TARGET POPULATION: Adult patients (older than 18 yr of age) with newly diagnosed brain metastases.
QUESTION: If whole brain radiation therapy (WBRT) is used, is there an optimal dose/fractionation schedule?
RECOMMENDATIONS: Level 1: A standard WBRT dose/fractionation schedule (ie, 30 Gy in 10 fractions or a biological equivalent dose [BED] of 39 Gy10) is recommended as altered dose/fractionation schedules do not result in significant differences in median survival or local control. Level 3: Due to concerns regarding neurocognitive effects, higher dose per fraction schedules (such as 20 Gy in 5 fractions) are recommended only for patients with poor performance status or short predicted survival. Level 3: WBRT can be recommended to improve progression-free survival for patients with more than 4 brain metastases.
QUESTION: What impact does tumor histopathology or molecular status have on the decision to use WBRT, the dose fractionation scheme to be utilized, and its outcomes?
RECOMMENDATIONS: There is insufficient evidence to support the choice of any particular dose/fractionation regimen based on histopathology. Molecular status may have an impact on the decision to delay WBRT in subgroups of patients, but there is not sufficient data to make a more definitive recommendation.
QUESTION: Separate from survival outcomes, what are the neurocognitive consequences of WBRT, and what steps can be taken to minimize them?
RECOMMENDATIONS: Level 2: Due to neurocognitive toxicity, local therapy (surgery or SRS) without WBRT is recommended for patients with ≤4 brain metastases amenable to local therapy in terms of size and location. Level 2: Given the association of neurocognitive toxicity with increasing total dose and dose per fraction of WBRT, WBRT doses exceeding 30 Gy given in 10 fractions, or similar biologically equivalent doses, are not recommended, except in patients with poor performance status or short predicted survival. Level 2: If prophylactic cranial irradiation (PCI) is given to prevent brain metastases for small cell lung cancer, the recommended WBRT dose/fractionation regimen is 25 Gy in 10 fractions, and because this can be associated with neurocognitive decline, patients should be told of this risk at the same time they are counseled about the possible survival benefits. Level 3: Patients having WBRT (given for either existing brain metastases or as PCI) should be offered 6 mo of memantine to potentially delay, lessen, or prevent the associated neurocognitive toxicity.
QUESTION: Does the addition of WBRT after surgical resection or radiosurgery improve progression-free or overall survival outcomes when compared to surgical resection or radiosurgery alone?
RECOMMENDATIONS: Level 2: WBRT is not recommended in WHO performance status 0 to 2 patients with up to 4 brain metastases because, compared to surgical resection or radiosurgery alone, the addition of WBRT improves intracranial progression-free survival but not overall survival. Level 2: In WHO performance status 0 to 2 patients with up to 4 brain metastases where the goal is minimizing neurocognitive toxicity, as opposed to maximizing progression-free survival and overall survival, local therapy (surgery or radiosurgery) without WBRT is recommended. Level 3: Compared to surgical resection or radiosurgery alone, the addition of WBRT is not recommended for patients with more than 4 brain metastases unless the metastases' volume exceeds 7 cc, or there are more than 15 metastases, or the size or location of the metastases are not amenable to surgical resection or radiosurgery.The full guideline can be found at: https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_3.
OBJETIVO: Proporcionar una guía basada en la evidencia sobre los enfoques óptimos de prevención y tratamiento en el manejo de neuropatías periféricas inducidas por quimioterapia (CIPN) en supervivientes de cáncer de adultos. MÉTODOS: Una búsqueda sistemática en la literatura identificó ensayos controlados aleatorios (ECA) relevantes para el tratamiento del CIPN. Los resultados primarios incluyeron la incidencia y la gravedad de la neuropatía medida por los cambios neurofisiológicos, los resultados informados por el paciente y la calidad de vida. RESULTADOS: Un total de 48 ECA cumplieron los criterios de elegibilidad y constituyen la base probatoria de las recomendaciones. Los ensayos tendieron a ser pequeños y heterogéneos, muchos con tamaños de muestra insuficientes para detectar diferencias clínicamente importantes en los resultados. Los resultados primarios variaron en los ensayos y, en la mayoría de los casos, los estudios no fueron directamente comparables debido a diferentes resultados, mediciones e instrumentos utilizados en diferentes momentos. La fuerza de las recomendaciones se basa en la calidad, cantidad y consistencia de la evidencia y el equilibrio entre beneficios y daños. RECOMENDACIONES: Sobre la base de la escasez de pruebas consistentes y de alta calidad, no hay agentes recomendados para la prevención de la CIPN. Con respecto al tratamiento del CIPN existente, los mejores datos disponibles apoyan una recomendación moderada para el tratamiento con duloxetina. Aunque los ensayos CIPN no son concluyentes con respecto a los antidepresivos tricíclicos (como la nortriptilina), la gabapentina y un gel tópico compuesto que contiene baclofeno, amitriptilina HCL y ketamina, estos agentes pueden ofrecerse sobre la base de datos que apoyen su utilidad en otras condiciones de dolor neuropático dadas Las limitadas otras opciones de tratamiento de la CIPN. Más investigación sobre estos agentes está garantizada.
Antecedentes: Los síntomas depresivos, fatiga y apatía son síntomas comunes en los adultos mayores con enfermedades médicas y los pacientes con enfermedad avanzada, y se han asociado con una morbilidad y mortalidad. El metilfenidato se ha utilizado para tratar estos síntomas, debido a su efecto rápido. A pesar de la larga historia de uso de metilfenidato para el tratamiento de los síntomas depresivos, fatiga y apatía, hay poca evidencia definitiva que apoye su uso.
OBJETIVO: El objetivo de este trabajo fue revisar la eficacia y tolerabilidad del metilfenidato en el tratamiento de los síntomas depresivos, fatiga y apatía en los adultos mayores con enfermedades médicas y los adultos que reciben cuidados paliativos.
MÉTODOS: Inglés-artículos en el idioma que presentan las revisiones sistemáticas, ensayos clínicos, o series de casos que describe el uso de metilfenidato para el tratamiento de los síntomas depresivos, fatiga o apatía en adultos con enfermedades médicas de esa edad o adultos que reciben cuidados paliativos fueron identificados. El metilfenidato palabras clave y depresivo o bien, la depresión, la fatiga, la apatía o se utiliza para buscar en la base de datos Cochrane, MEDLINE, PsycINFO, e International Pharmaceutical Abstracts. Los artículos incluidos abordaron los síntomas de depresión, la fatiga, la apatía o en el (1) adultos mayores (por lo general, la edad mayor o igual a 65 años), particularmente aquellos con enfermedades graves concomitantes, (2) adultos que reciben cuidados paliativos, y (3) adultos con otras enfermedades crónicas enfermedades. Me excluyeron los artículos sobre el tratamiento de la depresión en adultos jóvenes sanos, el trastorno bipolar y el trastorno por déficit de atención y la narcolepsia, el síndrome de fatiga crónica y trastornos relacionados.
RESULTADOS: Un total de 19 ensayos controlados de metilfenidato en adultos con enfermedades médicas mayores de esa edad o los pacientes en cuidados paliativos fueron identificados. Desafortunadamente, sus resultados contradictorios, el reducido tamaño de la muestra, y de mala calidad metodológica limitada la capacidad para hacer inferencias respecto a la eficacia del metilfenidato, aunque la evidencia de la tolerancia era más fuerte. La evidencia disponible sugiere la posible eficacia del metilfenidato para los síntomas depresivos, fatiga y apatía en varias poblaciones de pacientes con enfermedades médicas.
CONCLUSIÓN: En la ausencia de pruebas definitivas de la eficacia, los ensayos de dosis bajas de metilfenidato en adultos enfermos que padecen de depresión, fatiga, o la apatía, con la supervisión de la respuesta y los efectos adversos, son las adecuadas.
PURPOSE: Cancer-related fatigue contributes to negative outcomes relative to psychosocial and symptom distress, functional status, and quality of life, and yet it is often underdiagnosed and management is frequently suboptimal. DESIGN: Systematic database searches were conducted, and primary research reports and meta-analyses of quantitative studies of interventions for fatigue published in English were identified and critically examined. RESULTS: This paper reviews the etiology and evaluation of cancer-related fatigue and analyzes current empirical evidence supporting pharmacologic and nonpharmacologic techniques for its management. DISCUSSION: A variety of pharmacologic and nonpharmacologic techniques to manage cancer-related fatigue have been studied, although most of the evidence is from single-arm pilot studies with small sample sizes, rather than from adequately powered, multicenter, randomized controlled trials. Continued research in ethnically and racially diverse samples is needed to identify the interventions that are most effective in specific cancer subpopulations and to develop and test interventions for fatigue at each phase in the illness trajectory.
Adult patients (older than 18 yr of age) with newly diagnosed brain metastases.
QUESTION:
If whole brain radiation therapy (WBRT) is used, is there an optimal dose/fractionation schedule?
RECOMMENDATIONS:
Level 1: A standard WBRT dose/fractionation schedule (ie, 30 Gy in 10 fractions or a biological equivalent dose [BED] of 39 Gy10) is recommended as altered dose/fractionation schedules do not result in significant differences in median survival or local control. Level 3: Due to concerns regarding neurocognitive effects, higher dose per fraction schedules (such as 20 Gy in 5 fractions) are recommended only for patients with poor performance status or short predicted survival. Level 3: WBRT can be recommended to improve progression-free survival for patients with more than 4 brain metastases.
QUESTION:
What impact does tumor histopathology or molecular status have on the decision to use WBRT, the dose fractionation scheme to be utilized, and its outcomes?
RECOMMENDATIONS:
There is insufficient evidence to support the choice of any particular dose/fractionation regimen based on histopathology. Molecular status may have an impact on the decision to delay WBRT in subgroups of patients, but there is not sufficient data to make a more definitive recommendation.
QUESTION:
Separate from survival outcomes, what are the neurocognitive consequences of WBRT, and what steps can be taken to minimize them?
RECOMMENDATIONS:
Level 2: Due to neurocognitive toxicity, local therapy (surgery or SRS) without WBRT is recommended for patients with ≤4 brain metastases amenable to local therapy in terms of size and location. Level 2: Given the association of neurocognitive toxicity with increasing total dose and dose per fraction of WBRT, WBRT doses exceeding 30 Gy given in 10 fractions, or similar biologically equivalent doses, are not recommended, except in patients with poor performance status or short predicted survival. Level 2: If prophylactic cranial irradiation (PCI) is given to prevent brain metastases for small cell lung cancer, the recommended WBRT dose/fractionation regimen is 25 Gy in 10 fractions, and because this can be associated with neurocognitive decline, patients should be told of this risk at the same time they are counseled about the possible survival benefits. Level 3: Patients having WBRT (given for either existing brain metastases or as PCI) should be offered 6 mo of memantine to potentially delay, lessen, or prevent the associated neurocognitive toxicity.
QUESTION:
Does the addition of WBRT after surgical resection or radiosurgery improve progression-free or overall survival outcomes when compared to surgical resection or radiosurgery alone?
RECOMMENDATIONS:
Level 2: WBRT is not recommended in WHO performance status 0 to 2 patients with up to 4 brain metastases because, compared to surgical resection or radiosurgery alone, the addition of WBRT improves intracranial progression-free survival but not overall survival. Level 2: In WHO performance status 0 to 2 patients with up to 4 brain metastases where the goal is minimizing neurocognitive toxicity, as opposed to maximizing progression-free survival and overall survival, local therapy (surgery or radiosurgery) without WBRT is recommended. Level 3: Compared to surgical resection or radiosurgery alone, the addition of WBRT is not recommended for patients with more than 4 brain metastases unless the metastases' volume exceeds 7 cc, or there are more than 15 metastases, or the size or location of the metastases are not amenable to surgical resection or radiosurgery.The full guideline can be found at: https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_3.
