigue varies during the postoperative period, with a reduction in the 12 months after surgery. Various factors (e.g., stress, anxiety, depression, pain, changes in sleep patterns) seem to influence the severity of fatigue. More evidence is needed to explore the relationship between immediate postoperative fatigue and the evolution of fatigue during the period following surgical treatment for cancer.

Prevention of nausea and vomiting: methods and utility after surgery in cancer patients?

Most cancer patients experience nausea and vomiting after surgery. Today, many methods of treatment have been developed and used for the control of such symptoms. The most important are drug therapy, relaxation, oxygen therapy and gas therapy. In addition, dexamethasone, massage therapy and using a Venturi mask have also proven effective. Due to the nature of gas consumption which leads to nausea it is recommended that use of N2O in the operating room be avoided or applied in combination with oxygen or other gases with fewer complications.

Cancer cachexia and anabolic interventions: a case report

BACKGROUND

Standard-of-care (SOC) cancer treatments are primarily aimed at reducing size and progression of a tumor. There is a need for successful supplemental anabolic therapies to combat cancer cachexia in addition to these SOC treatment modalities. Anabolic interventions, including testosterone and amino acid supplements, may be beneficial in reducing and/or reversing muscle wasting in these patient populations.

METHODS

A 48-year-old Caucasian female with recurrent cervical cancer was scheduled to receive three 21-day cycles of cisplatin and topetecan chemotherapy. She qualified, consented, and enrolled into a blinded interventional pilot study where she received daily whey protein (10 g, three times per day with meals) and a weekly injection of testosterone enanthate (100 mg intramuscular) before and during the SOC chemotherapy treatment period. Body composition, serum inflammatory markers, mixed muscle protein synthesis and breakdown rates, physical function, fatigue, and quality of life were assessed before and after the intervention period.

RESULTS

Body composition, as assessed by an increase in body weight and lean body mass and reduction in fat mass; physical function; fatigue; and quality of life each improved across the entire intervention period despite general increases in inflammatory markers and no improvements in muscle protein turnover towards the end of the intervention.

CONCLUSIONS

Concomitant treatment of oral amino acids and testosterone may be a viable therapeutic option for fighting cachexia and improving body composition and quality of life during chemotherapeutic treatment of recurrent cervical cancer. These positive outcomes may be attainable over time despite overall poor inflammatory status.

A randomized phase III clinical trial of a combined treatment for cachexia in patients with gynecological cancers: evaluating the impact on metabolic and inflammatory profiles and quality of life

OBJECTIVES

Gynecological neoplastic disease progression is characterized by specific energy metabolism alterations and by symptoms including fatigue, anorexia, nausea, anemia, and immunodepression, which result in a cachexia syndrome and a marked decrease in patient quality of life (QoL). Therapeutic protocols associated with appropriate and effective psychological and social support systems are essential to counteract the symptoms of neoplastic disease in incurable patients.

METHODS

A phase III randomized study was performed to establish the most effective and safest treatment to improve the key symptoms in advanced gynecological cancer patients, i.e., lean body mass (LBM), resting energy expenditure (REE), fatigue, and QoL. In addition, the impact of the treatment arms on the main metabolic and inflammatory parameters, including C-reactive protein (CRP), interleukin (IL)-6, tumor necrosis factor (TNF)-α, leptin, reactive oxygen species (ROS), and glutathione peroxidase, was evaluated. The change in the Glasgow Prognostic Score (GPS) during treatment was also assessed. A total of 104 advanced-stage gynecological cancer patients were enrolled and randomly assigned to receive either megestrol acetate (MA) plus l-carnitine, celecoxib, and antioxidants (arm 1) or MA alone (arm 2). The treatment duration was 4 months.

RESULTS

The combination arm was more effective than arm 2 with respect to LBM, REE, fatigue, and global QoL. As for the secondary efficacy endpoints, patient appetite increased, and ECOG PS decreased significantly in both arms. The inflammation and oxidative stress parameters IL-6, TNF-α, CRP, and ROS decreased significantly in arm 1, while no significant change was observed in arm 2.

CONCLUSIONS

The combined treatment improved both immunometabolic alterations and patient QoL. Multimodality therapies for cachexia ideally should be introduced within a context of "best supportive care" that includes optimal symptom management and careful psychosocial counseling.

Randomized phase III clinical trial of five different arms of treatment in 332 patients with cancer cachexia

PURPOSE

A phase III, randomized study was carried out to establish the most effective and safest treatment to improve the primary endpoints of cancer cachexia-lean body mass (LBM), resting energy expenditure (REE), and fatigue-and relevant secondary endpoints: appetite, quality of life, grip strength, Glasgow Prognostic Score (GPS) and proinflammatory cytokines.

PATIENTS AND METHODS

Three hundred thirty-two assessable patients with cancer-related anorexia/cachexia syndrome were randomly assigned to one of five treatment arms: arm 1, medroxyprogesterone (500 mg/day) or megestrol acetate (320 mg/day); arm 2, oral supplementation with eicosapentaenoic acid; arm 3, L-carnitine (4 g/day); arm 4, thalidomide (200 mg/day); and arm 5, a combination of the above. Treatment duration was 4 months.

RESULTS

Analysis of variance showed a significant difference between treatment arms. A post hoc analysis showed the superiority of arm 5 over the others for all primary endpoints. An analysis of changes from baseline showed that LBM (by dual-energy X-ray absorptiometry and by L3 computed tomography) significantly increased in arm 5. REE decreased significantly and fatigue improved significantly in arm 5. Appetite increased significantly in arm 5; interleukin (IL)-6 decreased significantly in arm 5 and arm 4; GPS and Eastern Cooperative Oncology Group performance status (ECOG PS) score decreased significantly in arm 5, arm 4, and arm 3. Toxicity was quite negligible, and was comparable between arms.

CONCLUSION

The most effective treatment in terms of all three primary efficacy endpoints and the secondary endpoints appetite, IL-6, GPS, and ECOG PS score was the combination regimen that included all selected agents.

Fatigue in gynecological cancer patients during and after anticancer treatment

CONTEXT

Research has indicated that individuals with gynecological cancer experience severe fatigue.

OBJECTIVES

This longitudinal survey aimed to analyze the fatigue experienced over the course of one year by a gynecological cancer population, to determine if the fatigue was more severe than that reported by females without cancer, and to identify variables associated with cancer-related fatigue (CRF).

METHODS

Data were collected over a 12-month period before, during, and after anticancer treatment. Fatigue was assessed using the Multidimensional Fatigue Symptom Inventory-Short Form. Participants with cancer also completed the Rotterdam Symptom Checklist.

RESULTS

Sixty-five cancer patients (mean age = 57.4 years, standard deviation [SD] = 13.9) and 60 control subjects (mean age = 55.4 years, SD = 13.6) participated. Descriptive analysis and repeated measurements modeling indicated that the cancer participants reported worse fatigue than the noncancer individuals before, during, and after anticancer treatment (P < 0.001) and that the level of fatigue in persons with cancer changed with time (P = 0.02). A forward stepwise regression demonstrated that psychological distress level was the only independent predictor of CRF during anticancer treatment (P < 0.00), explaining 44% of the variance in fatigue. After treatment, both psychological distress level (P < 0.00) and physical symptom distress (P = 0.03) were independent predictors of fatigue, accounting for 81% of the variance.

CONCLUSION

Psychological distress level is an important indicator of CRF in gynecological cancer. Interventions focused on the reduction of psychological distress may help alleviate CRF.

Phase II nonrandomized study of the efficacy and safety of COX-2 inhibitor celecoxib on patients with cancer cachexia

Chronic inflammation is one of the main features of cancer cachexia. Experimental and clinical studies showed that cyclooxygenase-2 inhibitors, such as celecoxib, may be beneficial in counteracting major symptoms of this devastating syndrome. We carried out a prospective phase II clinical trial to test the safety and effectiveness of an intervention with the COX-2 inhibitor celecoxib (300 mg/day for 4 months) on key variables of cachexia (lean body mass, resting energy expenditure, serum levels of proinflammatory cytokines, and fatigue) in patients with advanced cancer at different sites. A sample of 24 patients was enrolled from January to December 2008 and all were deemed assessable. A significant increase of lean body mass and a significant decrease of TNF-alpha were observed. Moreover, an improvement of grip strength, quality of life, performance status, and Glasgow prognostic score was shown. There were no grade 3/4 toxicities. Patient compliance was very good; no patient had to reduce the celecoxib dosage nor interrupt treatment. Our results showed that the COX-2 selective inhibitor celecoxib is an effective single agent for the treatment of cancer cachexia. Although the treatment of cancer cachexia, a multifactorial syndrome, is more likely to yield success with a multitargeted approach; in the present study, we were able to show that a treatment, such as celecoxib, addressing a single target, albeit very important as chronic inflammation, could have positive effects. Therefore, phase III clinical trials are warranted to test the efficacy and safety of celecoxib.

The measurement of fatigue in chronic illness: a systematic review of unidimensional and multidimensional fatigue measures

Fatigue is a common symptom associated with a wide range of chronic diseases. A large number of instruments have been developed to measure fatigue. An assessment regarding the reliability, validity, and utility of fatigue measures is time-consuming for the clinician and researcher, and few reviews exist on which to draw such information. The aim of this article is to present a critical review of fatigue measures, the populations in which the scales have been used, and the extent to which the psychometric properties of each instrument have been evaluated to provide clinicians and researchers with information on which to base decisions. Seven databases were searched for all articles that measured fatigue and offered an insight into the psychometric properties of the scales used over the period 1980-2007. Criteria for judging the "ideal" measure were developed to encompass scale usability, clinical/research utility, and the robustness of psychometric properties. Twenty-two fatigue measures met the inclusion criteria and were evaluated. A further 17 measures met some of the criteria, but have not been tested beyond initial development, and are reviewed briefly at the end of the article. The review did not identify any instrument that met all the criteria of an ideal instrument. However, a small number of short instruments demonstrated good psychometric properties (Fatigue Severity Scale [FSS], Fatigue Impact Scale [FIS], and Brief Fatigue Inventory [BFI]), and three comprehensive instruments demonstrated the same (Fatigue Symptom Inventory [FSI], Multidimensional Assessment of Fatigue [MAF], and Multidimensional Fatigue Symptom Inventory [MFSI]). Only four measures (BFI, FSS, FSI, and MAF) demonstrated the ability to detect change over time. The clinician and researcher also should consider the populations in which the scale has been used previously to assess its validity with their own patient group, and assess the content of a scale to ensure that the key qualitative aspects of fatigue of the population of interest are covered.