PHASE OF CARE: Multiple phases of care

Two hundred two references were retrieved. The total number of references included and reviewed for updating was not provided. No quality rating is identified.

• Energy conservation
• Physical activity
• Cognitive behavioral therapy (CBT) for sleep shown to be effective
• Counseling

• Limited evidence search
• No quality rating of studies considered
• Studies included for evidence level determination not specified

The guidelines provide suggestions for screening and identify some tools for fatigue assessment and some key interventions for the management of fatigue. They provide an overview of relevant evidence for multiple types of interventions. Major suggestions are identified in the recommendations section of this summary.

PURPOSE: To provide recommendations for antiemesis in patients with cancer

RESOURCE TYPE: Consensus-based guideline

PHASE OF CARE: Active antitumor treatment

No detailed information about literature searching or evidence grading was provided, and most recommendations were based on low-level evidence and consensus. A panel developed the recommendations.

• Triple drug therapy with NK1, 5HT3, and dexamethasone
• Netupitant-containing regimen
• Olanzapine, palonosetron, and dexamethasone for the acute phase and olanzapine for the delayed phase

• 5HT3 and dexamethasone with or without NK1 and either dexamethasone monotherapy, 5HT3, or NK1 plus dexamethasone for the delayed phase
• Netupitant-containing regimen
• Olanzapine regimen

• Limited provision of the evidence base for recommendations
• Much of the guideline is consensus-based.

This guideline provides a good resource for identifying the emetogenicity of various oral and IV chemotherapy agents, and it provides recommendations for radiation-related nausea and vomiting. The guideline is limited in that the full evidence base for all adjuvant recommendations is not provided, and the full strategy for the search and review of evidence is not stated.

PHASE OF CARE: Multiple phases of care

242 references were retrieved. No specific rating of study quality is described and most evidence is at the level of consensus.

For anxiety and depression, psychotherapy with or without psychotropic drugs is recommended. Social service and chaplain counseling are suggested. Specific algorithms for chaplain interventions are provided.

Most recommendations are consensus-based.  Limited search database

Suggestions for management of distress, and guidelines for the use of the NCCN Distress Thermometer and for distress screening are provided.

PHASE OF CARE: Late effects and survivorship

All recommendations were based on lower level evidence and consensus.

Physical activity and memory aids were recommended for cognitive impairment. SSRIs and SNRIs were recommended for depression as first-line treatment, and benzodiazepines were recommended as first-line treatment for anxiety. Physical activity, cognitive behavioral therapy, psychoeducation, and the consideration of psychostimulants were recommended for fatigue.

• Mainly consensus for most recommendations
• Limited database use  
• Full results of search not provided

This guideline gave numerous recommendations and suggestions for various aspects of patient needs. Most recommendations were consensus-based.

The objective of the guidelines is to provide palliative care practice guidelines for patients with cancer, facilitating the appropriate integration of palliative care into oncology practice.

These are consensus-based guidelines.

Included in the guidelines are multiple phases of care with palliative care applications. 

The NCCN made recommendations on the following symptoms.

Anorexia
Nutritional support, including enteral and parenteral feeding, should be considered. Appetite stimulants such as megestrol acetate and corticosteroids can be used when appetite is an important aspect of quality of life.

Chemotherapy-Induced Nausea and Vomiting (CINV)
Recommendations include prochlorperazine, haloperidol, metoclopramide, or benzodiazepines. Adding 5-HT₃ receptor agonists, anticholinergics, antihistamines, corticosteroids, antipsychotics, and cannabinoids also can be considered. Palliative sedation can be considered as a last resort.

Constipation
Increase fluid intake, dietary fiber, and physical activity. Opioid-induced constipation should be anticipated and treated prophylactically with laxatives.

Dyspnea
Pharmacologic interventions include opioids or benzodiazapines. Scopolamine, atropine hyoscyamine, and glycopyrrolate are options to reduce excessive secretions.

Pain
Do not reduce opioid dose for symptoms such as decreased blood pressure or respiratory rate. Palliative sedation can be considered for refractory pain.

Sleep/Wake Disturbances
For refractory insomnia with no underlying physiologic cause, pharmacologic management includes diazepam, zolpidem, and sedating antidepressants. Cognitive behavioral therapy may be effective. If present, restless leg syndrome can be treated with ropinirole.

• Recommendations are predominantly consensus- rather than evidence-based. 
• Recommendations are generally based on low-level evidence. 
• Recommendations regarding CINV seem particularly out of date and are not in concert with current evidence.

Recommendations provide expert opinion/consensus-level suggestions for management of various symptoms. Many recommendations, such as those for CINV, do not agree with current evidence in these areas.

RESOURCE TYPE: Consensus-based guideline

PROCESS OF DEVELOPMENT: Guidelines were developed by a panel

These guidelines did not provide a specific search strategy or information about literature search results.

• Dyspnea: Use fans, cooler temperatures, stress management, and relaxation therapy; use morphine if the patient is opioid-naïve, and add benzodiazepines symptoms are not relieved by opioids; give oxygen for subjective relief; reduce excessive secretions with scopolamine, atropine ophthalmic solution, or glcopyrrolate.
• Anorexia: Consider an appetite stimulant such as megestrol acetate, olanzapine, dexamethasone, or a cannabinoid.
• Constipation: Use senna with or without docusate; add other laxatives as needed; consider methylnaltrexone for opioid-induced constipation.
• Diarrhea: Administer loperamide; recommend the Bananas, Rice, Applesauce and Toast (BRAT) diet; consider atropine, corticosteroids, infliximab, or octreotide.

These recommendations were made mainly by consensus, and the guidelines provided no information about literature search results and appeared to use only one database for searching. All suggestions were based on low-level evidence and uniform consensus.

These guidelines provided numerous suggestions for the management of various symptoms, but they were not truly evidence-based. In those aspects for which there was no research evidence, the guidelines provided expert opinion suggestions for management.

To ensure that all cancer patients with fatigue were identified and treated promptly and effectively.  These guidelines included recommended standards of care for assessment and management of fatigue in children, adolescents, and adults with cancer.

The guidelines were evidence- and consensus-based. The guidelines were multidisciplinary, and all recommendations were category 2A unless otherwise stated.

The guidelines provided several algorithms for assessment and management based on age group, level of self-reported fatigue, and phase of treatment.

Screening

• All patients with cancer should be screened for the presence or absence of fatigue at regular intervals as a vital sign.
  • Age older than 12 years:  Screen on a 0-to-10 scale or as none, mild, moderate, or severe.
  • Age 7 to 12 years:   Use 1-to-5 scale (1 = no fatigue and 5 = worst).
  • Age 5 to 6 years:  Screen using “tired” or “not tired.”

Focused Evaluation of Fatigue

• A focused history and assessment of contributing factors should be performed when screening indicates moderate to severe fatigue.
  • Age older than 12 years:  score of 4 to 10
  • Age 7 to 12 years:  score of 3 to 5
  • Age 5 to 6 years:  “tired”
• Focused history should
  • Rule out recurrence or progression of cancer
  • Include a review of systems
  • Include an in depth fatigue history, including onset and patterns, associated/alleviating factors, and interference with function.
• Assessment of treatable contributing factors, such as
  • Other related symptoms
  • Anemia
  • Sleep disturbance
  • Medication and side effects
  • Comorbidities
  • Activity and fitness level.

Management and Interventions

• Active Treatment
  • Education and counseling regarding known patterns of fatigue and reassurance that treatment-related fatigue is not necessarily indicative of progression of disease.
  • General management strategies to include self-monitoring, energy conservation techniques, and use of distraction
  • Nonpharmacologic interventions to include activity enhancement, physically based therapies (such as massage), psychosocial interventions, nutritional consultation, and cognitive behavioral therapy for sleep
  • Pharmacologic interventions to include consider psychostimulants, treatment of anemia as indicated, and consideration of mediation for sleep
• Posttreatment
  • Education and counseling about known fatigue patterns and self-monitoring of fatigue levels
  • General management and nonpharmacological and pharmacological interventions as for active treatment above
• End of Life
  • Education and counseling about known fatigue patterns and as an expected end of life symptom
  • General strategies as per active treatment and post treatment
  • Nonpharmacologic interventions to include activity enhancement, psychosocial interventions, and nutrition consultation
  • Pharmacologic interventions as per active and post treatment

Within activity enhancement information, the guideline cites several synthesized reviews regarding the use of exercise and concludes that

• Improvement in fatigue was not noted with all diagnoses.
• It is reasonable to encourage all patients to engage in a moderate level of physical activity during and after cancer treatment.
• Referral to exercise specialists or physical therapy should be triggered by
  • Patients with comorbid conditions, such as chronic obstructive pulmonary disease or cardiac disease
  • Recent major surgery
  • Specific functional or anatomical deficits
  • Substantial deconditioning.
• Exercise should be used with caution in patients with
  • Bone metastases
  • Immunosuppression or neutropenia
  • Thrombocytopenia
  • Anemia
  • Fever or active infection
  • Limitations due to other illnesses.

Because fatigue is a subjective experience, it was recommended that assessment should use patient self-reports and other sources of data.

Several barriers were identified related to effective treatment for fatigue.  Due to barriers, it was stated that screening for fatigue needs to be emphasized.  Rescreening was emphasized because fatigue may exist beyond the period of active treatment.

Factors identified as potential causative agents that should be specifically assessed were outlined.  These factors were pain, emotional distress, sleep disturbance, anemia, nutrition, activity level, medication side effects, and other comorbidities.

It was noted that fatigue often occurs as part of a symptom cluster, often with sleep disturbance, emotional distress, or pain, so that assessment of these problems and institution of effective treatment is essential.

The importance of comprehensive assessment, including review of all current medications and noncancer comorbidities, was identified.  For example, it was noted that there can be thyroid dysfunction after radiation therapy for various cancers or use of biological and that hypogonadism can be associated with fatigue.

• The majority of studies regarding the impact of exercise on fatigue were performed in patients with limited types of cancer, and findings may not be applicable to all types of patients.  In addition, the timing and amount of exercise for various groups are not clear.  There are also few longitudinal studies examining fatigue in long-term disease-free survivors, although fatigue can be a long-term or late effect.
• Although the guideline was structured according to phase of treatment, recommended interventions did not vary according to phase of treatment.  There were minimal differences in recommended content of education and counseling.
• There was little evidence regarding effective management of fatigue in end of life care.
• There was no discussion of prevention related to fatigue.

To provide clinical practice guidelines for the evaluation and treatment of distress — a normal feeling of vulnerability to a feeling that leads to disabling problems, such as depression and anxiety — in adult patients with cancer

• Evidence-based guidelines    
• Consensus development involving a panel composed of physicians, psychiatrists, psychologists, and social workers

• Phases of care: multiple phases 
• Clinical application: palliative care

Results were not stated.

Recommended standards of care include

• Screening all patients for distress, at initial visits and appropriate intervals
• Distress management according to guidelines
• Having committees to implement standards, provide relevant education and training to healthcare professionals
• Having mental health professionals and certified chaplains available
• Providing a distress-thermometer screening tool
• Identifying at-risk patients and periods of increased vulnerability, to define appropriate screening intervals

Evaluation should include measures relating to level of distress, behavior symptoms, psychiatric history and medications, pain and symptom control, body image and sexuality issues, impaired capacity, safety, potential medical causes, and psychological disorders.

Management algorithms should be provided for dementia, delirium, mood disorder, psychotic disorder, adjustment disorder, anxiety disorder, personality disorder, and substance-related disorder.

Treatments identified for use include psychotherapy, anxiolytics, antidepressants, psychoeducation, cognitive behavioral therapy, social work and counseling interventions, spiritual counseling and ethics, and palliative care consultation according to algorithms.

• The evidence is mainly \"lower level,\" and recommendations are primarily consensus-based. 
• The panel did not include a nursing member.
• Many recommendations tend to focus on approaches to care for patients with significant mental disorders or for those referred to a mental health team. 
• The guidelines provide limited suggestions regarding low-level distress associated with physical symptoms.

The guidelines provide recommended pathways regarding assessment and management of distress. They do not provide a nursing perspective or identify a role for nursing in patient management.

RESOURCE TYPE: Consensus-based guideline

PHASE OF CARE: Not specified or not relevant

• Recommends psychological interventions with or without antianxiety or antidepressants to treat anxiety
• Recommends psychological interventions with or without antidepressants to treat depression
• Provides algorithms for social work counseling and chaplain interventions

Limited information on the quality of evidence was retrieved. All recommendations were mainly consensus based.

This guideline provides very general level treatment algorithms based on the results of an initial distress screening, and recommends further assessment and intervention determination if overall distress is 4 or above on the distress thermometer.

The guidelines recommend the following for management of opioid-induced constipation.

Preventive Measures:

• Take polyethylene glycol or a combination of stool softener and stimulant laxative daily.
• Maintain adequate fluid intake.
• Maintain adequate fiber intake. Compounds such as psyllium are not recommended because they are unlikely to control opioid-induced constipation.

If Constipation Occurs:

• Rule out other causes and begin treating.
• Titrate stool softeners and laxatives as needed.
• Consider coanalgesics to enable opioid dose reduction.

Persistent Constipation:

• Consider the addition of agents such as magnesium hydroxide, bisacodyl, rectal suppository, lactulose, and sorbitol.
• Use enemas.
• Consider methylnaltrexone 0.15 mg/kg subcutaneously daily.

Recommendations were identified as having low-level evidence and uniform consensus.