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October 2017 VOL 8, NO 10

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Fatigue Guidelines

Early Peek at MASCC Guidelines for Cancer-Related Fatigue

A panel of experts has developed a preliminary set of the first Multinational Association of Supportive Care in Cancer (MASCC) guidelines for the management of cancer-related fatigue. These guidelines were based on extensive literature reviews and meetings among panel members. They will be tweaked a bit further and then published, said speakers at the 2017 MASCC Annual Meeting.

“We had no international guidelines for cancer-related fatigue,” said Karen Mustian, PhD, MPH, Associate Professor in the departments of surgery, radiation oncology, and public health sciences at the University of Rochester, Rochester, NY, “the mastermind” of the fatigue guideline process.

Before embarking on developing MASCC-specific guidelines, the panel reviewed existing fatigue-related guidelines from the American Society of Clinical Oncology, the National Comprehensive Cancer Network, the Oncology Nursing Society, and from the pain community. “We recommended that we consider endorsing a good existing guideline, but the request was turned down by the MASCC Board, who felt that we needed systematic reviews and levels of evidence that MASCC holds guidelines to,” she explained.

That led to intensive meetings of a group of international experts in fatigue. “It was a labor-intensive process. Each person searched and reviewed all relevant literature. Then we had a full-day meeting in Adelaide, Australia, to report findings and develop initial consensus on recommendations. This solidified our methodological approach,” she explained.

To give some idea of the scope of review for each section of the guidelines, for the Exercise section, 17,003 articles were reviewed and 91 chosen. For Psychosocial guidelines, 19,000 articles were reviewed and 19 selected. For Pharmaceuticals, Nutraceuticals, and Phytopharmaceuticals, 541 were reviewed and 49 selected. For Integrative Therapies, 655 were reviewed and 46 selected.

Guidelines deemed “recommended” were based on Level 1 evidence. A second criterion, “reasonable to suggest,” was reserved for guidelines based on Level II and III evidence. “No guideline possible” was reserved for Level IV evidence, when little or no evidence is available, or when the committee lacked consensus on interpretation of existing evidence.

Current Iteration of MASCC Guidelines for Cancer-Related Fatigue

For the purposes of the guidelines, cancer-related fatigue was defined as a distressing, overwhelming, multidimensional sense of physical and/or mental tiredness characterized as exhaustion associated with cancer and/or its treatments. Cancer-related fatigue is not proportional to recent physical or mental activity and cannot be alleviated by simple rest or sleep alone.

Screening for cancer-related fatigue is suggested at appropriate intervals from diagnosis to survivorship, daily for inpatients, and during all ambulatory follow-up visits. Screening should be done with reliable patient-reported measures that assess the presence and severity of fatigue.

Patients should have a comprehensive evaluation, including a focused family history, disease status, treatable factors that contribute to fatigue, and lab and other diagnostic testing when needed.

No recommendations were made for Exercise, but Exercise falls under “reasonable to suggest” for early- and late-stage cancer patients. Aerobic or anaerobic exercise or a combination of the two, walking, weight lifting, and yoga can be suggested. These should be done at low, moderate, and vigorous intensity levels, in 18- to 90-minute sessions, from 2 to 6 times per week.

No guideline is possible for promising modes of exercise that include dance, tai chi, and others.

For the category of Psychosocial, the panel said “no recommendation possible” based on current evidence. But it is “reasonable to suggest” psychosocial interventions in early- and late-stage patients during and after completion of therapy. The following strategies can be suggested: cognitive behavioral therapy and/or educational therapy; energy conservation, imagery coping, cognitive restructuring, recognizing negative thoughts, beliefs, or meaning; and behavioral management strategies. These therapies can be used for 1 to 24 weeks.

Regarding pharmaceutical intervention, the panel strongly recommended the following: Do not use paroxetine or modafinil; do not use short-acting methylphenidate in patients with advanced cancer.

Pharmaceuticals that are “reasonable to use” include dexamethasone or methylprednisolone in advanced-stage disease in patients under active treatment. No guideline was possible for donepezil, eszopiclone, thyroid-releasing hormone, abiraterone, sertraline, and megestrol.

No “recommendations” or “reasonable to use” guidelines were possible for Nutraceuticals.

Promising nutraceuticals are ginseng, guarana, mistletoe, and ATP infusion.

No “recommendations” were possible for Integrative Therapies, but those that were deemed “reasonable to suggest” include hypnosis, acupuncture, and acupressure.

“No guideline possible” was cited for aromatherapy, massage, energy therapy, relaxation therapy, music therapy, light therapy, and laughter therapy, but several were “promising.”

“These recommendations are not set in stone. After they undergo further review, they may be a little different,” Dr Mustian told listeners.

She said that systematic reviews of each section will be published one-by-one on the MASCC website and in the Journal of Cancer Care, along with the main article on the guidelines. These systematic reviews will point out limitations and where the next steps of the science should be directed.

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