Assessing Symptom Burden in Cancer   DiaLog: Making Headway in Hematology, by Guillermo Garcia-Manero, MD, Associate Professor, Department of Leukemia   Helping Kids Make Smart Food Choices   Expanding Therapy Options for Advanced Cancerhttps://openworks.mdanderson.org/oncolog/1167/thumbnail.jp

Garcia-Manero, Guillermo, MD

Munch, Joe

Witter, Diane

English

OpenWorks @ MD Anderson

University of Texas MD Anderson Cancer Center OpenWorks @ MD Anderson OncoLog MD Anderson's Report to Physicians (All issues) OncoLog MD Anderson's Report to Physicians 2008 OncoLog Volume 53, Number 02, February 2008 Joe Munch The University of Texas MD Anderson Cancer Center Diane Witter The University of Texas MD Anderson Cancer Center Guillermo Garcia-Manero MD The University of Texas MD Anderson Cancer Center Follow this and additional works at: https://openworks.mdanderson.org/oncolog  Part of the History of Science, Technology, and Medicine Commons, and the Oncology Commons Recommended Citation Munch, Joe; Witter, Diane; and Garcia-Manero, Guillermo MD, "OncoLog Volume 53, Number 02, February 2008" (2008). OncoLog MD Anderson's Report to Physicians (All issues). 177. https://openworks.mdanderson.org/oncolog/177 This Newsletter is brought to you for free and open access by the OncoLog MD Anderson's Report to Physicians at OpenWorks @ MD Anderson. It has been accepted for inclusion in OncoLog MD Anderson's Report to Physicians (All issues) by an authorized administrator of OpenWorks @ MD Anderson. For more information, please contact rml-help@mdanderson.org. A Publication of 4 6 7 8 M. D. Anderson Phase I Trials In Brief House Call DiaLog Cancer CenterExpanded program Leukemia vaccine Kids can learn to Hematology meeting puts experimental shows response in choose good foods showcases advances Making Cancer History" therapies to the test some patients while having fun in cancer treatment REPORT TO PHYSICIANS Assessing Symptom Burden in Cancer Researchers are aiming to help clinicians better manage the physical and emotional toll of disease and treatment. By Joe Munch Until recently, assessing the symptoms caused by cancer and its treatments-let alone managing them-often took a back seat to other aspects of clinical care. Typically, symptoms were not treated until after they presented in patients, and when clinicians did address their patients' symptoms, they targeted the obvious­pain and fatigue---but tended to overlook other symptoms that interfered with their patients' lives. As cancer patients live longer, however, more clinicians are focus-ing not only on prolonging life, but also on -improving quality of life. And that means addressing patients' symptoms before they become serious issues. The Department of Symptom Research at Dr. Charles Cleeland and Dr. Xin Shelley Wang are taking symptom research beyond the realm of pain and fatigue. The University of Texas M. D. Anderson Cancer Center is working toward that aim by assessing and exploring possible avenues of effectively treating patients' symptom burden-the physical and emotional toll of cancer and its treatments. The department is running clinical studies aimed at reducing or preventing symptoms in cancer patients, surveying patients to better define the characteristics and severity of those symptoms, and making an effort to understand their underlying causes. Xin Shelley Wang, M.D., M.P.H., an associate professor of symptom research, is the principal investigator for many of these studies. Much of her work focuses on the role of inflammatory cytokines in symptom burden. She and other researchers have discovered that certain symptoms seem to be correlated with each other-that they may in fact be caused by the same biologic mechanism. Investigating these mechanisms may lead to a more informed approach of treat­ing symptom burden in cancer patients. "The goal is to target those mechanisms that cause (Continued on page 2) TI-E lNIVERSITY OF TEXAS MDAN)ERSON CANCER CENTER 2 OncoLog • February 2008Assessing Symptom Burden in Cancer(Continued from page 1)symptom burden so we can do a betterjob of managing and preventing symp-toms,” Dr. Wang said.The search for better dataThe first step in locating and target-ing the biologic mechanisms that causesymptom burden in cancer patients isidentifying the symptoms and treat-ments that cause the most distress.However, many of the symptoms thatcontribute to a patient’s symptom bur-den—like fatigue, poor appetite, anddrowsiness—cannot be measured easilyor objectively. “You cannot just ask apatient, ‘Do you have hypertension?’You need to measure it by taking thatpatient’s blood pressure,” Dr. Wang said.“But when you ask, for example, ‘Do you have pain, and how bad is it?’ noobjective measure exists—you have to trust the patient.”To better understand how symptomsinterfere with patients’ lives, to betterprepare patients for the symptoms oftheir cancer treatment, and ultimately, to use that information to help eliminatesymptom burden, researchers in theDepartment of Symptom Research havebeen developing and are using symptomassessment tools—surveys designed togauge the severity of symptoms patientsexperience while undergoing cancertreatments. Charles Cleeland, Ph.D.,McCullough Professor of CancerResearch and chair of the Department of Symptom Research, has been at theforefront of the symptom research fieldfor more than 20 years. In the late 1980s,while at the University of Wisconsin, he spearheaded the development of theBrief Pain Inventory, a tool that is usedto assess pain and its effects on patients’lives and that has become a major clini-cal trial and epidemiologic measure forpain in patients with cancer and otherdiseases. Later, after he arrived at M. D.Anderson, Dr. Cleeland and his col-leagues developed the Brief FatigueInventory, a similar measure that is used to assess fatigue and its byproductsin patients. Yet, even as he and his col-leagues were developing the Brief FatigueInventory, it became clear that pain andfatigue were not isolated problems andthat patients were, in fact, experiencing a constellation of symptoms.“We thought that we still weren’tcapturing the multitude of symptomsthat patients have. We never will, butlet’s go a little higher in the number we try to tackle,” Dr. Cleeland said. “So we did a lot of work with patientsand tried to find out, at least for thepatients here, what symptoms botheredthem the most.” Assessing the burdenTo address this need, Dr. Cleelandand his colleagues in the Department of Symptom Research developed the M. D. Anderson Symptom Inventory, or MDASI, a brief, two-part, multiplesymptom assessment tool modeled onthe Brief Pain and Brief Fatigue inven-tories. On the survey, patients are firstasked to rate on a 0 to 10 scale theseverity of 13 “core” symptoms—pain,fatigue, nausea, vomiting, disturbedsleep, distress, shortness of breath, problems remembering things, lack ofappetite, drowsiness, dry mouth, sadness,and numbness or tingling—experiencedin the last 24 hours, with 0 representing“not present” and 10 representing “as badas you can imagine.” Next, patients ratehow those symptoms have interfered withsix aspects of their lives—general activi-ty, mood, work (including work aroundthe house), relations with other people,walking, and enjoyment of life—with 0representing “did not interfere” and 10representing “interfered completely.” “If you just ask patients, for example,‘Do you have any pain?’ that’s an insuffi-cient question because it doesn’t giveyou any boundaries,” Dr. Cleeland said.“But if you ask, ‘On a 0 to 10 scale,what is your pain?’ patients can give you some idea of the severity of it.”Because each disease, stage, andtreatment can cause different symptoms,the MDASI’s core items have been sup-plemented with symptoms that are spe-cific to certain types of cancer and theirtreatment. For example, gastrointestinalcancer patients typically have problemswith diarrhea, whereas advanced-stagelung cancer patients often use morphineand thus have problems with constipa-tion. Neither of the symptoms is includedamong the core items on the MDASI,but they may seriously interfere withpatients’ lives. These disease-specific“modules” enable the inclusion of dis-ease-specific symptoms without makingthe surveys extremely long, as would be the case if all possible symptoms ofall possible cancers were included. Data collected with the MDASI in a large patient group can be used to helppredict the severity of symptoms associ-ated with a particular cancer or cancertreatment. That information in turn canbe used to help health care provider andpatient alike prepare for treatment. “Forinstance,” Dr. Cleeland said, “for certainhead and neck cancers, chemotherapy is combined with radiation therapy,whereas the treatment used to be radia-tion therapy alone. We can use theMDASI to show that the difference in symptom burden associated with thecombined therapies is significantly worsefor the patient. You wouldn’t want tostop using the combined therapy, butwith that knowledge you certainly couldprepare better for making the patientmore comfortable.” While a handful of patients maymanipulate their MDASI responses to draw attention to themselves, exag-gerating the severity of their symptoms,Dr. Cleeland believes that the converseis probably a bigger problem. Patientswho fear that their responses will botherthe physician, instigate additional cancertreatments, or preclude them from participating in trials of experimentalcancer therapies are more likely toThe goal is to targetthose mechanisms that cause symptomburden so we can do abetter job of managingand preventing symptoms.”– Dr. Xin Shelley Wangreport their symptoms as less severe thanthey really are. However, Dr. Cleelandsaid, most of the responses are thoughtto be accurate self-assessments. “Whatwe have seen in 20-plus years is that themajority of patients seem to use theseassessment tools in the same way, andthat for the majority of patients thenumbers have a similar meaning, notonly in the United States but across dif-ferent cultures and countries,” he said. Dr. Wang, who has been workingwith researchers from around the globeto validate foreign language versions of the MDASI, echoed Dr. Cleeland’ssentiments: “It doesn’t matter if your ‘5’is equal to my ‘5’ or is equal to anotherperson’s ‘5.’ Basically, when someonereports a ‘5,’ we observe impairment ofthe patient’s daily function. And when a patient goes from reporting a ‘0’ toreporting a ‘5,’ or goes to reporting an‘8,’ for that patient, it’s a big change.”And that big change needs to beaddressed before a patient winds up inan emergency room.Applications for interventionAccording to Dr. Cleeland, one ofthe advantages of the MDASI is that itis “intuitively interpretable” by patientsand physicians alike. Moreover, mostpatients can complete the survey infewer than 5 minutes. Its uncomplicated,straightforward design makes the MDASIeasily adaptable to a computer- and tele-phone-based interactive voice response(IVR) system that can be used to moni-tor patients at home. The IVR-MDASIis designed to keep clinicians in touchwith patients’ needs throughout theirdisease courses: The system generatesautomated follow-up phone calls to out-patients; when prompted by the system,a patient reports the severity of his orher symptoms by pushing buttons on thetelephone keypad. If the patient reportsa sudden increase in symptom severity,the IVR-MDASI alerts the patient’shealth care providers so that appropriatemeasures can be taken to help bettermanage the patient’s symptom burden. “The end of the therapy doesn’t mean the end of the symptom burden,”Dr. Wang said. In some cases, she noted,symptom burden actually increases aftertreatment ceases. “Even for patients who do not come back to the clinic on a weekly basis anymore because theyhave completed therapy, we still need to address how they’re dealing with their symptoms.” Care providers rely on patients toreport their symptoms. This does notpresent much of a problem if a patient is in the hospital and has almost con-stant contact with his or her care staff.However, Dr. Cleeland said, “We haveshifted so much of our care to the outpa-tient setting. That, in turn, leaves it up to the patients to decide when theyneed to go in for unscheduled care, andit’s almost the rule that patients willwait way too long to do that. One of thethings that intrigues us is whether, if weare monitoring these patients and find-ing that their symptoms are changing,we might be able to prevent some badevents from happening.”To test the feasibility of the IVR-MDASI as an effective symptom assess-ment and tracking tool, researchers have recently incorporated it into clinical trials aimed at assessing thesymptom burden in patients undergoingsurgery for lung cancer, chemotherapyfor non–small-cell lung cancer, andautologous blood or bone marrow transplantations. Looking forward In collaboration with other depart-ments at M. D. Anderson, the Department of Symptom Research isdoing research to determine the effec-tiveness of novel treatments designed to relieve patients’ symptom burden.Ongoing studies are exploring the possibility that various behavioral interventions, such as aural distractionor positive imagery, are effective atdecreasing symptom burden duringtreatment; investigating the use ofmethylphenidate as an effective treat-ment of fatigue in breast cancer patientsundergoing chemotherapy; and usingfunctional magnetic resonance imagingto determine and measure the interac-tion between the activation sites in the brain that are associated with morphine, positive imagery, and pain in healthy volunteers.For her part, Dr. Wang is workingwith the Department of Thoracic andCardiovascular Surgery to study theprevalence, severity, and interference of multiple symptoms in advanced lungcancer after surgery or chemotherapy.She is also investigating the role ofsymptom-related cytokines in lung andgastrointestinal cancer patients undergo-ing chemotherapy and radiation therapy.Researchers draw blood samples and correlate cytokine levels with the symptoms patients experience from therapy. The department’s research may oneday lead to a clearer picture of symptomburden—and may help provide themeans to target and eliminate it. In the meantime, the benefit of symptomresearch, Dr. Wang said, is that it setsthe bar for practitioners: physicians nowhave a starting point when confrontedwith their patients’ symptoms.“So many clinical trials have beendone and so many symptom manage-ment guidelines have been published,and people are beginning to understandthe importance of controlling symptomburden,” Dr. Wang said. “Today, you can actually do something to keep cancer patients from suffering from their symptoms. This you could notimagine 20 years ago.” ●For more information, call the Department ofSymptom Research at 713-745-3470 or visitwww.mdanderson.org/departments/PRG.www.mdanderson.org/oncolog • OncoLog 3If we are monitoringoutpatients and findingthat their symptoms are changing, we mightbe able to prevent some bad events from happening.”– Dr. Charles CleelandPHYSICIANS: THIS PATIENT INFORMATION SHEET IS YOURS TO COPY AND PASS ON TO PATIENTS. Helping Kids Make Smart Food Choices The age;old problem of getting kids to eat their veggies might be tougher than ever. Today's parents have to compete with fast food, vending machine snacks, sodas, and other options that are quick and easy-and often far from healthy. But you can help your children develop better eating habits. Learning about groceries You might be surprised to learn that children will usually pick nutritious foods when given the choice. But it's up to parents to give them those choices, and spicing up your trips to the grocery store is a great place to start. "Getting kids involved in the grocery shopping teaches them how to pick out produce and other ingredients," said Kristen Bardon, R.D., L.D., senior clinical dietitian in the Department of Clinical Nutrition at The University of Texas M. D. Anderson Cancer Center. "It also helps them learn how to prepare healthy meals." Have your kids help put together the shopping list, and be sure to suggest lots of fresh fruits and vegetables. That way you can talk about healthy choices before ever getting to the store. Children will be more interested in food that's good for them when they have a chance to make some of the decisions. And you'll learn more about what they like and don't like. Once at the store, take the children on a scavenger hunt for healthy foods, Ms. Bardon suggests. This will make shopping exciting and helps them look beyond the junk food aisles. Try these tips for a successful scavenger hunt: • Show your kids a picture of a fruitor vegetable and askthem to find it.• Have them describeHealthy Diet Recommendations You can find a world of information about food recommendations for children on the Internet. Here are a couple of sources to help you get started. www.americanheart.org The American Heart Association offers an eating pattern for families at its Web site. Highlights include: ✓ Eat foods that are low in saturated fat, trans fat, cholesterol, sodium,and added sugars.✓ Serve whole-grain and/or high-fiber breads and cereals.Look for "whole grain" as the first ingredient on the food label.✓ Serve a variety of fruits and vegetables each day, but limitthe amount of juice kids drink. Each meal should containat least one fruit or vegetable.✓ Don't overfeed your kids. Typical calorie needs are about900 per day for a 1-year-old child, 1,800 per day for a14- to 18-year-old girl, and 2,200 per day for a 14-to 18-year-old boy (or more for active teens).www.fruitsandveggiesmatter.gov For recipes and eating tips, visit the Web site "Fruits and Veggies-More Matters:• The site includes a calculator that you can use to figure out specific food serving information for your child. The "More Matters" program is sponsored by the U.S. government and private partners. the shape, color, and size of fruits and vegetables they see. • Have them count fruits andvegetables.• Encourage them to find fruits andvegetables that they haven't eatenbefore.Benefits of a healthy diet By being a good role model for healthy eating, you also can set children on a lifelong path of making the right food choices. "It's important for kids to start eating healthy early in life," Ms. Bardon said. "Healthy eating can help prevent many problems as they get older, including obesity, diabetes, heart disease, and some cancers." Not only can eating well help prevent problems down the road, it's important for growing kids to take in the nutrients provided by fruits, vegetables, and other healthy foods. But these nutrients are even more important for children who have cancer or another major illness. ''These children need a healthy, well-balanced diet sufficient in protein and calories," Ms. Bardon said. ''Protein helps the body heal, and calories produce energy and help kids keep up their weight."• For more information, talk to your physician, or: • call askMDAnderson at1-877-632-6789• visit the Department ofClinical Nutrition's Web siteat ,www.mdanderson.org/departments/nutrition• visit www.mdanderson.org OncoLog, February 2008 ]. LeBas @2008 The Unit,e,sity of Texas M. D. Anderson Cance,- Center 

OncoLog Volume 53, Number 02, February 2008

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OncoLog Volume 53, Number 02, February 2008

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