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Evidence-Based Recommendations for Cancer Fatigue, Anorexia, Depression, and Dyspnea

Sydney M. Dy, Karl A. Lorenz, Arash Naeim, Homayoon Sanati, Anne Walling, Steven M. Asch

From the Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles; and RAND Health, Santa Monica; and University of California, Irvine, CA

Corresponding author: Sydney M. Dy, MD, MSc, Health Policy and Management, Oncology, and Medicine, Johns Hopkins University, 624 N Broadway, Rm 609, Baltimore, MD 21205; e-mail: sdy{at}jhsph.edu

Purpose The experience of patients with cancer often involves symptoms of fatigue, anorexia, depression, and dyspnea.

Methods We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel.

Results For fatigue, providers should screen patients at the initial visit, for newly identified advanced cancer, and at chemotherapy visits; assess for depression and insomnia in newly identified fatigue; and follow up after treatment for fatigue or a secondary cause. For anorexia, providers should screen at the initial visit for cancer affecting the oropharynx or gastrointestinal tract or advanced cancer, evaluate for associated symptoms, treat underlying causes, provide nutritional counseling for patients undergoing treatment that may affect nutritional intake, and follow up patients given appetite stimulants. For depression, providers should screen newly diagnosed patients, those started on chemotherapy or radiotherapy, those with newly identified advanced disease, and those expressing a desire for hastened death; document a treatment plan in diagnosed patients; and follow up response after treatment. For general dyspnea, providers should evaluate for causes of new or worsening dyspnea, treat or symptomatically manage underlying causes, follow up to evaluate treatment effectiveness, and offer opioids in advanced cancer when other treatments are unsuccessful. For dyspnea and malignant pleural effusions, providers should offer thoracentesis, follow up after thoracentesis, and offer pleurodesis or a drainage procedure for patients with reaccumulation and dyspnea.

Conclusion These standards provide a framework for evidence-based screening, assessment, treatment, and follow-up for cancer-associated symptoms.

Supported by a grant from Amgen Inc to the RAND Corporation.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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