ASCO Develops New Guidelines Addressing Issues Faced by Cancer Survivors

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The American Society of Clinical Oncology (ASCO) has developed new guidelines on three problems that cancer survivors often deal with: fatigue, neuropathy, and anxiety and depression.

The three guidelines are the first of a series of 18 guidelines addressing survivorship care that ASCO plans to put out.

All three guidelines were published online on April 14, 2014 by the Journal of Clinical Oncology.

ASCO is a national organization of oncologists and other cancer care providers. ASCO guidelines give doctors recommendations for treatments and testing that are supported by much credible research and experience.

Neuropathy is the general term for pain and numbness caused by damage to the nerves of the peripheral nervous system. Your peripheral nervous system brings signals from the brain and spinal cord to the other, “peripheral,” parts of your body, such as the hands and feet.

For people diagnosed with breast cancer, the most common cause of neuropathy is chemotherapy, often referred to as chemotherapy-associated peripheral neuropathy. Chemotherapy-associated neuropathy can start any time after treatment begins, and it may worsen as treatment continues. Usually it begins in the toes, but it can also include the legs, arms, and hands.

The ASCO neuropathy guideline committee was co-chaired by Dawn Hershman, M.D. of Columbia University, who is also a Professional Advisory Board member. The guidelines point out that no studies have shown any medicines can prevent chemotherapy-associated neuropathy.

Because some of the medicines currently used to treat or prevent neuropathy may cause side effects or interfere with other cancer medicines, the guidelines recommend NOT using these medicines/supplements to prevent neuropathy:

  • acetyl-L carnitine (ALC)
  • amifostine (brand names: Ethyol, Ethiofos)
  • amitriptyline (brand names: Amitid, Amitril, Elavil, Endep)
  • calcium/magnesium
  • diethyldithio-carbamate (DDTC)
  • glutathione
  • nimodpine (brand names: Nimotop, Nymalize)
  • Org 2766
  • all-trans-retinoic acid (also called tretinoin) (brand name: Vesanoid)
  • rhuLIF (recombinant human leukemia inhibitory factor)
  • vitamin E

The guidelines say that if there is no scientific evidence showing these medicines help neuropathy, then it’s probably best not to take them.

The only treatment recommended for treating chemotherapy-associated neuropathy is the antidepressant Cymbalta (chemical name: duloxetine).

While there wasn’t enough evidence for the committee to recommend these medicines to treat neuropathy:

  • tricyclic antidepressants, including Norpramin, Tofranil, Pamelor, Vivactil, and Surmontil
  • gabapentin (brand names: Horizant, Neurontin)
  • a gel containing baclofen, amitriptyline, and ketamine (also called BAK gel)

the experts thought that these medicines might be reasonable to try for selected patients.

Fatigue can be hard to describe. You feel like you don’t have any energy and are tired all the time. But there’s not a specific cause, such as doing errands all day, working out, or other exertion. When you’re tired from exertion, if you get enough sleep that night, you usually feel better the next day. With fatigue, you feel tired all the time and lose interest in people and the things you normally like to do. Fatigue is the most common side effect of breast cancer treatment. Some doctors estimate that 9 out of 10 people experience some fatigue during treatment and it can last for months after treatment ends.

The ASCO guidelines on fatigue recommend:

  • all cancer patients be screened for fatigue at least once a year
  • anyone who reports moderate to severe fatigue should have a comprehensive assessment
  • any treatable contributing factors, such as pain, depression, sleep problems, lack of exercise, poor diet, anemia, and treatment side effects, should be addressed

The guidelines also say that fatigue is best treated by remedies that don’t involve medicines, including:

  • Physical activity: Doctors should encourage all fatigue sufferers to do at least 150 minutes of moderate exercise (fast walking, cycling, swimming) per week, with two more strength training session per week, unless the strength sessions shouldn’t be done because of lymphedema or other issues. Survivors who have a high risk of injury from exercise, such as people with neuropathy or heart problems, should be referred to a physical therapist or exercise specialist.
  • Psychosocial interventions: Cognitive behavioral therapy and other types of talk-educational therapy have been shown to ease fatigue in cancer survivors. Doctors should refer people to psychosocial therapists who specialize in cancer.
  • Mind-body interventions: Complementary and holistic mindfulness-based therapies such as yoga and acupuncture have been shown to reduce fatigue in cancer survivors. More research is needed before touch therapy, massage, music therapy, relaxation therapy, Reiki, and Qigong can be recommended. Doctors should refer people to licensed/certified practitioners who specialize in cancer.

The guidelines say that some stimulants and other medicines that boost wakefulness can help ease fatigue in people with severe cases or people who are still receiving cancer treatment. But there isn’t much scientific evidence that these medicines help treat fatigue in people who have finished cancer treatment and are considered disease-free. Some small studies have looked at using certain supplements, such as ginseng and vitamin D, to treat fatigue, but the results are mixed and the committee didn’t feel it could recommend them.

Anxiety and depression
Anxiety is a feeling of fear or uneasiness. Mild anxiety is part of everyday life. You might feel anxious before you take a test or go to an important meeting at work. Mild anxiety goes away after you’re out of the situation that caused it. Severe anxiety doesn’t go away and makes you unable to relax.

Similarly, depression is more than feeling down in the dumps or sad for a few days. Feelings of depression don’t go away and can interfere with your everyday life. Symptoms of depression include:

  • sadness
  • loss of interest or pleasure in activities you used to enjoy
  • change in weight
  • difficulty sleeping or sleeping all the time
  • energy loss
  • feeling worthless, helpless, or hopeless
  • thoughts of death or suicide

The ASCO guidelines on anxiety and depression were adapted from the recommendations of the Pan-Canadian Practice Guideline on Screening, Assessment, and Care of Psychosocial Distress (Depression, Anxiety) in Adults with Cancer, which was developed by the Canadian Partnership Against Cancer and the Canadian Association of Psychosocial Oncology in 2010.

The anxiety and depression guidelines recommend:

  • all people who’ve been diagnosed with cancer be screened periodically for depression and anxiety while they’re being treated and after treatment is finished
  • doctors should use established, credible tests to assess anxiety and depression
  • all people who’ve been diagnosed with cancer should be offered supportive care services, such as education about stressors and stress-reduction techniques
  • people with moderate to severe symptoms of anxiety or depression should be offered psychological, psychiatric, and psychosocial treatments, including:
    • cognitive behavioral therapy
    • structured exercise
    • group counseling
    • medicines, such as antidepressants
    • applied relaxation therapy
    • problem-solving therapy
    • a combination of any of the above therapies

If you’ve been diagnosed with breast cancer and have finished treatment, it’s important to focus on what’s now most important: your good health. You have to make sure you get the best ongoing care – both physically and mentally – and live your best life.

If you’re dealing with neuropathy, fatigue, anxiety, or depression – or a combination of more than one of these conditions – talk to your doctor as soon as possible. Don’t suffer in silence. As the new ASCO guidelines demonstrate, there are treatments available to help ease all these conditions.

Make a deal with yourself: you will do the best you can to love yourself, speak up for yourself, take care of yourself, and take advantage of the best care possible. Remember, there’s only one of you and YOU deserve the best outcome possible both physically and emotionally.

For more information on each condition, including ways to manage it, visit the following pages:

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