ASCO Guidelines Address Key Symptoms Affecting Cancer Survivors

ASCO has released guidelines for the prevention and management of symptoms such as anxiety, depression, fatigue, and neuropathies, which affect many cancer survivors.

The American Society of Clinical Oncology (ASCO) has released its first ever guidelines for prevention and management of symptoms that affect many cancer survivors. In three separate publications based on available medical literature and other guideline sources, ASCO members have published clinical practice guides for anxiety and depression, fatigue, and chemotherapy-induced neuropathy.

These guides are part of a planned ASCO series that addresses cancer survivorship issues.

A cancer survivor is a broad term defined by the American Cancer Society (ACS) as any person diagnosed with cancer starting from the time of their diagnosis through the course of his or her life, but is mainly focused on the period of time after active cancer therapy ends. ACS estimates that a total of 13.7 million Americans who have had a history of cancer were alive as of January 1, 2012. This population is projected to increase to 18 million (9.2 million women and 8.8 million men) by 2022.

Among male survivors, the most common cancers are prostate (43%), colon and rectal (9%), and melanoma (7%). For female survivors, the most common cancers are breast (41%), uterine (8%), and colon and rectal (8%).

This survivor population has physical and mental health challenges as a result of the effects of the specific cancer and treatment, as well as psychological effects from the diagnosis and treatment process. Studies and evidence from real-world clinical care show that the transition from active treatment to post-treatment is important, including addressing unique health issues and health risks for these patients. How patients care for themselves and whether their concerns are addressed clinically affect their long-term health outcomes.

The anxiety and depression guideline was adapted from the Pan-Canadian Practice Guideline on Screening, Assessment, and Care of Psychosocial Distress (Depression, Anxiety) in Adults With Cancer. The guidelines on cancer survivors’ fatigue combined a pan-Canadian guideline on cancer-related fatigue and two National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines on cancer-related fatigue and general cancer survivorship. The ASCO guideline on chemotherapy-induced neuropathy is novel, developed by a group of experts from different disciplines and based on a review of 48 randomized controlled trials for neuropathy treatment, as well as outcome and quality of life reports.

Key Guideline Recommendations

For anxiety and depression:

• All patients should be periodically evaluated for depression and anxiety symptoms using validated protocols.

• Treatment of patients with depression or anxiety should be tailored based on severity of symptoms and history of depression. Follow-up of patients is crucial, as many symptomatic patients are less likely to comply with referrals and treatments.

• Health care providers should be aware of their institutions’ resources for treatment of depression and anxiety and should have patients make use of supportive care services, including those that facilitate prevention and mitigation of symptoms.

For fatigue:

• Regular screening is highly recommended, starting at the time of diagnosis and continuing after completion of primary treatments, at least annually and using semi-quantitative or quantitative measures.

• Patients should be offered education and advice about managing fatigue following treatment. Maintaining adequate levels of physical activity are encouraged, particularly walking.

• Other non-drug treatments such as psychosocial interventions and mind-body interventions (yoga, acupuncture) are encouraged.

• Pharmacological interventions for post-treatment patients are not encouraged, as there is limited evidence that drugs are effective in reducing fatigue in those who have completed therapy and are currently disease-free.

For neuropathy:

• Duloxetine is recommended for treatment of chemotherapy-induced peripheral neuropathy (CIPN).

• No agents are recommended for prevention of CIPN during active chemotherapy treatment.

• No strong clinical evidence for benefits from other agents such as tricyclic antidepressants, gabapentin, and topical gels containing baclofen, amitriptyline HCL, and ketamine are seen, but they may be tried in certain patients.