Why Do We Care About Supportive Care in Patients With Cancer?
Jerry L. Spivak, MD*
Generally speaking, patients who have anemia as a comorbidity are more likely to have an adverse outcome compared with patients without anemia. This fact has been shown in patients with Hodgkin's disease, non-Hodgkin's lymphoma, heart disease, HIV, and renal disease, with different mechanisms in each–but it is unequivocal in cancer. If a patient is anemic during cancer therapy, that patient will not do as well. Depending on the cancer study, local renal control, metastases, and survival are worse in patients with anemia compared with patients who are not anemic during therapy.
Anemia is common in patients with cancer, and its causes are many. Anemia is important as a sign of disease; it might be the first harbinger of cancer or indicate a comorbid condition that needs to be treated before cancer therapy can begin. Patients who are anemic during cancer therapy are more symptomatic in terms of fatigue and lack of energy, which has a definite impact on quality of life. Anemic patients undergoing chemotherapy are more likely to require blood transfusions, which has an obvious impact on survival. In cases involving other diseases and in which anemia has been corrected, survival has been improved. Improved survival hasn't yet been proven in patients with cancer, but it has been shown that with radiotherapy, correcting anemia does make a difference in outcome.
We now have pharmacologic means for correcting anemia without resorting to transfusion, and the side effects are negligible. How can we best take advantage of these therapies to improve quality of life and outcome in our patients? First we must be sure there are no other correctable causes of anemia, then we must choose the appropriate situation in which improving anemia will alleviate patient symptoms.
Similarly, neutropenia, which commonly follows myelosuppressive chemotherapy, affects both quality of life and outcome in patients with cancer. The cost of treatment and the danger of the infections that follow neutropenia demand that we use preventive measures when appropriate and the best available treatments when neutropenia does occur.
The most important recent development in preventing and treating neutropenia has been the development of colony-stimulating factors, or cytokines, which decrease the incidence and duration of febrile neutropenia. Especially in older patients, cytokines as a supportive care option allow us to offer chemotherapy to patients who would have been directed to hospice care only a few years ago. In patients of all ages, once fever or infection occurs, cancer treatment must either be delayed or given with reduced dosages. Cytokines, however, are allowing clinicians to keep patients on time and at full dose with their chemotherapy, which has a direct effect on mortality risk.
Supportive care for other conditions–notably nausea, emesis, and mucositis–is undergoing positive change as well. The majority of patients undergoing chemotherapy experience nausea and/or vomiting, which are among the most common causes of patient morbidity. Nausea and vomiting might also cause discontinuation of chemotherapy, significantly influencing patient outcomes. Preventive treatment that diminishes acute nausea and vomiting is now available, and other treatments are showing good effect in delayed nausea. Research continues into treatments for oral mucositis-a condition also often associated with the discontinuation or reduction of cancer therapy, with resultant negative effect on outcomes. Several lines of inquiry are showing promise.
This issue of Advanced Studies in Medicine includes a review article by Dr Stephen J. Noga discussing the importance of supportive care in patients with cancer as well as recent advances in this therapeutic area. Dr Noga reviews the risks and complications of anemia, neutropenia, nausea and emesis, and oral mucositis, as well as the prevention of and available treatment for each.
Dr Noga and I also participate in a joint clinician interview, which is preceded by a brief review of the national supportive care guidelines. We discuss the need for supportive care as it relates to patient quality of life, the strengths and weaknesses of the national guidelines, and how our individual practices at Johns Hopkins differ from those guidelines.
The joint interview is followed by an interview with Dr John H. Fetting III, who is heavily involved in the development of the supportive care guidelines at Hopkins. He discusses the motivation behind the development of the guidelines and the importance of standardizing care from both the quality-of-care and cost-effectiveness perspectives. The issue concludes with 2 case studies that demonstrate supportive care for anemia and neutropenia in patients undergoing chemotherapy.
The emergence of successful, evidence-based treatments for anemia and neutropenia offers hope that increasing numbers of patients with cancer can experience improved health-related quality of life and, perhaps, improved clinical outcomes. New treatments for nausea, emesis, and mucositis are also showing improved results, suggesting that these side effects of cancer treatment need no longer go untreated or undertreated. It is critical that as clinicians we make ourselves aware of the need for supportive care in cancer and keep ourselves up to date on the available and emerging treatments for the conditions that so commonly result from cancer therapy.
*Professor of Medicine and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Jerry L. Spivak, MD, Johns Hopkins University School of Medicine, Traylor 924 - Hematology, 600 North Wolfe St, Baltimore, MD 21287. E-mail: firstname.lastname@example.org.