Updated NCCN Survivorship Guidelines

May 2014, Vol 5, No 4

Hollywood, FL—Cancer survivorship guidelines have been expanded to include the management of neuropathic pain and cancer-associated cognitive dysfunction, said speakers at the 2014 National Comprehensive Cancer Network (NCCN) meeting.

Between 20% and 40% of patients with cancer have neuropathic pain, said Susan G. Urba, MD, Professor of Medical Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, and it “is one of the most common reasons that cancer patients stop their treatment early.”

The NCCN guidelines call for universal screening for pain in all patients with cancer, and if pain is present, a comprehensive pain assessment to identify the etiology and to determine patient goals for comfort and function.

Neuropathic Pain
For cancer-related neuropathic pain, antidepressants and anticonvulsants, such as gabapentin (Neurontin) and pregabalin (Lyrica), are first-line adjuvant analgesics. These can be used alone or in conjunction with opioids, said Dr Urba.

“Analgesic effectiveness is not dependent on antidepressant activity,” said Dr Urba, and, therefore, the analgesic dose [of antidepressants] may be lower than that used for the treatment of depression. Start with a low dose, she advised, and increase the dosage every 3 to 5 days if tolerated.

Duloxetine (Cymbalta) was tested specifically in patients with chemotherapy-induced neuropathy, and was found to significantly decrease the level of pain interference with daily function and to improve quality of life compared with placebo. Venlafaxine (Effexor) was also significantly superior to placebo on the outcomes of complete relief of neuropathy and a >50% relief of neuropathy in patients with oxaliplatin (Eloxatin)-induced neuropathy.

Topical agents, which work best when combined with an opioid, antidepressant, or anticonvulsant, are now included in the NCCN guidelines.

Cognitive Impairment
Cancer-associated cognitive change is now being recognized in NCCN survivorship guidelines, which address the management of patients who do not receive central nervous system (CNS)-directed treatments, but who may be experiencing cognitive change.

“For a subset of patients, cancer and cancer treatment disrupt ‘normal’ cognitive functions,” said Elizabeth A. Kvale, MD, Director, Supportive Care and Survivorship Outpatient Clinic, University of Alabama at Birmingham Comprehensive Cancer Center. The effect precedes cancer treatment in some patients: as many as 30% of patients experience cognitive impairment before adjuvant therapy.

“Chemobrain” has been the common vernacular for cancer-associated cognitive impairment, but this label ignores the many contributors to cognitive changes, said Dr Kvale. The mechanisms thought to contribute to cancer-associated cognitive dysfunction include direct toxicity of chemotherapy to neurons, microvascular damage that contributes to white matter changes, and inflammatory mediators that are toxic to neurons and that impair CNS function.

There are currently no brief sensitive tools to screen for the disorder, but neuropsychologic testing can substantiate the patient’s experience. Neuroimaging confirms structural and functional changes in the brain of patients with cancer-associated cognitive impairment, but is not helpful in diagnosis.

“Current management strategies are patient-centered, supportive, and nonspecific,” Dr Kvale said. “Reassurance and watchful waiting are not unreasonable strategies for patients exhibiting symptoms of cancer-associated cognitive dysfunction. For most patients these symptoms will resolve on their own over the course of time. Reassuring them that this is not a progressive dementing condition is a perfectly reasonable thing to do.”

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