Panel Urges Control of Cancer-Related Pain, Depression, Fatigue

BETHESDA, Maryland—Labeling the treatment of pain, depression, and fatigue in many cancer patients inadequate, a National Institutes of Health (NIH) state-of-the-science panel has called for optimal symptom control for all cancer patients from diagnosis and throughout their illness. It also called for escalated funding to support research on the definition, occurrence, assessment, and treatment of all three problems.

"Currently, cancer-related pain, depression, and fatigue are undertreated, and this situation is simply unacceptable," said chair Donald L. Patrick, PhD, MSPH, professor and director of the Social and Behavioral Sciences Program, Department of Health Services, University of Washington, Seattle. "There are effective strategies to manage these symptoms, and all patients should have optimal symptom control."

The 13-member panel spent 2 days listening to expert testimony and drafting a statement. It released its final report on the third day of the conference after hearing public comments on the draft. Although sponsored by the National Cancer Institute and NIH’s Office of Medical Applications of Research, and co-sponsored by six other NIH units and the FDA, the panel was an independent body, and its statement does not represent NIH or federal policy.

In its report, the panel addressed five issues—occurrence, the reliability and validity of methods for clinical assessment, the effectiveness of treatments, impediments to effective symptom management, and future directions for research.

With regard to the occurrence of pain, depression, and fatigue, "published studies on all three symptoms are virtually restricted to prevalence data; there are no reliable incidence studies," the report said. Prevalence studies estimate a range of 14% to 100% for pain, 1% to 42% for depression, and 4% to 91% for fatigue. The estimates’ lack of consistency stems from both conceptualization and measurement problems, and weaknesses in research methodology, the panel said.

Assessment

Most clinical assessments of pain, depression, and fatigue rely on self-reporting by patients, who do the best job of assessing the severity of their own symptoms, but the sickest patients often cannot complete symptom questionnaires. Although a number of assessment tools exist, only a few assess all three symptoms simultaneously.

"The reliability and validity of many of these instruments have been established in cancer patients," the report said. "Less is known about clinically useful cutoff scores and assessment of meaningful changes over the course of illness. There are few established symptom assessment instruments for children, older adults, individuals with cognitive impairments, and individuals from different ethnic and cultural groups."

Treatment

Treatment of pain, depression, and fatigue pose problems throughout the course of cancer, and the treatment of these side effects may relieve or, conversely, exacerbate others. Because cancer pain shares mechanisms with pain from other causes, treatment approaches can be extrapolated from other pain management models, including the World Health Organization’s three-step analgesic ladder.

Treatment for cancer-related depression is substantially the same as in other medical conditions, the panel said. A variety of antidepressants have shown benefit in randomized, controlled studies, and meta-analyses of cognitive-behavior and psychosocial interventions have substantiated modest benefit.

The panel said there is little convincing evidence that effective therapies exist to counter fatigue, but did note that epoetin alfa (Epogen, Procrit) "is an effective intervention for patients with anemia-related fatigue."

Barriers to providing effective pain relief to cancer patients involve providers, patients and their families, and the health care system, the report said.

Among providers, these barriers include a lack of awareness of the patient’s pain, inadequate training in pain management, a lack of time and resources, seeing the cure of cancer as a higher priority than treating symptoms, and concern about legal and regulatory sanctions for overusing narcotics. Patients and families may believe that pain is inevitable with cancer and nothing can be done for it; they may fear that addiction will develop and that reporting pain will distract providers from treating the cancer. Medication costs may also be a factor.

System barriers include a lack of communication between oncologists and primary care providers, poorly coordinated care, the priority of cure over symptom management, regulatory barriers to effective pain control, and a lack of reimbursement for symptom management.

"Impediments to management of depression in cancer patients include many of the same factors described for pain," the panel said. Major barriers to effective management of fatigue include a lack of awareness that fatigue is the most prevalent symptom, lack of knowledge of the causes of fatigue, and lack of proven methods to treat fatigue.

A common strategy for improving cancer symptom management involves regular symptom assessment, the panel said, followed by quality improvement interventions that include educating providers and patients, following treatment algorithms, and regular reassessment and follow-up of symptom scores.

"Strategies for decreasing system barriers need to be addressed at the national or regional level," the report said. "Regulatory barriers need to be revised to maximize convenience, benefit, and compliance, and to minimize cost and narcotic diversion for illegal purposes." It specifically urged refills for opioid prescriptions, refills by telephone, stocking by pharmacies of appropriate products, and adequate reimbursement for medications and symptom management.

Future Research

The panel’s list of areas for future research ranged from conceptual models to direct systematic research into pain, depression, and fatigue, to enhanced training of physicians and other health care providers in managing the symptoms of cancer and its treatment.

It suggested research to determine whether these symptoms differ qualitatively and quantitatively between cancer and noncancer patients; to provide accurate estimates of symptom incidence; to explore patients’ psychological and physiological accommodations to cancer symptoms; and to develop tumor-specific and pain-specific treatments. The full text of the report in draft form is available at http://consensus.nih.gov.