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P. Davidson
Moderator of
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E12 - Symptom Control - Pain, Dyspnoea and Fatigue (ID 12)
- Event: WCLC 2013
- Type: Educational Session
- Track: Supportive Care
- Presentations: 3
- Moderators:P. Davidson, D. Currow
- Coordinates: 10/30/2013, 14:00 - 15:30, Bayside 103, Level 1
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E12.1 - Dyspnoea (ID 428)
14:05 - 14:30 | Author(s): D. Currow
- Abstract
- Presentation
Abstract not provided
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E12.2 - Pain (ID 429)
14:30 - 14:55 | Author(s): M.J. Johnson
- Abstract
- Presentation
Abstract
Pain in lung cancer Lung cancer is the most common cancer globally with 1.6 million people diagnosed with the disease during 2008; over half of them in the developing world. Nearly 90% are due to smoking, or passively smoking, tobacco. The mortality to incidence ratio is 0.86, reflecting dismal survival [http//:globocan.iarc.fr/factsheet.asp] . Therefore, the focus of care remains one of palliation despite increased options for cancer directed treatment. Optimal symptom relief must play a central role. A systematic review of pain in people in with lung cancer found an overall weighted mean prevalence of pain in 47% patients (6 – 100%); the wide variation reflecting the different patient settings (1). However, for studies in general hospitals, just over one third of lung cancer patients had pain, and the weighted mean prevalence in a cancer treatment centre was 65%. Most pain is attributed to the cancer, either directly, or due to treatment (weighted mean prevalence; 13%). Pain is most common in the chest, then, pain in the spine. Patients may have multiple sites of pain, with other symptoms such as breathlessness, cough, and fatigue; pain considered to be one of the top three most distressing. Severe pain is associated with reduced survival, and interferes with function, enjoyment of life, mood and work(2). According to surviving relatives, of the 85% patients who had pain in the last year of life, over 50% found it very distressing(3). Management Assessment. All symptom management should start with a full assessment which extends beyond physical concerns into psychosocial and spiritual domains, and treatments (and involvement of relevant team members) tailored to the needs of the individual, remembering the effect on their family and friends. There are many extensive pain assessment tools which are not easy to use in daily clinical practice. Systematic assessment of every patient attending clinic, or admitted to hospital is often overlooked, but simple aide memoirs for the busy clinician are available and effective(4), or simple screening patient report scales. Where patient reported symptoms have been embedded in oncology clinical practice and linked to symptom management protocols, outcomes have improved(5-7). Symptom monitoring should be related to factors that patients rate as important such as effect on function and relationships with family and friends rather than a score(8). The linking of assessment to education (clinician and patient) and clinical guidance is important and shown to be more effective than education alone(9). Interventions for pain control Radiotherapy. Most pain is from the primary tumour, often with haemoptysis and cough. Palliative radiotherapy is effective but not extensively documented. One RCT study in non-small cell lung cancer shows improvement in pain in three quarters. Other symptoms also improved, along with function and wellbeing(10). Bony metastases are common in lung cancer, if present over 55% lead to one or more skeletal related events. Palliative radiotherapy is the most effective treatment. Onset of relief is between a few days and 1 month, and lasts between 3 to 6 months(11;12). A Cochrane review in 2000 calculated a number needed to treat to give complete relief in one patient at one month as 4.2 (95% CI 3.7 – 4.7)(13). A single fraction of 8Gy is as effective as higher multi-fractionated doses for the acute relief of pain, although of shorter duration(14). Opioids and other analgesics. The WHO analgesic ladder remains the standard approach to analgesic use in cancer pain with morphine still the most cost-effective first line strong opioid; cheaper than the equally effective oxycodone(15;16). In the presence of significant renal dysfunction, fentanyl, alfentanil and methadone are the least likely to cause harm (17). A systematic review confirms a small further benefit with the addition of a non-steroidal anti-inflammatory drug (NSAID), although the contributory studies were too small to comment on toxicity(18). Given the recent data on cardiovascular toxicity of NSAIDS, naproxen and low dose ibuprofen appear to be the safest in this group(19). Incident pain due to bone metastases is difficult to manage with analgesics alone because the direct relationship to periods of activity; the average duration of incident pain is 60 minutes and so may be improving before oral morphine may be fully absorbed. The newer transmucosal fentanyl preparations may be more helpful, with an onset of action of 10 minutes(20). Neuropathic pain often contributes to difficult to manage cancer pain. Opioids may provide benefit and a trial should be given. Standard adjuvant analgesics such as tricyclic antidepressants (duloxetine, amitriptyline) and anticonvulsants (gabapentin and pregabalin) and topical agents (capsaicin and lidocaine) may help but good quality trials in cancer pain are lacking(21). A recent RCT of ketamine for the palliation of refractory cancer pain found no benefit with ketamine(22). Another in patients with better performance status and where neuropathic pain is deemed to be the primary aetiology is almost closed to recruitment [ClinicalTrials.gov Identifier: NCT01316744]. Corticosteroids are commonly used for cancer pain although the evidence base is scant; a systematic review only found “low level evidence” for benefit (23). Bisphosphonates. Bisphosphonates are not routinely used for patients with lung cancer. A recent systematic review of bisphosphonate use in small cell lung cancer demonstrated improved pain control (RR 1.18; 95% CI 1.0 – 1.4), reduced skeletal related events (RR 0.81; 95% CIs 0.67 – 0.97) (24). However, many of the studies were of poor quality. Toxicity is usually restricted to transient flu-like or gastro-intestinal symptoms, but 15% of those with zoledronic acid developed renal dysfunction and 5% the distressing side-effect of osteonecrosis of the jaw. Newer agents such as denosumab may be tolerated better, but comparative trials in lung cancer are awaited. For the future In spite of these options, cancer pain, in general, is under-treated even where there is good access. Barriers include fear of, and poor education about, opioids in both patients and clinicians with consequent respective poor compliance and prescribing, and a lack of systematic screening of patient symptoms with full assessment if needed. Until assessment and management of pain is embedded into daily clinical practice, this feared symptom will remain a problem.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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E12.3 - Fatigue and Exercise (ID 430)
14:55 - 15:20 | Author(s): S. Kilbreath
- Abstract
- Presentation
Abstract
Cancer-related fatigue (CRF) is a well-acknowledged, very common, phenomena arising from treatment of cancer. It is defined as ‘a distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer treatment that is not proportional to recent activity and interferes with usual functioning’ [1]. In particular, the characteristics of CRF are different to those of fatigue experienced in the general population. In persons with lung cancer, the prevalence of CRF is very high, with 75 - 100% presenting with this symptom, and ≥50% reporting severity to be moderate to marked [2, 3]. The mechanisms underpinning CRF are multi-dimensional. These mechanisms include both central and peripheral components resulting from disturbances occurring across several systems, including physiological, biochemical, and psychological systems [4]. Factors that may contribute to CRF include side-effects of treatment such as anaemia, nutrition and fluid imbalance, sleep disturbances and systemic reactions to tissue injury induced by the disease and/or the treatment [5]. In addition, psychological factors can trigger or exacerbate CRF. Examples of psychological factors include anxiety and depression and difficulty in coping with treatments. Physical fatigue, often expressed as a feeling of weakness, lack of energy, or exhaustion associated with conducting activities of daily living, is thought to be due to a peripheral component. It is postulated that these sensations are a consequence of muscles having reduced capacity for a contractile response [4]. Several factors can conspire during cancer treatment to affect the contractile response of muscles, including insufficient oxygen transport and insufficient blood pumping to muscles, and severe impairment of skeletal-muscle function [5]. In persons with physical fatigue, sedentary habits reinforce fatigue, resulting in a vicious cycle. Exercise has the capacity to interrupt this downward decline. There is compelling evidence that exercise can address cancer-related physical fatigue. A recent Cochrane Review on the role of exercise for management of cancer-related fatigue identified 56 randomised controlled trials (RCTs); however, the majority were carried out in women with early breast cancer [6]. Not surprisingly, timing of interventions varied, with some occurring during treatment and others after cessation of adjuvant therapies. Mode and intensity of exercise also differed across studies: some interventions occurred in the home, while others were supervised at institutions or used a combined supervised/home based intervention. The major finding from this review was that aerobic exercise, including walking programs, or stationary arm or leg cycling significantly reduced fatigue both during and following cancer therapy. In addition, approximately half of the studies that included quality of life measures (n=17/35 studies) reported beneficial effects from exercise. In contrast, no consistent benefit from exercise was observed for anxiety or depression. Persons living with lung cancer, from Stage I to IV, appear to have the capacity to be physically active. In a systematic review on exercise interventions to improve exercise capacity and health-related quality of life in patients with non-small cell lung cancer, it was concluded that exercise is safe before and after treatments [7]. However, it was also noted that the studies reviewed were either case reports or small RCTs. Well-designed, appropriately powered RCT’s are required in this area. Two such studies are currently under way: Jones et al [8] are currently recruiting Stage I-IIIA non-small cell lung cancer patients treated surgically to participate in a study in which participants are randomised to one of four 16 week conditions: aerobic training alone; resistance training alone; combination of aerobic and resistance training; and attentioncontrol; and Vardy et al [9] are currently exploring the role of supervised aerobic physical activity with behavioural support specifically on fatigue. One finding from the systematic review [7] was that lung cancer patients who exercised following surgery, chemotherapy, or radiotherapy consistently reported improvements in fatigue. In addition, other symptoms such as dyspnoea, pain and cough were also reduced with exercise. The interventions were predominantly supervised aerobic training, lasting from 10 to 45 minutes, performed at moderate to high intensity, 3 times per week over a set period of weeks. Interval training of 3 – 5 minutes duration, repeated several times per day, is a common feature of exercise programs designed for lung cancer. In contrast, and similar to the findings from the Cochrane Review on exercise and fatigue [6], progressive resistance training was not effective in reducing fatigue in lung cancer patients who had completed 10 weeks of resistance training (n=17). Further clarity on the role of resistance training for management of fatigue in patients living with lung cancer will be determined from the study currently underway by Jones et al [8]. In conclusion, exercise is likely to be effective in reducing fatigue for persons living with Stage 1 – IV non-small cell lung cancer. However, it is important to recognise the support and supervision used in the interventions that demonstrated a significant reduction in fatigue. References: 1. Mock V. Evidence-based treatment for cancer-related fatigue. Journal of the National Cancer Institute. Monographs 2004:112-8 2. Iyer S, et al. The symptom burden of non-small cell lung cancer in the USA: a real-world cross-sectional study. Support Care Cancer 2013; epub ahead of print. 3. Sanders SL, et al. Supportive care needs in patients with lung cancer. Psychooncology 2010: 19:480-9 4. Ryan JL, et al. Mechanisms of cancer-related fatigue. Oncologist 2007:12 Suppl 1:22-34 5. Lucia A, Perez M. Cancer-related fatigue: can exercise physiology assist oncologists? The Lancet Oncology 2003:4: 616-25 6. Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev 2012:11:CD006145 7. Granger CL, et al. Exercise intervention to improve exercise capacity and health related quality of life for patients with Non-small cell lung cancer: a systematic review. Lung Cancer 2011: 72: 139-53 8. Jones LW, et al. The lung cancer exercise training study: a randomized trial of aerobic training, resistance training, or both in postsurgical lung cancer patients: rationale and design. BMC Cancer 2010:10:155 9. Dhillon HM, et al. The impact of physical activity on fatigue and quality of life in lung cancer patients: a randomised controlled trial protocol. BMC Cancer 2012:12:572Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
