ASCO Launches New Survivorship Guidelines

Roxanne Nelson

April 18, 2014

The American Society of Clinical Oncology (ASCO) has issued 3 new evidence-based clinical practice guidelines on the prevention and management of common symptoms that affect a large number of cancer survivors — neuropathy, fatigue, and depression and anxiety.

The number of cancer survivors in the United States has risen exponentially, from 3.0 million in 1971 to about 13.7 million currently.

That is good news, but the downside is that survivors often face long-term health issues related to their disease and treatment. Thus, there is an outstanding need for comprehensive guidance to assist clinicians in this management process. The ASCO recommendations reinforce the fact that both physical and psychological needs have to be addressed in this population.

The guidelines, published online April 14 in the Journal of Clinical Oncology, are the first in a series that will focus on survivorship care.

Peripheral Neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is a common treatment-related adverse event and can affect a patient's long-term quality of life. It is estimated that about 38% of patients who are treated with multiple agents develop CIPN, but this can vary, depending on the actual regimen and duration of treatment. Chemotherapy combinations associated with a higher incidence of CIPN are those that involve platinum drugs, vinca alkaloids, bortezomib, and/or taxanes.

Symptoms vary, and range from numbness and tingling to shooting pain in the arms and legs. If symptoms are really severe, dose reduction or another regimen might be necessary. For a minority of patients, severe symptoms can last for years.

"There is no clear panacea for neuropathy," said Gary Lyman, MD, MPH, cochair of the ASCO Survivorship Guidelines Advisory Group, in a statement. "Some of the drugs used for prevention or treatment of neuropathy may cause side effects or interfere with other drugs. We want to be clear that if there is no evidence of benefit from those drugs, it's probably best not to take them."

The neuropathy guidance is based on a literature review that included 48 randomized controlled trials. However, the studies tended to be small and heterogeneous, and many had insufficient sample sizes to detect clinically important differences in outcomes, the authors note.

Key CIPN Recommendations

No established agents are recommended for preventing CIPN, because of the "paucity of high-quality, consistent evidence and a balance of benefits versus harms."
The following agents should not be offered for prevention of CIPN: acetyl-L-carnitine, amifostine, amitriptyline, calcium plus magnesium, dietyldithiocarbamate, glutathione, nimodipine, Org 2766, all-trans retinoic acid, rhuLIF, and vitamin E.
Treating clinicians can offer duloxetine to patients with CIPN.
Although recommendations cannot be made for tricyclic antidepressants, gabapentin, or topical gels containing baclofen, amitriptyline, and ketamine because of the lack of strong evidence, it might be reasonable to try them in select patients.

A number of nonpharmacologic interventions have been investigated for their role in preventing or treating peripheral neuropathy, but they could not be included in this review because of the lack of data from randomized trials, the guideline authors note.

Fatigue

The fatigue guideline provides recommendations on screening, assessment, and treatment approaches for adult cancer survivors experiencing this symptom.

It is recommended that all cancer survivors be evaluated for symptoms of fatigue after they complete their treatment, and that they be offered strategies for fatigue management.

"Fatigue is an extremely common symptom in people with cancer," said Smita Bhatia, MD, MPH, cochair of the ASCO Survivorship Guidelines Advisory Group, in a statement. "We hope that this guideline will help ensure that screening for fatigue and appropriate management are incorporated in the care of every cancer survivor."

The authors conducted a systematic search of clinical practice guideline databases, guideline developer Web sites, and published health literature. This guideline is based on a Canadian guideline on fatigue and 2 guidelines from National Comprehensive Cancer Network on cancer-related fatigue and survivorship.

Key Fatigue Recommendations

Patients should be routinely screened for fatigue from diagnosis onward, including after the completion of primary treatment.
Screening should include a quantitative or semiquantitative assessment.
Patients should be educated about the differences between normal and cancer-related fatigue, causes of fatigue, and contributing factors.
Patients treated for fatigue should be observed and re-evaluated on a regular basis.
Patients should be offered strategies to manage fatigue, including physical activity, psychosocial interventions (e.g., cognitive and behavioral therapies, psychoeducational therapies), and mind–body interventions (e.g., yoga, acupuncture).

Anxiety and Depression Management

Most people experience some degree of depression, anxiety, and fear when diagnosed with cancer. Distress is very common, but the types and causes vary, said Dr. Bhatia. "Depression can go undetected unless it is specifically sought for and evaluated."

Recommendations in the anxiety and depression guideline were adapted from the Pan-Canadian Guideline on Screening, Assessment and Care of Psychosocial Distress (Depression, Anxiety) in Adults with Cancer.

Key Anxiety and Depression Recommendations

All cancer patients should be evaluated for symptoms of depression and anxiety, using validated measures.
All patients should be offered supportive care services; those with moderate or severe symptoms of anxiety and depression should be referred for appropriate interventions.
Providers should reassess patients for compliance with individual or group psychological or psychosocial referrals.

"Doctors sometimes don't give these symptoms much attention because they think it's normal that their patients are a little anxious or depressed about their disease," said Dr. Lyman. "But it's important to keep an eye on the symptoms and step in when they start to interfere with the patients' quality of life."

The authors of the neuropathy and fatigue guidelines report numerous financial relationships, which are detailed in the guidelines. The authors of the depression and anxiety guideline have disclosed no relevant financial relationships.

J Clin Oncol. Published online April 14, 2014. Neuropathy abstract, Fatigue abstract, Depression and anxiety abstract

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