Minimizing some of the most distressing symptoms of cancer and its treatment requires systematic screening and risk assessment, as well as a focus on the underlying cause of these symptoms, according to experts at the European Society for Medical Oncology (ESMO) Congress 2022. They noted that in many instances, nonpharmacologic interventions have a more favorable benefit-to-risk profile compared with pharmacologic interventions.
Cachexia
Cachexia occurs frequently in patients with advanced cancer. Contributing factors include intolerance of adequate food intake, a relevant decrease in daily physical activity, and metabolic derangements highlighted by systemic inflammation. Cancer-related cachexia is usually defined as weight loss >5% or a body mass index <20 kg/m2 with weight loss >2%, often in the presence of reduced food intake and systemic inflammation. This inflammation can induce anorexia and fatigue, said Jann Arends, MD, Department Head, Gastrointestinal and Nutrition Service, Clinic for Internal Medicine, Tumour Biology Centre, Universitätsklinikum Freiburg, Freiburg im Breisgau, Germany. Low muscle mass (sarcopenia) caused by cachexia in adults with solid tumors is associated with poor overall survival, cancer-specific survival, and disease-free survival.
“Screening all patients to detect those at risk of nutritional problems is recommended,” Dr Arends noted. “Those patients at risk should be diagnosed preferably by the GLIM [Global Leadership Initiative on Malnutrition] diagnostic scheme. Patients should simultaneously be assessed in detail to define nutritional problems, resulting in targeted individualized treatment.”
GLIM top 5 ranked criteria include 3 phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and 2 etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden).
Although there is no agreement on the best screening method for malnutrition, the following 4 tools are suggested: the Malnutrition Universal Screening Tool, the Short Nutritional Assessment Questionnaire, the Malnutrition Screening Tool, and Nutrition Risk Screening 2002.
If it is expected that a patient will live for ≥3 months, regular screening for nutritional risk should be performed, according to ESMO guidelines. If a patient is at nutritional risk, it is important to perform a comprehensive assessment that includes nutritional status, metabolic status, functional status, nutrition impact symptoms, gastrointestinal dysfunction, distressing symptoms (eg, pain, dyspnea), psychological and social distress, medication, and tumor status. A tailored intervention by a nutritionally trained professional team should then be initiated, said Dr Arends.
Anorexia, dysphagia, nausea, pain, obstruction, and malabsorption should all be treated and patients should receive counseling, oral nutritional supplements, and parenteral nutrition, if needed. Exercise training and anticancer treatment should be integrated to reduce tumor burden.
Emotional Distress, Cognitive Dysfunction, and Fatigue
The management of emotional distress, cognitive function, and fatigue was addressed by Karen Steindorf, MD, Division Head, Physical Activity, Prevention and Cancer, Deutsches Krebsforschungszentrum und Nationales Centrum für Tumorerkrankungen, Heidelberg, Germany.
Emotional distress encompasses a wide range of symptoms, including having difficulty thinking or remembering, as well as fatigue.
According to National Comprehensive Cancer Network (NCCN) guidelines, if patients are deemed a danger to themselves or others, suicide and homicide risk should be evaluated, and a psychiatric consultation should be ordered.
“If no danger to self or others, psychotropic medication is the only treatment that reached category 1 recommendation by the NCCN,” Dr Steindorf said. “Medications are at the forefront of evidence-based methods.” She added that these therapies may interact with medications used to treat cancer or other conditions.
Suspicion of anxiety requires a thorough evaluation in which co-factors are assessed and treated. Psychotherapy is an NCCN category 1 recommendation, with or without antidepressants and anxiolytics. However, addiction is a risk associated with these therapies, Dr Steindorf noted.
Cognitive dysfunction may result from a central nervous system tumor, which can be identified via neuroimaging. No standard treatment exists for patients with cancer-associated cognitive dysfunction. Cognitive behavioral therapy and rehabilitation programs are first-line interventions that may improve cognitive function.
Cancer-related fatigue is a persistent subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or its treatment that is not proportional to recent activity and that interferes with usual functioning.
“It can persist for months and even years,” said Dr Steindorf. “It reduces quality of life and can hinder return to work or their former life.” Contributing factors such as medication-related side effects, pain, emotional distress, anemia, sleep disturbance, nutritional deficits, and comorbidities should be addressed.
Nonpharmacologic interventions, including psychosocial interventions, are more effective than pharmacologic ones for fatigue. Physical activity and exercise are supported by level 1 evidence from the NCCN. Endurance training at a moderate intensity a minimum 3 times per week for a minimum of 30 minutes each session, and resistance training a minimum of twice per week have been shown to be effective for diminishing fatigue. Yoga is considered an NCCN category 1 recommendation.
Pharmacologic treatments may be considered after ruling out other causes of fatigue and failure of other interventions, Dr Steindorf explained.
Dyspnea and Cough
David Hui, MD, MSc, Associate Professor, Palliative Care and Rehabilitation Medicine, and Associate Professor, General Oncology, The University of Texas MD Anderson Cancer Center, Houston, ended the session by discussing strategies for managing dyspnea and cough.
“Dyspnea is very much a multidimensional symptom that requires a team to support patients,” he said.
Nonpharmacologic measures to treat breathlessness include breathing retraining to slow respiration, mobility aids, and pulmonary rehabilitation (ie, exercise of respiratory muscles). Moderately large and clinically significant improvements in dyspnea and fatigue can be realized. Dr Hui noted that fan or airflow therapy have demonstrated an improvement in dyspnea in multiple randomized controlled clinical trials.
The use of pharmacologic therapies for dyspnea remains controversial. Opioids are generally recommended but strong evidence to support systemic opioids is lacking. The use of benzodiazepines is optional. Corticosteroids are also an option but based on unfavorable risk-to-benefit ratio, Dr Hui said that he does not recommend routine use of high-dose dexamethasone in unselected patients with dyspnea. “There are higher levels of insomnia and more infections in patients treated with high-dose dexamethasone versus placebo,” he noted. Sertraline (Zoloft) is not recommended but other antidepressants are optional, he added.
Supplemental oxygen is generally not recommended and is only indicated when O2 saturation is <90%. In an open-label, randomized trial, noninvasive ventilation significantly improved dyspnea in hypoxemic patients with cancer who had dyspnea at rest, particularly among patients with hypoventilation. Both high-flow oxygen and noninvasive ventilation are associated with improvement in dyspnea in a study of inpatients with advanced cancer and in a separate study of nonhypoxemic hospitalized patients with cancer who had dyspnea at rest.
When it comes to managing cough, it is important to focus on the underlying cause, Dr Hui said. Effective interventions include cough suppression exercises, speech therapy, inhaled sodium cromoglycate, gabapentin (Neurontin), and aprepitant (Emend).