Yesterday we talked about fatigue and cancer treatment related fatigue. I started with an introduction about fatigue in elderly cancer patients because fatigue is both a symptom, a syndrome, and partly a component of frailty. So when we have to address fatigue in elderly cancer patients we have to keep in mind all these components of fatigue in the elderly subjects. Then we will add the cancer related fatigue that is both primary or secondary, related to cancer itself. Then we will add the cancer treatment related fatigue. So the problem of fatigue is that because it’s complex and very correlated with many problems – depression, cognitive dysfunction, pain and so on – it’s very badly evaluated and sometimes it’s considered as normal. It’s a very important problem for the patients because when they are requested to explain which is the first symptom, fatigue is symptom number one. So it’s really important to consider that.
My work challenge was to do an evaluation of the risk of fatigue, depending on the regimen of cancer treatment, in different contexts - the main solid tumour contexts and the main regimen. In fact, we decided to evaluate the rate of fatigue in 174 regimens and we had some information about fatigue as a toxicity of the regimen in around 70% of these cases. What is important to know and to understand and to see is that the reporting of fatigue increases with time, is really variable between the studies for the same regimen, perhaps is a little bit higher in elderly patients but not so much. In fact, the reporting of elderly specific data in this context is very low. Finally, the interest for fatigue is really dependant on the tumour setting. For example, the reporting of fatigue in metastatic breast cancer is very high, more than 80% of the regimen, when it’s very low for the adjuvant setting in the same tumour. Because of that the conclusions of my talk were to say that we should integrate the risk of fatigue in the balance of benefit-risk ratio for the treatment.
How is fatigue evaluated?
According to the NCICTC scoring system the fatigue is evaluated through the activities of daily living and that is very powerful for the geriatrician because we are used to using these activities of daily living. So grade 1 fatigue is a fatigue that is restored after rest; grade 2 is when it’s not restored after rest and inducing limitations in instrumental activities of daily living and grade 3 is not restored after rest and inducing limitations in basal activities of daily living. So that sounds very powerful for the geriatrician, I feel.
What does this mean for an elderly patient?
When you consider that for an elderly patient autonomy is the first target of the treatment we have to keep in mind that if we induce grade 3 fatigue because of our treatment we are not hitting the goal of our patients. So, considering all these aspects, I did an appeal that SIOG proposes recommendations about fatigue assessment in clinical trials and perhaps considers that, for the same efficacy, regimens with lower fatigue should be considered as preferential in the elderly patients.
Were there any interesting questions that were asked about your talk?
Yes, there was a very interesting question that was about the longitudinal evaluation of fatigue. A colleague explained that perhaps a grade 1 or 2 fatigue when it lasts very long, a long time, is perhaps more difficult to live with than a grade 3 fatigue for only three days in the cycle of chemotherapy. So that is also a very important point that must be considered, but not yet so much considered.
Is the NCICTC scoring system always appropriate to use?
There is a lot of debate considering the way to consider, to evaluate and to score fatigue. It’s important to know that the COMPARZ study that compared pazopanib to sunitinib in metastatic renal cancer, kidney cancer, was registered based on fatigue results as pazopanib induces less fatigue than sunitinib with the same results, efficacy results. That was the first time when a treatment was validated and reimbursed on the basis of patient reported outcome and in its condition on fatigue. The scoring system that was used was FACIT-F for fatigue, and it can be considered as better than the NCICTC scoring system but I would say something is better than nothing. When you analyse toxicity of the treatments the NCICTC is widely used so, for me, it’s worthwhile to use that.