Symptom Control in Cancer Rehabilitation. Ying Guo, MD Department of Palliative, Rehabilitation and Integrative Medicine UT MD Anderson Cancer Center

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1 Symptom Control in Cancer Rehabilitation Ying Guo, MD Department of Palliative, Rehabilitation and Integrative Medicine UT MD Anderson Cancer Center

2 Cancer Patients Symptoms Pain- 90% of patients with advanced cancer Fatigue 60-90% of cancer patients Cachexia/Anorexia Syndrome-80% patients with advanced cancer

3 How to Assess Symptoms

4 Symptom During Inpatient Rehabilitation Patients who were admitted to an acute inpatient rehabilitation unit (N=96). Patients median age was 64 years (range, 26 87y), and 49% were women. Cancer patient s symptom intensity is high at admission Symptoms with high intensity: Pain Fatigue Anorexia Insomnia

5 Average VAS Symptom During Inpatient Rehabilitation Admission Discharge 1 0

6 Symptom During Inpatient Rehabilitation Significant improvements Anxiety (P=.001) Constipation (P=.001) Fatigue (P=.002) Pain (P=.003) Appetite (P=.004) Insomnia (P=.04) Sense of well-being (P=.01)

7 Percentage of Patients Symptom During Inpatient Rehabilitation 80% 70% 60% 50% 40% 30% 20% 10% 0% Analgesics Appetite stimulant Mirtazapine Metoclopramide Antidepressants Methylphenidate Laxatives Hypnotics

8 Symptom During Inpatient Rehabilitation The poor appetite at admission scores correlated positively with hospital LOS (P<.001) Depression at admission scores also correlated positively with hospital LOS P=.05) Average acute rehabilitation LOS was 9 days.

9 Symptom at Outpatient Rehabilitation Clinic Survivorship definition by NCI: In cancer, a person is considered to be a survivor from the time of diagnosis until the end of life. Short-term survivor: 5 years since cancer diagnosis Long-term survivor: 5 years since cancer diagnosis Comparison of symptoms in short-term and long-term cancer survivor Similar symptom pattern Highest intensity symptoms are: Pain Fatigue Anorexia Insomnia

10 Characteristics of Patients in the Two Study Groups <5 YSD (N=133) 5 YSD (N=67) Age, Mean (SD) 53.4 (16.9) 57.8 (15.6) Female 63 (47.4) 40 (59.7) Weight (Kg), Mean (SD) 81.0 (22.2) 78.6 (21.9) Height (cm), Mean (SD) (10.5) (11.1) BMI, Mean (SD) 28.5 (8.3) 28.3 (8.1) N (%) N (%) Race Asian 7 (5.3) 7 (10.4) Black 14 (10.5) 12 (17.9) Hispanic 16 (12.0) 6 (9.0) White 94 (70.7) 42 (62.7) Unknown 2 (1.5) 0 Cancer Treatment History Prior Chemotherapy 75 (56.4) 44 (65.7) Prior Radiation therapy 74 (55.6) 44 (65.7) Prior Surgery 115 (86.5) 59 (88.1) Types of cancer Brain/spinal 42( 31.6) 15 (22.4) Breast 14 (10.5) 18 (26.9) Gastroenterological 12 (9.0) 5 (7.5) Head & Neck 10 (7.5) 4 (6.0) Leukemia 9 (6.8) 3 (4.5) Lung 7 (5.3) 3 (4.5) Lymphoma 4 (3.0) 5 (7.5) Melanoma 6 (4.5) 2 (3.0) Prostate 3 (2.3) 2 (3.0) Sarcoma 15 (11.3) 5 (7.5) Other* 11 (8.3) 5 (7.5)

11 Medians Comparison of Symptom based on ESAS in the Short-term and Long-term Survivor Groups 10 ESAS Symptoms <5 Year Since Diagnosis 5 Year Since Diagnosis Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Feeling of WellBeing Shortness of Breath Sleep

12 Comparison of Medications Used for Symptom Management in the Short-term and Long-term Survivor Groups 100% 90% 80% <5 Years Since Diagnosis 5 Years Since Diagnosis 70% 60% 50% 40% 30% 20% 10% 0%

13 Comparison of Symptom Treatment in the Short-term and Long-term Survivor Groups 132/200 (66%) total patients had fatigue ratings of 3 Methylphenidate is the most studied pharmacological agent for the treatment of cancer-related fatigue. 11/133(8%) of short-term survivors uses Methylphenidate 9/67 (13%) of long-term survivors uses Methylphenidate 99/200 (49.5%) total patients had anorexia ratings of 3 Appetite stimulants were prescribed for 61 (46%) of short-term survivors Appetite stimulants were prescribed for 27 (40%) of long-term survivors Among those patients with poor appetite ratings of 3, only 51/100 (51%) had appetite stimulants in their medication lists. 110 (56%) total patients had poor sleep ratings of 3 Hypnotics were prescribed for 20 (15%) of short-term survivors 14 (21%) of long-term survivors.

14 Symptoms are Under-treated Lack of effective and standardized treatment for these symptoms. Lack of emphasis in symptom control in rehabilitation community. Patient s hesitation in taking additional medications. Physician s worry of polypharmacy, and side effect of the medication.

15 Finding Reversible Causes-Pain Etiology of pain Neuropathic pain: Nociceptive pain: Somatic: Bony pain: bracing Joint pain: bracing, joint injection Myofascial pain: myofascial release, heat, cold, acupuncture, massage, stretching Visceral: distention due to gas/constipation: proper bowel and bladder management Secondary pain: Central sensitization and a windup phenomenon: causing prolongation and amplification nociceptive activity even after the cessation peripheral input: medication, acupuncture Spiritual pain: support from family, social worker, psychologist, chaplain, Priest

16 Case Report Plantar fasciitis in a 60 year old female patient with metastatic renal cancer Oxycontin ER (mg/day) Pain 0 1/2/2015 2/3/2015 3/2/2015 4/13/2015 7/6/2015 0

17 Finding Reversible Causes-Fatigue Central fatigue: Depression: involve supportive care on psychiatry Brain dysfunction due to brain metastasis/tumor Paraneoplastic neurological syndrome Peripheral fatigue: Effect of inflammatory cytokines (TNF alpha, IL-6,IL 1, IL-2): causing anorexia, progressive loss of muscle mass. Correct anemia: iron deficiency, Vitamin B12 deficiency, folate deficiency, GI bleed Bed rest, immobility lead to low exercise tolerance: endurance training and aerobic exercises Hb BUN Low Fe, high retic

18 Finding Reversible Causes-Fatigue Peripheral fatigue: Respiratory related to reason: Pulmonary toilet, each patient abdominal /diaphragmatic breathing Infections Endocrine disorders: adrenal insufficiency; hypothyroidism; hypogonadism Anticancer treatment related side effect, such as nausea and vomiting Poor sleep: cluster care Hypocalcemia Calcium Vit D

19 Finding Reversible Causes-Insomnia Anxiety: Cognitive behavior therapy Sun-downing/delirium Circadian rhythm dysfunction: Melatonin; increase exposure to sun, sleep hygiene Symptom control: frequent urination, pain, shortness of breath, depression and anxiety High-dose steroid-induced insomnia: taper down steroid, may use shortterm hypnotics.

20 Finding Reversible Causes-Anorexia/ Poor Appetite Medication caused: Pain medication: opioids Antibiotics Constipation: laxative and bowel program Disturbed GI function due to antibiotics treatment, chemotherapy, radiation treatment: probiotics