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Journal of Clinical Oncology, Vol 22, No 19 (October 1), 2004: pp. 4029 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.99.210
In Reply:The University of Texas M.D. Anderson Cancer Center, Houston, TX Dr Vale comments on numerous potential factors that contribute to fatigue in cancer and other conditions. Unfortunately, factors related to muscle cells, influence of proinflammatory cytokines or other byproducts on the brain, or abnormal perception within a normal muscular condition as described by the author are of interest, but are largely impossible to diagnose and have no defined treatment at the present time. The author proposes a role for selective seratonin reuptake inhibitor (SSRI0, most specifically citalopram) for the management of fatigue. However, the reference provided is based on a randomized controlled trial conducted on patients with chronic fatigue syndrome. There are multiple reasons why findings in this population may not be appropriate for fatigue in patients with advanced cancer. Additionally, significant improvement was observed in the chronic fatigue patients after 1 month of treatment. This long latency period may be quite acceptable for patients with chronic stable conditions, but it may be too long for patients with progressive cancer and a short expected survival. We believe that randomized controlled trials of citalopram would be of interest and that, ideally, weekly assessments should take place in order to better characterize the drug's role in cancer-related fatigue. The author comments on his perception of side effects of methylphenidate. Our experience,1-4 and that of other groups,5-7 suggests that this drug is reasonably well-tolerated even when used for prolonged periods. However, we uphold our conclusion that this is just a pilot study and that double-blind placebo-controlled trials are necessary before any attempt is made to use methylphenidate as a routine treatment for cancer-related fatigue. The author comments on the Functional Assessment for Chronic Illness Therapy Scale (FACIT) as a general quality-of-life scale. However, the scale used in this study was the FACIT-Fatigue (FACIT-F) scale. This scale has a validated fatigue subscore for 13 items. The results of our study are based on the modification of the fatigue subscore. This highly validated instrument has been used widely in fatigue research, including studies conducted on erythropoietin for the management of fatigue.8 The Edmonton Symptom Assessment Score (ESAS) has been independently validated as a highly reliable tool for the assessment of multiple symptoms including fatigue.9 The changes in the mean and standard deviation of the fatigue score in both the ESAS and the FACIT-F subscore are reported in Tables 2 and 3 of our article.10 The observed improvement included a decrease in fatigue of 7.2 ± 1.6 at baseline to 3 ± 1.9 at day 7 in the ESAS (P < .001), and an improvement of 17.5 ± 11.3 in the fatigue subscore of the FACIT-F at baseline to 34.7 ± 10 at day 7 (P < .001). We conclude that these are remarkable changes that justify randomized placebo-controlled trials. We are aware that such studies are currently taking place in a number of institutions including our own. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES 1. Bruera E, Brenneis C, Chadwick S, et al: Methylphenidate associated with narcotics for the treatment of cancer pain. Cancer Treat Rep 71:67-70, 1987[Medline] 2. Bruera E, Miller MJ, MacMillan K, et al: Neuropsychological effect of methylphenidate in patients receiving a continuous infusion of narcotics for cancer pain. Pain 48:163-166, 1992[CrossRef][Medline] 3. Vigano A, Watanabe S, Bruera E: Methylphenidate for the management of somatization in terminal cancer patients. J Pain Symptom Manage 10:167-170, 1995[CrossRef][Medline] 4. Bruera E, Fainsinger R, MacEachern T, et al: The use of methylphenidate in patients with incident cancer pain receiving regular opiates: A preliminary report. Pain 50:75-77, 1992[CrossRef][Medline] 5. Meyers C, Weitzner M, Valentine A, et al: Methylphenidate therapy improves cognition, mood and function of brain tumor patients. J Clin Oncol 16:2522-2527, 1998[Abstract]
6. Homsi J, Nelson K, Sarhill N, et al: A phase II study of methylphenidate for depression in advanced cancer. Am J Hosp Palliat Care 18:403-407, 2001
7. Breitbart W, Rosenfeld B, Kaim M, et al: A randomized, double-blind, placebo-controlled trial of psychostimulants for the treatment of fatigue in ambulatory patients with human immunodeficiency virus disease. Arch Intern Med 161:411-420, 2001 8. Turner R, Anglin P, Burkes R, et al: Epoetin alfa in cancer patients: Evidence-based guideline. J Pain Symptom Manage 22:954-965, 2001[CrossRef][Medline] 9. Chang V, Hwang S, Feuerman M: Validation of the Edmonton symptom assessment scale. Cancer 88:2164-2171, 2000[CrossRef][Medline]
10. Bruera E, Driver L, Barnes EA, et al: Patient-controlled methylphenidate for the management of fatigue in patients with advanced cancer: A preliminary report. J Clin Oncol 21:4439-4443, 2003
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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