Am Fam Physician. 2003;67(2):423-424
The National Institutes of Health (NIH) has released a consensus statement on the management of cancer symptoms, including pain, depression, and fatigue. The statement was prepared by a nonfederal, nonadvocate panel of experts in the field and is an independent panel report, not an official document of the NIH or the federal government. The conference, State-of-the-Science Conference on Symptom Management in Cancer: Pain, Depression, and Fatigue, was sponsored by the National Cancer Institute and the Office of Medical Applications of Research of the NIH in July 2002. The complete text of the statement can be found at www.consensus.nih.gov.
Because patients with cancer are living longer, there is a growing concern about their health-related quality of life and the quality of care they receive. About 1.3 million patients will be diagnosed with cancer this year, and approximately 60 percent will survive at least five years after diagnosis. Because of cancer's association with death and diminished quality of life, it is important to address the effects of the symptoms of cancer and to reduce the burden of cancer and its treatment. The most common symptoms of cancer and treatment include pain, depression, and fatigue. Evidence suggests that pain is frequently undertreated, and depression and persistent lack of energy progress as therapy becomes more aggressive. Physicians need to be able to identify who is at risk for these cancer-related symptoms, what treatments work best to address these problems, and how best to deliver interventions across the continuum of care.
The consensus panel addressed the following questions: What is the occurrence of pain, depression, and fatigue, alone and in combination, in patients with cancer? What are the methods used for clinical assessment of these symptoms throughout the course of cancer, and what is the evidence for their reliability and validity? What are the treatments for cancer-related pain, depression, and fatigue, and what is the evidence for their effectiveness? What are the impediments to effective symptom management in patients with cancer, and what are optimal strategies for overcoming these impediments?
The panel also identified several areas for future research, including developing conceptual models to direct research, exploring whether these symptoms differ between populations, improving the descriptive epidemiology of these symptoms, comparing simple screening strategies with more complex screening and diagnostic approaches, evaluating new treatments, and developing pain-specific treatment models.
Frequency of Symptoms
Estimates of the frequency of pain, depression, and fatigue in cancer patients are not precise enough to be reliable. The estimates for pain range from 14 to 100 percent. For depression, the range is 1 to 42 percent, and the range for fatigue is 4 to 91 percent. The report lists several reasons for the lack of consistency and weaknesses in research methodology.
Assessment of pain, depression, and fatigue should be an important step in the treatment of patients with cancer. A number of tools have been developed to help recognize and diagnose each symptom, but only a few questionnaires assess all three simultaneously. Characteristics, such as age, ethnicity, geographic distance from health care professionals, and coexisting conditions, also should be considered because they may affect the presentation and treatment of these symptoms. Repeated assessments should continue over the course of the illness.
Treating the Symptoms
Pain, depression, and fatigue are related to the underlying disease or its therapy, and they may persist in long-term survivors. Effective treatment of one of the symptoms may result in relief of other symptoms, but treatment of one symptom may exacerbate another. The three-step analgesic ladder developed by the World Health Organization provides adequate pain relief for the majority of patients. The first consists of nonsteroidal anti-inflammatory drugs (NSAIDs). As symptoms increase, the second tier adds a weak opioid to the NSAID. If the pain persists or worsens, the third tier substitutes a strong opioid. Around-the-clock pain medication compared with as-needed dosing may improve patient adherence and outcome. Discontinuation of analgesics because of adverse effects is infrequent.
Adjuvants can be administered for relief of neuropathic pain and to treat side effects of opioids. External beam radiotherapy is beneficial for patients with localized pain, and bisphosphonates may be effective for treatment of pain from bone metastases.
Adequate doses and duration of antidepressant medications in patients with cancer show benefit, and cognitive-behavior and psychosocial interventions have shown a modest benefit in treating depression related to cancer.
Fatigue is the most common symptom experienced by patients with cancer, but there is little convincing evidence for effective therapies.
Impediments to Symptom Management
There are many barriers to pain management, including lack of awareness of the patient's pain, concern about legal or regulatory sanction for overuse of opioids, fear that the drugs will lose their effectiveness, lack of adherence to treatment regimens, and lack of communication between family physicians and subspecialists.
Impediments to managing depression include many of the same factors described for pain. Not recognizing depression and inadequate resources or skills to treat depression are particularly important. Patients may associate a negative stigma with a psychiatric diagnosis and be reluctant to report their symptoms.
The major difficulties in managing fatigue in patients with cancer include a lack of awareness that it is the most prevalent symptom, lack of knowledge of the causes of fatigue, and lack of proven methods of treatment.
Strategies for Improving Symptom Management
The most common strategy for improving symptom management in patients with cancer includes a regular assessment of symptoms using visual analog or numeric rating scales, followed by continuous quality-improvement interventions to manage the identified symptoms. These interventions include educating physicians and patients, following treatment algorithms, and performing regular reassessment and follow-up of symptom scores. Regulatory barriers need to be revised to maximize convenience, benefit, and compliance and to minimize cost and narcotic diversion for illegal purposes. All opioid prescriptions for patients with cancer should be refillable with proper verification. Payors for health care need to reimburse adequately for symptom management and medications. Optimal pain relief needs to be a minimally accepted standard, so that inadequately treated pain can be considered an indicator of poor quality of care.
The NIH consensus statement concludes with the following recommendations:
Too many cancer patients with pain, depression, and fatigue do not receive adequate treatment for their symptoms.
Physicians should use brief assessment tools routinely to ask patients about pain, depression, and fatigue and to initiate evidence-based treatments.
Current evidence supporting the concept of cancer symptom clusters is insufficient, and additional theoretically driven research is warranted.
Research is needed on the definition, occurrence, assessment, and treatment of pain, depression, and fatigue alone and together through adequately funded prospective studies.
All patients with cancer should have optimal symptom control from diagnosis throughout the course of illness, irrespective of personal and cultural characteristics.
Cancer symptom management should be reassessed periodically.