| |
JNCCN - The Journal of the National Comprehensive Cancer Network
Table of Contents - Volume 5 Number 10
- NCCN Clinical Practice Guidelines in Oncology®
- Original Articles
NCCN Clinical Practice Guidelines in Oncology®
Pancreatic Adenocarcinoma
During 2007, an estimated 33,370 people will die of pancreatic cancer in the United States. This disease is the fourth most common cause of cancer-related death among men in the United States, with peak incidence in the seventh and eighth decades of life. The incidence is roughly equal between men and women, but African Americans appear to have a higher incidence than white Americans. Although the increase in risk is small, pancreatic cancer is firmly linked to cigarette smoking. No dietary risk factors have been clearly established, but dietary fat has been implicated in experimental models, and an increased body mass index is associated with increased risk. Occupational exposure to chemicals, such as beta-naphthylamine and benzidine, is also associated with an increased risk of pancreatic cancer. These guidelines discuss only tumors of the exocrine pancreas; to view the guidelines for neuroendocrine tumors, which are not included, please visit NCCN.org. Important updates for these guidelines include increased acceptance for gemcitabine and gemcitabine-based regimens for some patients, and discussion of the clinical trials of combination regimens.
Cancer-Related Fatigue
Fatigue is a common symptom in patients with cancer; it is nearly universal in patients undergoing cytotoxic chemotherapy, radiation therapy, bone marrow transplantation, or treatment with biologic response modifiers. The problem, which affects 70% to 100% of cancer patients, has been exacerbated by increased use of fatigue‑inducing multimodal treatments and dose‑dense, dose‑intense protocols. Cancer survivors report that fatigue is a disruptive symptom months and even years after treatment ends. Patients perceive fatigue to be the most distressing symptom associated with cancer and its treatment, more distressing even than pain or nausea and vomiting, which, for most patients, can generally be managed with medications. These guidelines synthesize available research and clinical experience in this field and provide recommendations for patient care.
Original Articles
Early Detection and Biomarkers in Pancreatic Cancer
David E. Misek, PhD; Tasneem H. Patwa; David M. Lubman, PhD; and Diane M. Simeone, MD
Major advances in cancer control will be greatly aided by early detection for diagnosing and treating cancer in its preinvasive state before metastasis. Unfortunately, because effective early detection and screening are not currently available for pancreatic ductal adenocarcinoma (PDAC), the fourth leading cause of cancer-related death in the United States, tumors are typically diagnosed at a late stage, frequently after metastasis. Partly because of low sensitivity and specificity, existing biomarkers such as CA19-9 are not adequate as early detection markers of pancreatic cancer. Thus, a great need exists for new biomarkers for pancreatic cancer. This article focuses on recent developments in the identification of new serum protein biomarkers that are useful in the early detection of PDAC.
Targets, Trials, and Travails in Pancreatic Cancer
Kamel Izeradjene, and Sunil R. Hingorani, MD, PhD
Pancreatic cancer is a highly aggressive and rapidly fatal disease. Current standard care for advanced disease improves survival modestly at best and provides palliation for a minority of patients. The need for new therapies is undisputed. This article describes new therapeutic strategies currently under investigation and discusses possible reasons that others have failed. New potential targets in the treatment of this formidable disease are suggested based on recent findings.
Update on Psychotropic Medications for Cancer-Related Fatigue
William Breitbart, MD, and Yesne Alici Evcimen, MD
Considerable symptom overlap occurs between fatigue and depression, and the conditions can coexist in cancer patients. Clarifying the relationship between depression and fatigue is necessary to effectively evaluate and treat cancer-related fatigue. Psychotropic agents that have been studied for cancer-related fatigue include psychostimulants, wakefulness-promoting agents, and antidepressants. Methylphenidate has been studied most and seems to be effective and well tolerated despite common side effects, such as insomnia and agitation. Some preliminary data support using modafinil in cancer-related fatigue, with less concern about tolerance or dependence. Antidepressant studies have shown mixed results. Paroxetine seems to show benefit for fatigue primarily in the presence of clinical depression. Bupropion, a norepinephrine/dopamine reuptake inhibitor, may have psychostimulant-like effects, and therefore may be more beneficial for treating fatigue. Randomized, placebo-controlled trials with specific agents are needed to further assess the efficacy and tolerability of psychotropic medications in the treatment of cancer-related fatigue.
Implementing the Fatigue Guidelines at One NCCN Member Institution: Process and Outcomes
Tami Borneman, MSN, RN, CNS; Barbara F. Piper, DNSc, RN, AOCN, FAAN; Virginia Chih-Yi Sun, MSN, RN, ANP; Marianna Koczywas, MD; Gwen Uman, PhD, RN; and Betty Ferrell, PhD, RN, FAAN
Fatigue, despite being the most common and distressing symptom in cancer, is often unrelieved because of numerous patient, provider, and system barriers. The overall purpose of this 5-year prospective clinical trial is to translate the National Comprehensive Cancer Network (NCCN) Cancer-Related Fatigue Clinical Practice Guidelines in Oncology into practice and develop a translational interventional model that can be replicated across settings. This article focuses on an NCCN member institution’s experience related to the first phase of the guidelines implementation, describing usual care compared with evidence-based guidelines. The most common barriers noted were patients’ belief that physicians would introduce the subject of fatigue if it was important (patient barrier); lack of fatigue documentation (professional barrier); and lack of supportive care referrals (system barrier). Findings showed several patient, professional, and system barriers that distinguish usual care from that recommended by the NCCN Cancer-Related Fatigue Guidelines.
Modifying Cancer-Related Fatigue by Optimizing Sleep Quality
Ann Malone Berger, PhD, RN, AOCN, FAAN, and Sandra A. Mitchell, CRNP, MScN, AOCN
Cancer-related fatigue is reported by patients to be the most distressing and persistent symptom experienced during and after treatment. Unrelieved fatigue often accompanies other symptoms and leads to decreased physical functioning and a lower health-related quality of life. Various factors, including daytime sleepiness and sleep disturbances, have been reported to influence perceptions of fatigue. This article shares current knowledge about the relationships among cancer-related fatigue, sleep disturbances, and daytime sleepiness and makes recommendations for routine screening, assessment, and interventions to modify fatigue through optimizing sleep quality in adult cancer patients. Evidence is reviewed for nonpharmacologic and pharmacologic interventions for optimizing sleep quality in patients with acute or chronic insomnia secondary to medical illnesses, including cancer.
Evidenced-Based Report on the Occurrence of Fatigue in Long-Term Cancer Survivors
Ilana M. Braun, MD; Donna B. Greenberg, MD; and William F. Pirl, MD
Although some cancer survivors report persistent fatigue years after treatment, little is known about the prevalence of this symptom in cancer survivors compared with the general population. This article examines current evidence for the occurrence of fatigue in long-term cancer survivors through reviewing published population-based studies that incorporated controls from the general population. Using the search criteria “fatigue AND cancer survivors” in PubMed, the authors identified 16 articles comparing fatigue severities in survivors of adult cancers with those in the general population. Among the studies that reported scores for the fatigue subscale of the European Organization for Research and Treatment of Cancer Core Questionnaire for Quality of Life (most studies), mean fatigue levels in cancer survivors ranged from 28.7 to 36.5 of an overall score of 100, and mean fatigue levels in matched general population controls ranged from 20 to 30 of 100. Inferences from the data are limited by variability in the definition of “survivor,” the fatigue assessments, and by the cross-sectional design of the studies. Prospective longitudinal studies are needed to determine causal relationships between excessive fatigue and surviving cancer.
|
|
E-mail
Print
Mark