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Cancer Care Should Include Symptom Management, Panel Says

Linda Wang

Although researchers have made substantial strides in the early detection and treatment of cancer, too many cancer patients with pain, depression, and fatigue receive inadequate treatment for their symptoms.

This was one of the main conclusions of an expert panel convened at the National Institutes of Health for a state-of-the-science conference focusing on the management of cancer symptoms. The panel, drawn from oncologists, pharmacists, pediatricians, nurses, psychiatrists, social workers, and cancer survivors, was charged with summarizing the evidence and providing directions for future research.

"[The conference] is one effort in a long sequence in the United States to call attention to the importance of symptoms and patient choices in the diagnosis, treatment, and rehabilitation of patients with cancer," said panel chair Donald L. Patrick, Ph.D., of the Department of Health Services at the University of Washington, Seattle.

During the day and a half of presentations, researchers emphasized the scarcity of data on cancer pain, depression, and fatigue—particularly on incidence. Based on a review of published studies, Donald P. Lawrence, M.D., a medical oncologist at the Tufts University School of Medicine in Boston, estimated that 14% to 100% of cancer patients will experience pain, 1% to 42% will experience depression, and 4% to 91% will experience fatigue, as a result of the cancer and its treatment.

Such enormous ranges are not meaningful in understanding the scope of the problem. Rather, they underscore the lack of consistency in research to recognize and diagnose cancer pain, depression, and fatigue—subjective symptoms that rely heavily on patient self-report.

Sometimes, patients experiencing fatigue do not report the symptom because they think it is a normal part of the disease and one that needs to be tolerated, explained Steven D. Passik, Ph.D., director of Symptom Management and Palliative Care at the University of Kentucky, Lexington. Other times, he said, fear of distracting the doctor from the treatment is to blame.

Health care workers can also add to the problem, he said. Those who are not familiar with treatments for cancer-related fatigue may think, "Why assess when I don’t have anything to offer?" In addition, clinical staff may be able to identify fatigue in patients but may lack the training to do a detailed assessment, he said.

It is true, however, that few tools are available to recognize and diagnose fatigue, and even fewer for special populations such as children, older adults, and minorities. To do the job better, researchers must first tease apart the causes of the problem, the panel concluded.

In contrast, many tools are available to recognize and diagnose pain and depression. However, some cancer patients experience pain, depression, and fatigue simultaneously (labeled by some as a symptom cluster). Few tools are available to assess these clusters, and there are questions about whether it is appropriate to consider the symptoms together conceptually as a cluster. Nevertheless, the panel concluded that there is enough evidence that it would be beneficial for doctors to include symptom rating scales in their clinical practice. One approach to managing multiple symptoms is to assess overall distress in a patient and then to explore possible contributors, such as pain, depression, and fatigue.

The goal is to be able to treat the pain, depression, and fatigue. Current treatments for pain include nonsteroidal anti-inflammatory drugs and opioids. In many situations it is not clear that one drug is superior to another, and it is unclear what is the proper sequencing or most effective combinations of analgesics.

For depression, antidepressants and psychosocial interventions have shown benefit. But for fatigue, the most common symptom experienced by patients with cancer, few effective therapies exist.

A point many researchers reiterated was the need for more symptom management studies on gender differences and special populations.

In describing barriers to effective management of symptoms, researchers pointed to inadequate training in the recognition of symptoms, a higher priority given to attempts to cure cancer than to treating symptoms, legal concerns regarding drug use, and patients’ reluctance to report symptoms.

One strategy to improve symptom management is to routinely assess symptoms and to follow that with appropriate intervention. The panel suggested that the National Cancer Institute and other cancer-related organizations should increase funding and awareness of symptom research and improve education among providers and the public. They added that health insurance companies need to reimburse adequately for symptom management and medications.

The panel’s suggestions for directions for future research included conducting large prospective studies to provide more accurate estimates of the incidence and prevalence of pain, depression, and fatigue; conducting studies to investigate the effectiveness of combinations and sequencing of pharmacologic and nonpharmacologic treatments; validating and disseminating guidelines for symptom management in cancer patients; and conducting research into system barriers to effective symptom control in people with cancer.

Paul S. Frame, M.D., panel member and a professor at the University of Rochester School of Medicine pointed out that the notion of pain, depression, and fatigue as natural accompaniments of cancer is changing. "What this whole effort is is to try to facilitate and help that change," he said.

Some panelists stressed that improvements in cancer symptom management have already been made and this conference is simply building on that. For example, physicians are much more aware of these symptoms than they were five years ago. Further, recent initiatives require the assessment of pain among hospital inpatients.

Still, there is a long way to go and changes do not happen overnight. Patrick emphasized the need for new treatments and interventions that are based in the biology and psychology of the symptom experience. It is also important to better train medical students about managing pain, depression, and fatigue in cancer patients.

"Each of us can take this back to our respective audiences and we need to think about how, together, we can move things forward in this field," said Jürgen Unützer, M.D., psychiatrist and associate professor-in-residence at the University of California at Los Angeles School of Medicine.

The draft statement is available at http://consensus.nih.gov.



             
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