2009NCCN指南-肿瘤相关的疲乏

Continue NCCN Clinical Practice Guidelines in Oncology™ Cancer-Related Fatigue V.1.2009 www.nccn.org Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® NCCN Cancer-Related Fatigue Panel Members Ann M. Berger, PhD, RN, AOCN UNMC Eppley Cancer Center at The Nebraska Medical Center Amy Pickar Abernethy, MD Duke Comprehensive Cancer Center Ashley Atkinson, RN, MSN, OCN University of Alabama at Birmingham Comprehensive Cancer Center Andrea M. Barsevick, PhD, RN, AOCN Fox Chase Cancer Center David Cella, PhD Robert H. Lurie Comprehensive Cancer Center of Northwestern University Bernadine Cimprich, PhD, RN University of Michigan Comprehensive Cancer Center Charles Cleeland, PhD The University of Texas M. D. Anderson Cancer Center # † # # # William S. Breitbart, MD Memorial Sloan-Kettering Cancer Center � � � Mario A. Eisenberger, MD The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Carmen P. Escalante, MD Þ The University of Texas M. D. Anderson Cancer Center Pamela Hinds, PhD, RN St. Jude Children's Research Hospital/ University of Tennessee Cancer Institute Paul B. Jacobsen, PhD H. Lee Moffitt Cancer Center & Research Institute Phyllis Kaldor, RN, MS, OCN Arthur G. James Cancer Hospital and Richard J. Solove Research Institute at The Ohio State University Jennifer A. Ligibel, MD Dana-Farber/Brigham and Women’s Cancer Center † � � # # † Matthew J. Loscalzo, MSW City of Hope Barbara A. Murphy, MD Vanderbilt-Ingram Cancer Institute Tracey O’Connor, MD Roswell Park Cancer Institute William F. Pirl, MD, Massachusetts General Hospital Cancer Center Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance Hope S. Rugo, MD ‡ UCSF Helen Diller Family Comprehensive Cancer Center Lynne I. Wagner, PhD Robert H. Lurie Comprehensive Cancer Center of Northwestern University £ † £ † † � � � Eve Rodler, MD ‡ # Nursing † Medical oncology Psychiatry, psychology, including health behavior Urology £ Supportive care including palliative, pain management, pastoral care and oncology social work ‡ Hematology/Hematology oncology Bone marrow transplantation Þ Internal medicine * Writing Committee Member � � � Continue * * * * * * NCCN Guidelines Panel Disclosures * Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® Table of Contents NCCN Cancer-Related Fatigue Panel Members Summary of Guidelines Updates Definition of Cancer-Related Fatigue (FT-1) Standards of Care for Cancer-Related Fatigue in Children/Adolescents and Adults (FT-2) Screening for Cancer-Related Fatigue (FT-3) Primary Evaluation (FT-4) Interventions for Active Treatment (FT-5) Interventions for Long-Term Follow-up (FT-6) Interventions for End of Life (FT-7) Guidelines Index Print the Cancer-Related Fatigue Guideline These guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2009. For help using these documents, please click here Discussion References Clinical Trials: Categories of Evidence and Consensus: NCCN The believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN member institutions, All recommendations are Category 2A unless otherwise specified. See NCCN click here: nccn.org/clinical_trials/physician.html NCCN Categories of Evidence and Consensus Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® Summary of major changes in the 1.2009 version of the Cancer-Related Fatigue guidelines from the 1.2008 version include: UPDATES Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Summary of the Guidelines Updates ( ) ( ) ( ) FT-4 FT-5 FT-7 � � � Assessment of treatable contributing factors: A new bullet was added “ General Strategies for Management of Fatigue; Energy conservation: “Nap time” was changed from 45 to 20-30 minutes. (Also for FT-6 and FT-7) Nonpharmacologic (Also for FT-6 and FT-7): Cognitive behavioral therapy (CBT) has a new corresponding footnote that states, “A type of psychotherapy that focuses on recognizing and changing maladaptive thoughts and behaviors to reduce negative emotions and facilitate psychological adjustment.” Stress management, Relaxation and Support groups were designated as “category 1” recommendations. “Sleep therapy” changed to “CBT for sleep”. Optimize level of activity ”. The constraints are listed as “Bone metastases, Immunosuppression/neutropenia, Thrombocytopenia, Anemia, Fever, and .” Medication side effects profile (ie, sedation)”. � � � � � Activity enhancement; Caution: “Fever” was changed to “Fever ” Psychosocial interventions: Nonpharmacologic; Activity enhancement: “Optimize level of activity” was changed to “ The panel removed “Consider referral to rehabilitation: physical therapy, occupational therapy, physical medicine” as a recommendation. or active infection � � � � with careful consideration of the following constraints Assessment of safety issues (ie, risk of falls, stability) Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. DEFINITION OF CANCER-RELATED FATIGUE Cancer-related fatigue is a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. FT-1 Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. STANDARDS OF CARE IN CHILDREN/ADOLESCENTS AND ADULT CANCER-RELATED FATIGUE MANAGEMENT � � � � � � � � � � � � � Fatigue is rarely an isolated symptom and most commonly occurs with other symptoms, such as pain, distress, anemia, and sleep disturbances, in symptom clusters. Therefore, patients should be screened for multiple symptoms that may vary according to diagnosis, treatment, and stage of disease. Fatigue is a subjective experience that should be systematically assessed using patient self-reports and other sources of data. Fatigue should be screened, assessed, and managed according to clinical practice guidelines. All patients should be screened for fatigue at their initial visit, at regular intervals during and following cancer treatment, and as clinically indicated. Fatigue should be recognized, evaluated, monitored, documented, and treated promptly for all age groups, at all stages of disease, prior to, during and following treatment. Patients and families should be informed that management of fatigue is an integral part of total health care. Health care professionals experienced in fatigue evaluation and management should be available for consultation in a timely manner. Implementation of guidelines for fatigue management is best accomplished by interdisciplinary teams who are able to tailor interventions to the needs of the individual patient. Educational and training programs should be implemented to ensure that health care professionals have knowledge and skills in the assessment and management of fatigue. Cancer-related fatigue should be included in clinical health outcome studies. Quality of fatigue management should be included in institutional continuous quality improvement (CQI) projects. Medical care contracts should include reimbursement for the management of fatigue. Disability insurance should include coverage for the continuing effects of fatigue. Rehabilitation should begin with the cancer diagnosis. � FT-2 Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Screen every patient for fatigue as vital sign at regular intervalsa,b � � � Age > 12 y: � � � Severity: 0-10 scale (0=No fatigue; 10=Worst fatigue you can imagine) or None, mild, moderate, severe Age 7-12 y: Severity 1-5 scale (1=No fatigue; 5=Worst) Age 5-6 y Use “tired” or “not tired” c None to mild (0–3)a,b � � Age 7-12 y (1-2) Age 5-6 y (Not tired) Moderate (4–6) or severe (7–10) a,b a,b � � Age 7-12 y Moderate (3) or Severe (4-5) Age 5-6 y Moderate or severe (Tired) � � Education plus general strategies to manage fatigued Ongoing reevaluation SCREENING a c Recommended screen: “How would you rate your fatigue on a scale of 0-10 over the past 7 days?” Fatigue scale for children is simplified: Use “tired” or “not tired” as screen for young children (age < 6 or 7 y). Butt Z, Wagner LI, Beaumont JL, et al. Use of a single-item screening tool to detect clinically significant fatigue, pain, distress, and anorexia in ambulatory cancer practice. Journal of Pain and Symptom Management 2008; 35(1): 20-30. b dSee “Patient/Family Education and Counseling” and “General Strategies for Management of Fatigue” based on clinical status: , , . Active Treatment (FT-5) Long Term Follow-up (FT-6) End of Life (FT-7) See Primary Evaluation (FT-4) FT-3 Education plus general strategies to manage fatigued Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Focused history Depression Anxiety Medication side effects profile (ie, sedation) � � � � � � � � � � Disease status and treatment Rule out recurrence or progression Current medications/medication changes Prescription/OTCs and supplements Review of systems In-depth fatigue history Onset, pattern, duration Change over time Associated or alleviating factors Interference with function Assessment of treatable contributing factors: Pain Emotional distress Anemia Sleep disturbance (eg, obstructive sleep apnea, restless leg syndrome, narcolepsy, insomnia) Nutrition Assessment Weight/caloric intake changes Fluid electrolyte imbalance: sodium, potassium, calcium, magnesium Activity level Decreased activity Decreased physical fitness Comorbidities Infection Cardiac dysfunction Pulmonary dysfunction Renal dysfunction Hepatic dysfunction Neurologic dysfunction Endocrine dysfunction (hypothyroidism, hypogonadism, adrenal insufficiency) � � � � � � � � � � � � � � � � � � � � � Pain See NCCN Cancer Pain Guideline Anemia See NCCN Cancer-and- Chemotherapy Induced Anemia Guideline Sleep disturbance Emotional distress See NCCN Distress Management Guideline PRIMARY SCORE: Age > 12 y (4-10), Age 7-12 y (3-5), or Age 5-6 y (Tired) EVALUATION FATIGUE MODERATE OR SEVERE Treatable contributing factors No other factors Nutrition Evaluation/Medical Interventions Activity level Comorbidities Active treatment Follow-up, no active treatment (except hormonal therapy) End of life See Interventions (FT-5) See Interventions (FT-6) See Interventions (FT-7) PATIENT CLINICAL STATUS FT-4 Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® INTERVENTIONS FOR PATIENTS ON ACTIVE TREATMENTe � � � Consider psychostimulants (methylphenidate or modafanil) after ruling out other causes of fatigue Treat for anemia as indicated Consider sleep medication i (See NCCN Guidelines) Cancer-and- Chemotherapy Induced Anemia Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. � � � � � Activity enhancement (category 1) Maintain optimal level of activity Consider initiation of exercise program Consider referral to rehabilitation: physical therapy, occupational therapy & physical medicine Caution: Anemia Psychosocial interventions Cognitive behavioral therapy (CBT) (category 1) Stress management (category 1) Relaxation Support groups (category 1) Attention-restoring therapy (eg, nature) Nutrition consultation CBT for sleep Sleep hygiene Stimulus control � � � � � � � � � � � Bone metastases Immunosuppression/neutropenia Thrombocytopenia Fever or active infection Limitations secondary to metastases or other illnesses Sleep restriction g � � � � � � h (See MS-9) See MS-10( ) eSee Discussion for information on differences between Active treatment, Long term follow-up, and End-of-life treatment. fInterventions should be culturally specific and tailored to the needs of patients and families because not all patients may be able to integrate these options due to variances in individual circumstances and resources. (Sahler OJZ, Varni JW, Fairclough DL, et al. Problem-Solving Skills Training for Mothers of Children with Newly Diagnosed Cancer: A Randomized Trial. Journal of Developmental & Behavioral Pediatrics. 23(2):77-86, April 2002) ( )See MS-1 Information about known pattern of fatigue during and following treatment Reassurance that treatment-related fatigue is not necessarily an indicator of disease progression � FT-5 Patient/Family Education and Counseling General Strategies for Management of Fatigue Nonpharmacologicf Pharmacologic SPECIFIC INTERVENTIONS � � � Self-monitoring of fatigue levels Energy conservation Set priorities Pace Delegate Schedule activities at times of peak energy Labor-saving devices Postpone nonessential activities Limit naps to 20-30 minutes or less so as to not interfere with night- time sleep quality Structured daily routine Attend to one activity at a time Use distraction (eg, games, music, reading, socializing) � � � � � � � � � Repeat evaluation See (FT-4) g h i Concern is with environment. Limit activity to environments where risk of infection is low. A type of psychotherapy that focuses on recognizing and changing maladaptive thoughts and behaviors to reduce negative emotions and facilitate psychological adjustment. Pharmacological interventions remain investigational, but have been reported to improve symptoms of fatigue in some patients. There is more evidence for methylphenidate and less for modafinil. These agents should be used cautiously and should not be used until treatment and disease specific morbidities have been characterized or excluded. Optimal dosing and schedule have not been established for use of psychostimulants in cancer patients. Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Cancer-Related Fatigue Guidelines Index Cancer-Related Fatigue TOC Discussion, References Practice Guidelines in Oncology – v.1.2009NCCN ® � � Energy conservation Set priorities Pace Delegate Schedule activities at times of peak energy Labor-saving devices Postpone nonessential activities Limit naps to 20-30 minutes or less so as to not interfere with night- time sleep quality Structured daily routine Attend to one activity at a time Use distraction (eg, games, music, reading, socializing) � � � � � � � � � �Activity enhancement (category 1) Maintain optimal level of activity Consider initiation of exercise program Consider referral to rehabilitation: physical therapy, occupational therapy, physical medicine Caution: Psychosocial interventions (category 1) CBT (category 1) Stress management (category 1) Relaxation Support groups (category 1) Attention-restoring therapy (eg, nature) Nutrition consultation CBT for sleep Sleep restriction Sleep hygiene Stimulus control � � � � � � � � Late effects of treatment (eg, cardiomyopathy) � � � � � � � � h ( ( ) See MS-9) See MS-10 Information about known pattern of fatigue during and following treatment Self-monitoring of fatigue levels � INTERVENTIONS FOR PATIENTS ON LONG-TERM FOLLOW-UPe Note: All recommendations are category 2A unless otherwise indicated. Clinical Tr