Pain, Depression, and Fatigue in Cancer

Pain, depression, and fatigue are the 3 most prevalent symptoms afflicting cancer patients. At some point in nearly every cancer patient’s battle, at least 1 of these problems leads to significant personal disruption. But more commonly pain, depression, and fatigue occur together in the same patient. Their complex interactions seem to compound and magnify the distress they produce. With this clinical reality in mind, it is appropriate to expand our research efforts in the area of integrative interventions for these conditions. The widespread suffering associated with pain, depression, and fatigue warrants a careful exploration of nonpharmacological therapies that have demonstrated efficacy in well-designed studies. This is all the more essential given that pharmacological treatments by themselves have not come close to fully mitigating these troublesome symptoms. On July 15-17, 2002, the National Institutes of Health (NIH) convened a state-of-the-science conference titled “Symptom Management in Cancer: Pain, Depression, and Fatigue.” Sponsored by the National Cancer Institute and the Office of Medical Applications of Research of the NIH, the conference was cosponsored by, among other agencies, the National Center for Complementary and Alternative Medicine—an indication of the potential relevance of integrative treatments in addressing these conditions that are so widely experienced by cancer patients. A draft consensus statement, posted on the NIH Web site shortly after the conference, identified research directions in these areas of major interest to integrative practitioners. We feel this official statement is of sufficient importance to bring it to the attention of all our readers. Five problems were posed in the draft consensus statement: (1) the occurrence of pain, depression, and fatigue in cancer; (2) the methods for clinical assessment of these conditions; (3) the treatments available; (4) the impediments to effective symptom management in cancer patients experiencing pain, depression, or fatigue; and (5) the directions for future research. The statement points out that there are now 9 million cancer survivors in the United States alone. With 1.3 million new cancer diagnoses yearly, and an approximate 60% 5-year survival rate, the number of cancer survivors will continue to grow in the coming years and the number of patients coping with pain, depression, and fatigue during and following treatment will steadily increase. With an evolving recognition that therapies of nutrition, the mind and spirit, sleep hygiene, and physical care—including Eastern approaches of yoga, chi gong, and specific breathing techniques—it is apparent to many of us in the field of integrative cancer medicine that there is immense potential for making substantial contributions toward the alleviation of such widespread suffering. The first problem to address in developing an effective means of managing such cancer problems is to know just how frequently these symptoms occur, for what duration, and with what intensity. As surprising as it may seem, we actually do not know with any accuracy how many people are experiencing pain, depression, fatigue, or, more likely, combinations of all 3 symptoms. Inconsistent estimates emerging from different studies attest to our very imprecise knowledge of any 1 symptom. For example, for those living with cancer, reports on the occurrence of pain vary anywhere from 14% to 100%, of depression from 1% to 42%, and of fatigue from 4% to an astonishing 92%. Certainly such widely varying findings reflect inconsistent measurements and methodologies, a lack of agreement on criteria for identifying symptoms, the impact of different research designs, and imprecisely defined study populations. The second problem is the lack of agreed-upon instruments for assessing these conditions in a clinical setting and the lack of ongoing monitoring and measurement. More than 100 methods exist for pain assessment, from very simple to complex and multidimensional approaches. Two simple factors—severity of pain and degree of functional and emotional impairment due to pain—may suffice to determine need for treatment. Follow-up assessments that use new technology such as e-mail or telephone-based response systems may assist in ongoing pain management. Measurements of depression include such instruments as the Hospital Anxiety and Depression Scale for which clinically useful cutoff scores have been established. At present, however, few validated instruments exist for measuring fatigue, and much work remains to be done in this area. The third problem cited in the report involves the development of more effective treatments for these symptoms in cancer patients and the evidence for their true benefits. The statement advocates the use of the World Health Organization 3-step analgesic ladder in pain management. Nonsteroidal anti-inflammatory Editorial