fausto roila oncologia medica, perugia, italy filechallenges at the system level

ARE GUIDELINES ON FATIGUE

REALLY APPLICABLE?

Fausto Roila

Oncologia Medica, Perugia, Italy

CONFLICT OF INTERESTS

NO CONFLICT

THE PROBLEMS

Evidence-based guidelines for CRF are

avalaible, yet inconsistently implemented

globally.

"Are we ready to implement guidelines for

cancer-related fatigue (CRF) into our

practice?"

FATIGUE: DEFINITION (ASCO, NCCN)

Cancer-related fatigue is a distressing, persistent,

subjective sense of physical, emotional, and/or

cognitive tiredness or exhaustion related to cancer

and/or cancer treatment that is not proportional to

recent activity and interferes with usual

functioning.

In comparison to the fatigue experienced by

healthy individuals, cancer-related fatigue is often

not alleviated by rest or sleep

FATIGUE: INCIDENCE

Cancer-related fatigue can occur before,

during and even long after anti-cancer

treatment has been completed

- up to 40% of pts report fatigue at diagnosis

- 80% and 90% of pts during chemotherapy and

radiotherapy, respectively

- 17%-53% of pts in the post-treatment phase

FATIGUE CONTRIBUTING FACTORS

TUMOUR-RELATED FACTORS AND

COMPLICATIONS Anemia, electrolyte abnormalities,

dehydration, renal, liver or hearth failure, anorexia/cachexia,

adrenal insufficiencies, fever.

PHYSICAL SYMPTOMS ASSOCIATED TO

TUMOUR OR ITS TREATMENT

Pain, dyspnea, difficulty swallowing, appetite loss

COMORBID CONDITIONS

Hypothyroidism, diabetes mellitus, COPD, cardiovascular

disease, infections

FATIGUE CONTRIBUTING FACTORS

PSYCHOLOGICAL/BEHAVIOURAL FACTORS

Anxiety, depression, sleep disorders, decreased physical

activity

SIDE EFFECTS OF OTHER MEDICATIONS

Opioids, psychiatric drugs, antihistamines, beta blockers,

corticosteroids

IATROGENIC FACTORS

Chemotherapy, radiotherapy, surgery, immunotherapy,

hormonal therapies, small-molecule targeted therapies

PHARMACOLOGICAL INTERVENTIONS

- PSYCHOSTIMULANTS (methylphenidate,

dexmethylphenidate, dexamphetamine,

modafinil, armodafinil)

- ANTIDEPRESSANTS

- ACETHYLCHOLINE INHIBITORS

- CORTICOSTEROIDS

- L-CARNITINE

- COENZIME Q10

INTERVENTIONS IDENTIFIED AS LIKELY TO BE BENEFICIAL

BY THE NCCN, ONS, CPAC/CAPO, AND ASCO GUIDELINES

• Address treatable contributors to fatigue

• Manage concurrent symptoms

• Physical activity/exercise

• Rehabilitation

• Psychoeducation

• Meditation, mindfulness-based stress reduction, and cognitive-

behavioral stress management

• Relaxation

• Cognitive-behavioral therapy for fatigue, depression, and pain

• Cognitive-behavioral therapy for sleep

• Yoga

CPAC/CAPO, Canadian Partnership Against Cancer/Canadian Association of

Psychosocial Oncology; ONS, Oncology Nursing Society

REDUCING PATIENT BARRIERS TO

PAIN AND FATIGUE MANAGEMENT

Borneman T, et al. J Pain Symptom Manage 2010; 39:486-501

SCREENING, EVALUATION, AND

MANAGEMENT OF CANCER-

RELATED FATIGUE: READY FOR

IMPLEMENTATION TO PRACTICE

Berger AM, et al. CA Cancer J Clin 2015; 65:190-211

DISSEMINATION AND IMPLEMENTATION OF

GUIDELINES FOR CANCER-RELATED FATIGUE

Berger AM, et al. J Natl Compr Cancer Netw 2016; 14:1336-38

TRANSLATION INTO PRACTICE: CHALLENGES AT THE PATIENT LEVEL

- Current barriers include attitudes and beliefs that CRF is an

expected result of cancer and its treatment and that CRF

will resolve when treatment ends

- In a study pts who experience fatigue do not report it to

their doctors because they feel it is inevitable (43%),

unimportant (34%) or untreatable (27%) (Stone P et al. Ann

Oncol 2000; 11: 971-975)

- Patients express fears of dose delays or discontinuance if

they report severe symptoms

TRANSLATION INTO PRACTICE: CHALLENGES AT THE PATIENT LEVEL

- All patients and families deserve, but do not consistently

receive, education and counseling.

- Pts should rate CRF severity and communicate its impact

on quality of life and their expectation that their symptoms

be addressed

TRANSLATION INTO PRACTICE: CHALLENGES AT THE CLINICIAN LEVEL

- Fatigue is a symptom of cancer that is poorly understood

by clinicians. Despite considerable efforts, a specific

etiology of, and biomarker for, fatigue has not been

discovered. The lack of mechanism-driven fatigue

interventions is a major barrier to better symptom control.

- Fatigue is a symptom that is not routinately assessed in the

clinical setting by clinicians

- Few patients receive treatment or advice from clinicians

above how to manage their fatigue


- Until recenty the lack of evidence-based pharmacologic

interventions posed a challenge at clinician levels. Already

now we have several beneficial nonpharmacologic

interventions.

- Two examples of models to accelerate the implementation

of interventions for CRF into practice are physical

activity/exercise in cancer survivorship and physical

rehabilitation for women with breast cancer (Stout NL, et al.

Cancer 2012; 118(8 suppl): 2191-2200)


- Clinicians should disseminate and implement these CRF

interventions in oncology practice and policy.

- Clinicians may lack the ability to provide these evidence-

based nonpharmacologic interventions in their settings and

communities.

- The important role of oncology leaders should be stressed.

- Evaluation of patient satisfaction with the management of

fatigue is important (if poor, increased costs)

TRANSLATION INTO PRACTICE: CHALLENGES AT THE SYSTEM LEVEL

- Healthcare system challenges include a lack of access to

and reimbursement for CRF interventions

- Clinics specifically focused on symptom control but CRF

management programs are not widely available for pts

- Multicomponent interventions are complex and difficult to

deliver with fidelity in routine clinical care. To overcome

this, key components of fatigue interventions need to be

included in manuals and standardized for delivery


- Interventions using protocols ready to be adapted for local

use and with diverse populations in a variety of settings

will promote evaluation of outcomes in the real world

- Strategies for building routine symptom screening into

clinical workflow include use of electronic health record.

There is a great need to test telehealth approaches to

making effective interventions widely available such as

cognitive behavioral therapy for sleep


- One widely used technique to measure and provide

feedback on implementation of recommendations is

through audit and feedback.

- Integrating a fatigue thermometer as a standard for CRF

screening could led to a database development very useful

especially when integrated into clinician workflow and the

electronic health records.

CANCER RELATED FATIGUE: IMPLEMENTING

GUIDELINES FOR OPTIMAL MANAGEMENT

Pearson EJM, et al. BMC Health Serv Res 2017;17:496

THE STUDY

- This Australian study aimed to identify barriers and

enablers to applying a cancer-related fatigue

guideline [the Canadian Association of the

Psychosocial Oncology (CAPO) guidelines] and to

derive implementation strategies

- A mixed-method study explored the feasibility of

implementing cancer-related fatigue guideline

THE STUDY

- Health pratictioners (HP) and managers (45) and

cancer survivors (C) (68) from different practice

settings participate in a modified Delphy study with

two survey rounds. The first round focused on

guidelines characteristics, compatibility with

current practice and experience and behaviour

change. The second survey built upon and

triangulated the first round.

Statement Survey N Agree (n)a

Agree (%)

There is a need for clinical guidelines

for management of cancer-related

fatigue (CRF) tailored for the

Australian context

HP1 43 34 79.1

C1 63 52 82.5

The benefits of the CAPO guideline

outweigh the costs, inconvenience or

discomfort

HP1 40 24 60.0

C1 32 28 87.5

I am satisfied with current approaches

to CRF management at my

workplace/health care facilityb

HP1 48 25 52.1

C1 97 46 47.4

I would adopt or trial the CAPO CRF

guideline in its current form

HP1 40 31 77.5

Survey 1 - General attitudes toward CAPO CRF guideline

aAgree or strongly agree;bParticipants answered for up to 3 health facilities; bolded figures indicate a priori definition of consensus

was met

FATIGUE RECOMMENDATIONS:

SCREENING

- All cancer pts should be screened for fatigue at their initial

clinical visit, and then regularly during and after their anti-

cancer treatment has ceased

- If on initial screening a patient refers fatigue an assessment

of its intensity should be performed using a valid

quantitative measure

INDICATORS OF FEASIBILITY OF GUIDELINE ELEMENTS

FATIGUE RECOMENDATIONS: COMPREHENSIVE AND FOCUSED ASSESSMENT

- Perform a focused fatigue history

- Evaluate disease status

- Assess treatable contributing factors

- As a shared responsability, the clinical team must decide

when referral to an appropriately trained professional (i.e.,

cardiologist, endocrinologist, etc.) is needed

- Consider performing laboratory evaluation based on the

presence of other symptoms and onset and severity of

fatigue

FATIGUE RECOMMENDATIONS:

EDUCATION AND COUNSELLING

- All patients should be offered specific education about

fatigue after treatment (i.e., difference between normal

and cancer-related fatigue, persistence of fatigue after

treatment, causes and contributing factors)

- Patients should be offered advice on general strategies to

help manage fatigue

- If treated for fatigue pts should be observed and re-

evaluate on a regular basis to determine if treatment is

effective or needs to be reassessed

FATIGUE SURVEY: CONCLUSIONS

- Both Health Professionals and Consumers participants

perceived a need for a cancer-related fatigue guidelines, but

Health Professionals were more cautious than Consumers

regarding its net benefit

- Cancer-related fatigue guideline elements were regularly

implemented approximately one-third of the time.

- Although perception of Health Professionals varied the

majority considered there was sufficient detail to implement

most guideline elements

fausto roila oncologia medica, perugia, italy filechallenges at the system level

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