Supportive care to relieve cancer-related fatigue underutilised by breast cancer survivors

Lugano, Switzerland, 22 May 2020 – Cancer-related fatigue is a prevalent and potentially persistent issue among breast cancer survivors, which can prevent them from returning to their previous life well after treatment ends and they are declared free of disease. A study, to be presented at the ESMO Breast Cancer Virtual Meeting 2020 (23-24 May), has now shown that existing recommendations and proven strategies for reducing fatigue, which can have physical, emotional as well as cognitive dimensions, may not be sufficiently adhered to by early breast cancer patients. (1)

Explaining the background to the analysis, study author Dr. Antonio Di Meglio of Gustave Roussy in Villejuif, France, stated: “Cancer-related fatigue is an issue that many patients complain about in the clinic, sometimes for years after the completion of treatment. Although there is a lot that we still don’t know about the different mechanisms underpinning fatigue, we now have specific, evidence-based recommendations for treating it: the first is to initiate or maintain adequate levels of physical activity and limit sedentary time as much as possible. Data also supports the use of psychosocial interventions such as cognitive behavioural therapy, which can help address maladaptive thoughts like over-dramatising or feelings of helplessness. Our aim with this study was to assess the real-world uptake of these recommendations.”

To do this, the research team drew on data from the CANTO cohort study, (2) which assessed long-term toxicities in early breast cancer patients from 26 French cancer centres for at least five years from the time of diagnosis. According to Di Meglio, “CANTO is unique in the field of survivorship research, as it enrolled over 10,000 breast cancer patients nationwide, of which we were able to include more than 7,000 in our analysis. The wealth of clinical, patient-reported and biological data collected makes it an ideal database to answer a lot of questions about cancer-related fatigue.” Di Meglio and his colleagues included in their analysis only women who had completed primary treatment and were free of disease, and examined patients’ reported utilisation of recommended strategies to treat fatigue over 12 months after a baseline assessment.

“These are patients who were free of disease and whom we would expect to return to their pre-cancer state within six to 12 months after the end of treatment. What we found, however, was that over a third of patients (36%) reported fatigue that we classify as severe at three to six months after treatment,” Di Meglio reported. “A majority of study participants (64%) complied with physical activity recommendations in the year that followed, but that still leaves a concerning proportion of women (36%) who were not sufficiently active or completely inactive during this period.”

The results additionally showed that patients who reported severe levels of fatigue at baseline were less likely than those with non-severe symptoms to adhere to recommendations of physical activity (60% versus 67%) in the year following the assessment. “The message here is that we need to work harder to encourage patients to stay active, and to make them understand that even if it seems counter-intuitive, it is exercise, not rest, that will help them to overcome fatigue,” said Di Meglio.

The analysis further brought to light that overall reported utilisation of supportive care was low in this patient population, with only one out of 10 women consulting a psychologist, one out of 12 seeing an acupuncturist and one out of 14 seeking help from a homeopath. “The striking fact here is that patients seem to be using strategies that we have robust evidence for and can refer them to, like psychotherapy, at roughly the same rates as approaches for which we do not have sufficient efficacy data and therefore cannot recommend, like homeopathy,” Di Meglio observed. “This suggests that patients may not be sufficiently aware of what the recommendations are, and that we as oncologists need to ensure they are educated about the options at their disposal to reduce fatigue. Better education may also help to diminish the fears and stigma that are still too often associated with psychosocial interventions.”

Patients’ physical activity uptake and utilisation of supportive care were additionally evaluated for different dimensions of fatigue, revealing differences in women’s behaviour depending on whether their fatigue was more physical, cognitive or emotional in nature. “Most notably, we found that patients with severe physical fatigue were less likely to adhere to physical activity recommendations, at 59% compared to 67% of those with non-severe physical fatigue, while high levels of emotional fatigue were more strongly linked to utilisation of psychological consultations, at 17% compared to 8% of non-severe patients in this domain,” Di Meglio reported.

He continued: “We also expected women experiencing severe overall fatigue to rely much more heavily on supportive care measures, but in fact they were only 1.3 times more likely to seek out the help of a psychologist, for example, than patients with non-severe fatigue. This may be explained in part by the fact that psychosocial interventions in this context usually come with out-of-pocket costs for patients. That is something our findings may contribute to changing in the future – especially considering that untreated cancer-related fatigue can have long-term social and financial consequences for survivors, some of whom we know never return to their previous life.”

Prof. Gabriella Pravettoni, Director of the Psycho-Oncology Division at the European Institute of Oncology (IEO) in Milan, Italy, commented on the findings: “The fact that the strategies patients adopt to manage side-effects are strongly correlated to the type of fatigue they are suffering from is particularly interesting, because patients experiencing significant physical fatigue, for example, may actually benefit substantially from seeing a psychologist. We know that physical activity is proven to reduce cancer-related fatigue, but on its own it does not guarantee the inner healing of the individual.”

Pravettoni continued: “By focusing too much on physical activity as the primary remedy for cancer-related fatigue, we are omitting the importance of working on patients’ motivation and resilience to help them maintain that activity level and recover fully in the long term. If we leave these women without psychological support, other interventions are almost certain to be less effective as a result. What is truly needed is a 360-degree approach whereby healthcare professionals make therapeutic recommendations in line with patients’ unique characteristics and needs. This is all the more important in the context of the current health emergency, which can cause patients to experience strong negative emotions like fear and uncertainty and add to their existing psychological burden from potentially traumatic experiences related to their cancer diagnosis and treatment.”

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1 Abstract 183O ‘Use of physical activity (PA) and supportive care (SC) among patients (pts) with early breast cancer (BC) reporting cancer-related fatigue (CRF)’ will be presented by Antonio Di Meglio during the Proffered Paper session 1 on Saturday, 23 May, 12:45 to 14:15 (CET) on Channel 1. Annals of Oncology, Volume 31, Supplement 2, May 2020

2 CANTO cohort study:

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183O – Use of physical activity (PA) and supportive care (SC) among patients (pts) with early breast cancer (BC) reporting cancer-related fatigue (CRF)

A. Di Meglio1, C. Charles2, E. Martin1, J. Havas1, A.S. Gbenou1, A-L. Martin3, S. Everhard3, E. Laas4, O. Tredan5, L. Vanlemmens6, C. Jouannaud7, C. Levy8, O. Rigal9, M. Fournier10, P. Soulie11, A. Dumas12, G. Menvielle13, F. André1, S. Dauchy2, I. Vaz-Luis1

1INSERM UMR 981, Gustave Roussy, Villejuif, France, 2DISSPO, Gustave Roussy, Villejuif, France, 3R&D, UNICANCER, Paris, France, 4Medical Oncology, Institut Curie, Paris, France, 5Medical Oncology, Centre Léon Berard, Lyon, France, 6Medical Oncology, Centre Oscar Lambret, Lille, France, 7Medical Oncology, Institut Jean Godinot, Reims, France, 8Medical Oncology, Centre François Baclesse, Caen, France, 9Medical Oncology, Centre Henri Becquerel, Rouen, France, 10Medical Oncology, Institut Bergonié, Bordeaux, France, 11Medical Oncology, Institut de Cancérologie de L’ouest -Paul Papin, Angers, France, 12Universite de Paris, ECEVE UMR 1123, INSERM, Paris, France, 13Sorbonne Université, INSERM, Institut Pierre Louis d’Épidémiologie et de Santé Publique, Paris, France?

Background: CRF is highly prevalent in early BC. PA and psychosocial interventions were proven to be effective in several meta-analyses and are recommended management strategies for CRF. Some randomized trials support the use of acupuncture, while there are no data showing benefits of homeopathy for CRF. We aimed to assess use of PA and SC among pts with early BC.

Methods: Pts with stage I-III BC were prospectively included from the CANTO cohort (NCT01993498). Baseline CRF was evaluated shortly after treatment using EORTC-C30 for global CRF and EORTC-FA12 for its physical, emotional and cognitive domains. A score of 40 or higher defined CRF as severe (Abrahams HJ, Ann Oncol 2016). Data on adherence to PA recommendations (10 MET-hours/week or more) and SC consultations with a psychologist, acupuncturist or homeopath were collected in CANTO and therefore served as outcomes. Multivariable logistic regression examined associations between baseline CRF status (severe v not) and use of PA or SC consultations over the 12 months after baseline CRF assessment. Covariates included socio-demographics and psychological distress.

Results: Among 9691 pts included in CANTO, 6282 had available data on PA and 7598 on SC consultations. At baseline, 36% pts reported severe global CRF, and 36%, 23% and 14% pts reported severe physical, emotional and cognitive CRF, respectively. Overall, 64% pts were adherent to PA recommendations and only 10% pts saw a psychologist, whereas 8% saw an acupuncturist and 7% a homeopath. Pts reporting severe global CRF (v not severe) were less likely to adhere to PA recommendations (60% v 67%; adjusted odds ratio [aOR] 0.82, 95% CI 0.72-0.94), but more likely to see a psychologist (14% v 7%; aOR 1.31, 1.07-1.59), acupuncturist (10% v 6%; aOR 1.51, 1.22-1.86) or homeopath (10% v 6%; aOR 1.55, 1.25-1.92). There were differences in use of PA and SC consultations by CRF domain: pts reporting severe physical CRF showed lower adherence to PA (59% v 67%; aOR 0.73, 0.63-0.85), whereas pts with severe emotional CRF were more prone to psychology consultations (17% v 8%; aOR 1.41, 1.10-1.82).

Conclusions: This large study calls for the need to optimize and personalize the uptake of recommendations to manage CRF among pts with early BC.

Clinical trial identification: NCT01993498.

Legal entity responsible for the study: Unicancer.

Funding: Agence nationale de la Recherche (ANR-10-COHO-0004); Susan G. Komen (CCR17483507 to I. Vaz-Luis); Odyssea; Gustave Roussy.

Disclosure: A. Di Meglio: Honoraria (self): ThermoFisher. I. Vaz-Luis: Honoraria (self): Novartis; Honoraria (self): Kephren; Honoraria (self): AstraZeneca; Advisory/Consultancy: Ipsen; Honoraria (self): Amgen. All other authors have declared no conflicts of interest.