The Relationship Between Inflammatory Biomarkers and Symptom Distress in Lung Cancer Patients Undergoing Chemotherapy

Nonpharmacological Interventions for the Fatigue-Pain-Sleep Disturbance Symptom Cluster in Lung Cancer Patients: Best Evidence Summary

OBJECTIVES

This study aimed to summarize the most effective evidence on nonpharmacological interventions for the fatigue-pain-sleep disturbance symptom cluster in lung cancer patients and to provide evidence-based management methods for clinical team and lung cancer patients.

METHODS

Guided by the "6S" pyramid model, we retrieved evidence on fatigue, pain, and sleep disturbance management from relevant websites and databases, and unpublished gray literature was also searched. The time frame of the search ranged from database establishment to September 30, 2023. Two researchers independently evaluated the literature quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) for guidelines, and the Assessment of Multiple Systematic Reviews II (AMSTAR II) for systematic reviews. Two people independently extracted and summarized the evidence according to the first principle of high-quality evidence and newly published evidence. The included evidence was graded by the JBI Evidence Pre-Grading System.

RESULTS

A total of 52,238 articles were retrieved, of which 60 articles, including 18 guidelines, 18 JBI best practice recommendations, one Up To Date clinical practice, and 23 systematic reviews, were included. Overall, 49 pieces of evidence from six dimensions-screening, assessment, management, education, referral, and follow-up-were summarized. Forty-three pieces of evidence were level 1, three pieces of evidence were level 4, and three pieces of evidence were level 5.

CONCLUSIONS

The best 49 pieces of evidence on nonpharmacological interventions for the fatigue-pain-sleep disturbance symptom cluster in lung cancer patients were summarized in this study, and these nonpharmacological interventions are scientific and comprehensive.

IMPLICATIONS FOR NURSING PRACTICE

This study can provide guidance for clinical team to improve the fatigue-pain-sleep disturbance symptom cluster management. These evidence items can be implemented by clinical team to reduce the symptom burden and improve the self-management ability of symptoms in lung cancer patients.

Neurodegenerative disease pathways are perturbed in patients with cancer who self-report cognitive changes and anxiety: A pathway impact analysis

BACKGROUND

Cancer-related cognitive impairment (CRCI) and anxiety co-occur in patients with cancer. Little is known about mechanisms for the co-occurrence of these two symptoms. The purposes of this secondary analysis were to evaluate for perturbed pathways associated with the co-occurrence of self-reported CRCI and anxiety in patients with low versus high levels of these two symptoms and to identify potential mechanisms for the co-occurrence of CRCI and anxiety using biological processes common across any perturbed neurodegenerative disease pathways.

METHODS

Patients completed the Attentional Function Index and the Spielberger State-Trait Anxiety Inventory six times over two cycles of chemotherapy. Based on findings from a previous latent profile analysis, patients were grouped into none versus both high levels of these symptoms. Gene expression was quantified, and pathway impact analyses were performed. Signaling pathways for evaluation were defined with the Kyoto Encyclopedia of Genes and Genomes database.

RESULTS

A total of 451 patients had data available for analysis. Approximately 85.0% of patients were in the none class and 15.0% were in the both high class. Pathway impact analyses identified five perturbed pathways related to neurodegenerative diseases (i.e., amyotrophic lateral sclerosis, Huntington disease, Parkinson disease, prion disease, and pathways of neurodegeneration-multiple diseases). Apoptosis, mitochondrial dysfunction, oxidative stress, and endoplasmic reticulum stress were common biological processes across these pathways.

CONCLUSIONS

This study is the first to describe perturbations in neurodegenerative disease pathways associated with CRCI and anxiety in patients receiving chemotherapy. These findings provide new insights into potential targets for the development of mechanistically based interventions.

Comparing the sensitivity of fatigue and sleep disturbance assessment tools in women with advanced cancer undergoing chemotherapy

Objective

This study aims to investigate the variations in fatigue and sleep disturbances among female patients with advanced lung cancer (ALC) and advanced breast cancer (ABC) during chemotherapy.

Methods

A total of 36 female patients with ALC and 36 with ABC, all of whom had completed their first cycle of chemotherapy, were included. Fatigue was assessed using the General Fatigue Scale (GFS), and sleep disturbances were evaluated using the Pittsburgh Sleep Quality Index (PSQI) at designated time points throughout the chemotherapy process.

Results

Linear regression analysis indicated that variables such as age, education level, employment status, cancer type, clinical stage, and symptom distress had no significant correlation with either fatigue or sleep disturbances. The GFS significantly discriminated fatigue among the ALC, ABC, and combined groups, while the PSQI demonstrated a significant distinction in sleep disturbance only within the ALC and combined groups.

Conclusions

In summary, when considering the findings of both assessments in this study, the GFS score exhibited greater sensitivity in detecting fatigue than the PSQI score did for identifying sleep disturbances in advanced cancer patients undergoing chemotherapy.

Relationships among Inflammatory Biomarkers and Self-Reported Treatment-Related Symptoms in Patients Treated with Chemotherapy for Gynecologic Cancer: A Controlled Comparison

Previous research suggests that inflammation triggers cancer-treatment-related symptoms (i.e., fatigue, depression, and disruptions in sleep and physical activity), but evidence is mixed. This study examined relationships between inflammatory biomarkers and symptoms in patients with gynecologic cancer compared to age-matched women with no cancer history (i.e., controls). Patients (n = 121) completed assessments before chemotherapy cycles 1, 3, and 6, and 6 and 12 months later. Controls (n = 105) completed assessments at similar timepoints. Changes in inflammation and symptomatology were evaluated using random-effects mixed models, and cross-sectional differences between patients and controls in inflammatory biomarkers and symptoms were evaluated using least squares means. Associations among inflammatory biomarkers and symptoms were evaluated using random-effects fluctuation mixed models. The results indicated that compared to controls, patients typically have higher inflammatory biomarkers (i.e., TNF-alpha, TNFR1, TNFR2, CRP, IL-1ra) and worse fatigue, depression, and sleep (ps < 0.05). Patients reported lower levels of baseline physical activity (p = 0.02) that became more similar to controls over time. Significant associations were observed between CRP, depression, and physical activity (ps < 0.05), but not between inflammation and other symptoms. The results suggest that inflammation may not play a significant role in fatigue or sleep disturbance among gynecologic cancer patients but may contribute to depression and physical inactivity.

The Association Between Sleep Disturbance and Proinflammatory Markers in Patients With Cancer: A Meta-analysis

BACKGROUND

Sleep disturbance is one of the symptoms with high incidence and negative influence in patients with cancer. A better understanding of the biological factors associated with sleep disturbance is critical to predict, treat, and manage this condition.

OBJECTIVE

The aim of this study was to determine the correlation between sleep disturbance and proinflammatory markers in adult patients with cancer.

METHODS

A systematic search was conducted in 7 databases from inception to March 1, 2020, for this meta-analysis. Two reviewers independently screened the studies, extracted data, and appraised the quality of the studies. Meta-analyses were conducted using Stata 12.0 software.

RESULTS

Sixteen studies were included. Results indicated that sleep disturbance was associated with higher levels of the overall proinflammatory markers and that the effect size was small yet significant. Further subgroup analyses suggested that sleep disturbance was significantly associated with interleukin-6 and C-reactive protein, but not with interleukin-1β or tumor necrosis factor-α. Meta-regression results indicated that only the sample source affected the association between sleep disturbance and proinflammatory markers.

CONCLUSION

There was a positive relationship between sleep disturbance and selected proinflammatory markers in adult patients with cancer.

IMPLICATION FOR PRACTICE

This review provides empirical support for the association between sleep disturbance and certain proinflammatory markers. Healthcare providers can further explore specific biomarkers to precisely identify the individuals at risk of sleep disturbance and develop targeted strategies for therapeutic and clinical interventions.

Cancer-related inflammation and depressive symptoms: Systematic review and meta-analysis

BACKGROUND

Depressive symptoms in patients with cancer are associated with poor quality of life and decreased survival. Although inflammation is reliably associated with depression in otherwise healthy individuals, the association in patients with cancer remains unclear. Given the high prevalence of cancer-related inflammation, the authors aimed to establish the relationship between inflammation and depression in cancer patients based on extant literature.

METHODS

A systematic review and meta-analysis was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and registered under Prospero ID CRD42021226743. Three databases were searched including PubMed, the Cochrane Library, and PsycINFO using the following criteria for inclusion: 1) measurement of a peripheral inflammatory marker, 2) use of a validated tool/scale to measure depression, and 3) a cancer diagnosis. Risk of publication bias was assessed by Funnel plot and Egger test.

RESULTS

Seventy-three studies were included in the systematic review and 54 studies (n = 5017) were included in meta-analyses. Associations with depressive symptoms were significant for peripheral blood interleukin (IL)-6 (standardized mean difference [SMD] = 0.59; 95% confidence interval [CI], 0.35-0.82), I²  = 57.9%; tumor necrosis factor (TNF) (SMD = 0.73; 95% CI, 0.35-1.11), I²  = 74.1%; and C-reactive protein (CRP) (SMD = 0.57; 95% CI, 0.27-0.87), I²  = 0%. IL-5, IL-13, albumin, and neutrophil-to-lymphocyte ratio were associated with depressive symptoms but based on fewer studies. Most cancer settings were represented; the number of studies per inflammatory marker varied from 1 to 52.

CONCLUSIONS

Although peripheral inflammatory markers were unevenly studied, the most studied markers (IL-6, TNF, and CRP) were associated with depressive symptoms in cancer patients and may be useful for management of depressive symptoms in the cancer setting.

LAY SUMMARY

Peripheral blood inflammatory markers (IL-6, TNF, and CRP) were associated with depressive symptoms in various cancer settings. Although further studies are warranted, these findings may help identify and manage depressive symptoms in patients with cancer.

STOP Pain Project-Opioid Response in Pediatric Cancer Patients and Gene Polymorphisms of Cytokine Pathways

Moderate to severe cancer pain treatment in children is based on the use of weak and strong opioids. Pharmacogenetics play a central role in developing personalized pain therapies, as well as avoiding treatment failure and/or intolerable adverse drug reactions. This observational study aimed to investigate the association between IL-6, IL-8, and TNFα genetic single nucleotide polymorphisms (SNPs) and response to opioid therapy in a cohort of pediatric cancer patients. Pain intensity before treatment (PIt0) significantly differed according to IL-6 rs1800797 SNP, with a higher PI for A/G and G/G individuals (p = 0.017), who required a higher dose of opioids (p = 0.047). Moreover, compared to G/G subjects, heterozygous or homozygous individuals for the A allele of IL-6 rs1800797 SNP had a lower risk of having a PIt0 > 4. Dose24h and Dosetot were both higher in G/G individuals for TNFα rs1800629 (p = 0.010 and p = 0.031, respectively), while risk of having a PIt0 > 4 and a ∆VAS > 2 was higher for G/G subjects for IL-6 rs1800795 SNP compared to carriers of the C allele. No statistically significant association between genotypes and safety outcomes was found. Thus, IL-6 and TNFα SNPs could be potential markers of baseline pain intensity and opioid dose requirements in pediatric cancer patients.

Serum tumor necrosis factor-α, interleukin-1β, interleukin-6, and interleukin-17 relate to anxiety and depression risks to some extent in non-small cell lung cancer survivor

Introduction

Inflammatory cytokines are proposed as modulators for the pathogenesis of anxiety and depression (anxiety/depression), and anxiety/depression are frequently existed in non‐small cell lung cancer (NSCLC) survivors. However, no published study has explored the association of inflammation cytokines with anxiety/depression in NSCLC survivors.

Objectives

We aimed to evaluate serum tumor necrosis factor‐α (TNF‐α), interleukin‐1 beta (IL‐1β), interleukin‐6 (IL‐6), interleukin‐17 (IL‐17) levels, and their correlations with anxiety/depression in NSCLC survivors.

Methods

Totally, 217 NSCLC survivors and 200 controls were recruited. Then, inflammatory cytokines in serum samples were detected by enzyme‐linked immunosorbent assay (ELISA). Besides, their anxiety/depression status was assessed by Hospital Anxiety and Depression Scale (HADS).

Results

HADS‐anxiety score, anxiety rate, anxiety severity, HADS‐depression score, depression rate, and depression severity were all increased in NSCLC survivors compared with controls (all P < 0.001). Regarding inflammatory cytokines, TNF‐α, IL‐1β, and IL‐17 levels were higher (all P < 0.01), while IL‐6 (P = 0.105) level was of no difference in NSCLC survivors compared with controls. Furthermore, TNF‐α, IL‐1β, IL‐6, and IL‐17 were all positively associated with HADS‐A score (all P < 0.05), anxiety occurrence (all P < 0.05), HADS‐D score (all P < 0.05), and depression occurrence (all P < 0.05) in NSCLC survivors, while the correlation‐coefficients were weak. Additionally, multivariate logistic regression analyses disclosed that TNF‐α (both P < 0.05) and IL‐1β (both P < 0.001) were independently correlated with increased anxiety and depression risks in NSCLC survivors.

Conclusion

Serum TNF‐α, IL‐1β, IL‐6, and IL‐17 are related to increased anxiety and depression risks to some extent in NSCLC survivors.

Symptom Clusters Change Over Time in Patients With Lung Cancer During Perichemotherapy

BACKGROUND

Lung cancer has become the leading cause of cancer-related deaths in China, and patients often experience multiple symptoms and substantial discomfort. Understanding and managing concurrent symptoms of patients with lung cancer are crucial during perichemotherapy.

OBJECTIVE

To determine the types and components of symptom clusters according to the severity dimension and to understand how they change over time during perichemotherapy in a homogeneous population of patients with lung cancer.

METHODS

Patients were recruited using convenience sampling. The Chinese version of the MD Anderson Symptom Inventory and the revised lung cancer module were used to measure multiple symptoms at the following 3 separate points: 2 weeks before chemotherapy (T1), chemotherapy cycle 1 (T2), and chemotherapy cycle 4 (T3). Symptom clusters were identified by exploratory factor analysis.

RESULTS

A total of 144 patients with non-small cell lung cancer participated in the study. Six symptom clusters were identified at the 3 time points. Among the 6 symptom clusters, 3 symptom clusters remained stable at all time points, and differences were found in symptom clusters before and after chemotherapy.

CONCLUSIONS

Symptom clusters can change during perichemotherapy, showing some stability and differences over time.

IMPLICATIONS FOR PRACTICE

An improved understanding of symptom cluster trajectories in patients with lung cancer may facilitate effective assessment, prevention, and management of multiple concurrent symptoms. These findings will help clinicians to develop predictive interventions and reduce the symptom burden of patients undergoing chemotherapy.

P2X Receptors: Potential Therapeutic Targets for Symptoms Associated With Lung Cancer - A Mini Review

Symptoms associated with lung cancer mainly consist of cancer-associated pain, cough, fatigue, and dyspnea. However, underlying mechanisms of lung cancer symptom clusters remain unclear. There remains a paucity of effective treatment to ameliorate debilitating symptoms and improve the quality of life of lung cancer survivors. Recently, extracellular ATP and its receptors have attracted increasing attention among researchers in the field of oncology. Extracellular ATP in the tumor microenvironment is associated with tumor cell metabolism, proliferation, and metastasis by driving inflammation and neurotransmission via P2 purinergic signaling. Accordingly, ATP gated P2X receptors expressed on tumor cells, immune cells, and neurons play a vital role in modulating tumor development, invasion, progression, and related symptoms. P2 purinergic signaling is involved in the development of different lung cancer-related symptoms. In this review, we summarize recent findings to illustrate the role of P2X receptors in tumor proliferation, progression, metastasis, and lung cancer- related symptoms, providing an outline of potential anti-neoplastic activity of P2X receptor antagonists. Furthermore, compared with opioids, P2X receptor antagonists appear to be innovative therapeutic interventions for managing cancer symptom clusters with fewer side effects.

A Longitudinal Analysis of Inflammation and Depression in Patients With Metastatic Lung Cancer: Associations With Survival

BACKGROUND

Depression and inflammation are concomitantly elevated in patients with lung cancer and may have collective survival implications. However, the longitudinal relationship between depression and inflammation in patients with metastatic lung cancer is not fully appreciated. We hypothesized that longitudinal changes in inflammation and depression would be concordant; that longitudinally elevated inflammation would lead to greater depression over time; and that depression with inflammation would be more persistent than depression without inflammation.

METHODS

Patients with metastatic lung cancer (n = 68) were assessed for clinically significant depression (Hospital Anxiety and Depression Scale ≥ 8) and inflammation (C-Reactive Protein ≥ 1 mg/L) along with demographic variables. Survival estimations were made using Cox Proportional Hazard Model and Kaplan-Meier plot analyses.

RESULTS

At baseline (T1), 15% had depression and 35% had increased inflammation followed by 18% with depression and 38% with increased inflammation 4.7 months later (T2). The odds ratio of depression in the presence of clinically significant inflammation was 4.8 at T1 and 5.3 at T2. Between time points, inflammation difference correlated with depression difference (r = -.26, p = .03). Significant depression at both time points was associated with a 4 fold risk of inferior survival while significant inflammation at any time point was associated with >3 fold risk of inferior survival.

CONCLUSIONS

Depression and inflammation track together over time and have variable implications on survival. Persistent depression is particularly detrimental but incidental inflammation is more sensitive to predicting poor survival. These findings have implications for treating depression early in the lung cancer trajectory.

Periodontal disease, sleep duration, and white blood cell markers in the 2009 to 2014 National Health and Nutrition Examination Surveys

BACKGROUND

Elevated levels of inflammatory biomarkers are consistently associated with chronic conditions, for which periodontitis and sleep are established risk factors. We examined the relationships between periodontitis, hours of sleep and white blood cell (WBC) markers among a nationally representative sample of US adults.

METHODS

Cross-sectional study using existing demographic, examination, laboratory and questionnaire data on 11,813 participants (5,814 men and 5,999 women, mean age ± SE; range: 52.74 ± 0.24; 30 to 80 years) from the 2009 to 2014 National Health and Nutrition Examination Surveys. Unadjusted, sex- and age-adjusted, as well as fully adjusted linear and logistic regression models were conducted in addition to generalized structural equations models, while considering sampling design complexity. β, odds ratios with their 95% confidence intervals, indirect effects and mediation proportions were estimated.

RESULTS

The weighted mean WBC count was 7,130 cells/µL, with the WBC 5-part differential estimated in terms of percentages of lymphocytes (29.50%), monocytes (7.99%), neutrophils (59.03%), eosinophils (2.84%), and basophils (71.88%). Furthermore, 36.2% of participants reported <7 hours of sleep and 49.8% had periodontitis. In fully adjusted models controlling for sociodemographic, lifestyle, and health characteristics, neither WBC markers nor periodontitis were related to hours of sleep. By contrast, periodontitis was directly related to WBC count and %neutrophils and inversely related to %lymphocytes, especially among men. However, the relationship of periodontitis with %neutrophils and %lymphocytes may be modified by hours of sleep, as it was specific to individuals reporting ≥7 hours of sleep.

CONCLUSION

Periodontitis may be directly related to WBC count and %neutrophils and inversely related to %lymphocytes, especially among men and individuals reporting ≥7 hours of sleep, with implications for primary and secondary prevention.

Chemotherapy agents induce tartrate-resistant acid phosphatase 5a contributing to the symptom distress in lung cancer patients

Tartrate-resistant acid phosphatase 5a (TRACP5a) is mainly secreted by activated macrophages in chronic inflammation. Serum TRACP5a is associated with symptom distress in lung cancer patients during chemotherapy. Therefore, this study aimed to investigate whether chemotherapy drugs modulate TRACP5a as an inducible marker for symptom distress in lung cancer patients during chemotherapy. In clinical analysis, lung cancer participants completely received the six-cycle chemotherapy process (n = 42). Clinical determinations for TRACP5a, C-reactive protein (CRP), interleukin-6 (IL-6), white blood cells, monocytes, and hemoglobin were analyzed at six time points: BL, C1d8, C2d1, C4d1, C4d8, and Ed28. Meanwhile, five questionnaires for fatigue, sleep disturbance, pain, depression, and confusion were finished before drug treatment. For monocyte-to-macrophage differentiation, THP-1 cells were treated with phorbol 12-myristate 13-acetate (PMA). TRACP5a secretion in THP-1 cells was determined at the following days up to 6 days after 1-day incubation of chemotherapy drugs by dot blotting. Clinical analysis revealed that TRACP5a significantly increased at C1d8 and C4d8, but dropped at C2d1 and Ed28. CRP and IL-6 displayed a broad-range variation, resulting in no significant difference among the assessment time points. In contrast, monocytes decreased at C1d8 and C4d8, but rose again at C2d1 and Ed28. In symptom distress, the changes only in fatigue and sleep disturbance were positively associated with the trend in TRACP5a. In PMA-treated THP-1 cells, TRACP5a significantly increased after stimulation with gemcitabine and paclitaxel. Taken together, induction of TRACP5a by chemotherapy drugs might be generated from monocyte-differentiated macrophages, further causing clinical symptom distress in lung cancer patients.

The risk factors for depression in cancer patients undergoing chemotherapy: a systematic review

PURPOSE

This systematic review aims to identify the risk factors for depression in cancer patients undergoing chemotherapy.

METHODS

Eight electronic databases were searched from inception of the databases established until August 2017. References for the included studies were retrieved by manual searching. The quality of the eligible studies was appraised by two persons using the 11-item checklist of the Agency for Healthcare Research and Quality (AHRQ).

RESULTS

Among 5988 potentially relevant articles, 43 studies were eligible, with 17 studies of high quality and 25 studies of moderate quality. A total of 65 factors were extracted, including sociodemographic characteristics (n = 20), physiological condition (n = 20), disease and treatment (n = 12), and psychosocial factors (n = 13). Only social support, anxiety, perceived stress, and self-efficacy were found to be consistently associated with depression in cancer patients. There is not enough evidence to support the link between the other 61 factors and depression in cancer patients undergoing chemotherapy.

CONCLUSIONS

This review suggests that the development of depression programs should take social support, anxiety, perceived stress, and self-efficacy into account. More original studies with rigorous design are necessary to further confirm those 61 inconclusive risk factors for depression in cancer patients receiving chemotherapy.