Electroacupuncture for the management of symptom clusters in cancer patients and survivors (EAST).

BACKGROUND: Neuropsychiatric symptoms, comprising cognitive impairment, fatigue, insomnia, depression, and anxiety, are prevalent and may co-occur during and after chemotherapy treatment for cancer. Electroacupuncture (EA), which involves mild electrical stimulation with acupuncture, holds great potential in addressing the management of individual symptoms. However, there is a lack of studies evaluating if EA can manage concurrent neuropsychiatric symptoms in cancer (i.e., symptom cluster). Hence, we designed a trial to evaluate the efficacy, safety, and feasibility of administering EA as an intervention to mitigate neuropsychiatric symptom clusters amongst cancer patients and survivors. METHODS: The EAST study is a randomized, sham-controlled, patient- and assessor-blinded clinical trial. Sixty-four cancer patients and survivors with complaints of one or more neuropsychiatric symptom(s) in the seven days prior to enrollment are recruited from the University of California Irvine (UCI) and Children's Hospital of Orange County (CHOC). Individuals with needle phobia, metastases, bleeding disorders, electronic implants, epilepsy, exposure to acupuncture in the three months prior to enrollment, and who are breastfeeding, pregnant, or planning to get pregnant during the duration of the study will be excluded. Screening for metal fragments and claustrophobia are performed prior to the optional neuroimaging procedures. Recruited patients will be randomized (1:1) in random blocks of four or six to receive either ten weekly verum EA (treatment arm, vEA) or weekly sham EA (control arm, sEA) treatment visits with a follow-up appointment four to twelve weeks after their last treatment visit. The treatment arm will receive EA at 13 acupuncture points (acupoints) chosen for their therapeutic effects, while the control arm receives minimal EA at 7 non-disease-related acupoints. Questionnaires and cognitive assessments are administered, and blood drawn to assess changes in symptom clusters and biomarkers, respectively. CONCLUSION: The EAST study can provide insight into the efficacy of EA, an integrative medicine modality, in the management of cancer symptom clusters in routine clinical practice. TRIAL REGISTRATION: This trial is registered with clinicaltrials.gov NCT05283577.

Longitudinal evaluation of dehydroepiandrosterone (DHEA), its sulfated form and estradiol with cancer-related cognitive impairment in early-stage breast cancer patients receiving chemotherapy.

The purpose of this study is to elucidate how patient-reported cognitive symptoms manifest from variations in hormone levels or precursors such as dehydroepiandrosterone (DHEA) and its sulfated form [collectively termed as DHEA(S)] and to investigate their association in breast cancer survivors. Levels of estradiol and DHEA(S) were compared between early-stage breast cancer patients with and without cancer-related cognitive impairment (CRCI) during adjuvant chemotherapy. Data were analyzed from 242 patients (mean age ± SD = 50.8 ± 9.2 years) who had completed FACT-Cog v.3.0, blood draws and questionnaires. Regression model was used to fit the magnitude of change in each respective biomarker levels against overall cognitive impairment status while adjusting for clinically important covariates. There was reduction in mean plasma levels of estradiol and DHEAS during and towards the end of chemotherapy (p-values < 0.001). Compared to non-impaired patients, smaller magnitude of decline was observed in DHEA(S) levels in patients reporting CRCI, with significant association between decline in DHEAS levels and acute onset of CRCI at 6 weeks from baseline (adjusted ß of 0.40, p-value of 0.02). In contrast, patients reporting CRCI showed greater magnitude of decline in estradiol compared to non-impaired patients, although this was not found to be statistically significant. There was an association between magnitude of change in biomarker levels with self-reported CRCI which suggests that the hormonal pathway related to DHEAS may be implicated in acute CRCI for breast cancer survivors. Our findings help to improve biological understanding of the pathway from which DHEAS may correlate with cognitive dysfunction and its impact on cancer survivors.

Diet and exercise advice and referrals for cancer survivors: an integrative review of medical and nursing perspectives.

PURPOSE: To examine the perspectives of medical and nursing health professionals concerning their roles and responsibilities in providing dietary and exercise advice to cancer survivors, and referrals to allied health professionals. METHODS: An integrative review. PubMed, CINAHL, PsycINFO, Embase, Web of Science databases, and bibliographies of relevant studies were searched from December 2011 to June 2021. All studies were eligible for inclusion. The Mixed-Methods Appraisal Tool (MMAT) was used to critically appraise included studies. Data were extracted and synthesised regarding the perspectives of medical and nursing health professionals on their roles, responsibilities, barriers, and facilitators. RESULTS: Twenty-one studies involving 3401 medical and nursing health professionals and 264 cancer survivors of diverse cancer types were included. Ten quantitative, nine qualitative, and two mixed-methods studies were eligible. All included studies met at least 80% of the quality criteria in the MMAT. Major findings include the following: (1) medical and nursing health professionals were unclear on their roles in providing dietary and exercise advice to cancer survivors but agreed they play a key role in referrals to dietitians and exercise professionals; (2) most cancer survivors valued the involvement of their general practitioner when receiving dietary and exercise advice. CONCLUSION: Although medical and nursing health professionals understand that referrals to allied health professionals form part of their role, there is a lack of clarity regarding their roles to provide dietary and exercise advice to cancer survivors. Future studies should address barriers and facilitators of dietary and exercise advice and referral by medical and nursing health professionals.

Implementing a community-based shared care breast cancer survivorship model in Singapore: a qualitative study among primary care practitioners.

BACKGROUND: The adaptability of existing recommendations on shared care implementation to Asian settings is unknown. This qualitative study aims to elicit public- and private-sectors primary care practitioners' (PCPs) perspectives on the sustainable implementation of a shared care model among breast cancer survivors in Singapore. METHODS: Purposive sampling was employed to engage 70 PCPs from SingHealth Polyclinics, National University Polyclinics, National Healthcare Group Polyclinics, and private practice. Eleven focus groups and six in-depth interviews were conducted between June to November 2018. All sessions were audio-recorded and transcribed verbatim. Guided by the RE-AIM framework, we performed deductive thematic analysis in QSR NVivo 12. RESULTS: PCPs identified low-risk breast cancer survivors who demonstrated clear acceptability of PCPs' involvement in follow-up as suitable candidates for shared care. Engagement with institution stakeholders as early adopters is crucial with adequate support through PCP training, return pathways to oncologists, and survivorship care plans as communication tools. Implementation considerations differed across practices. Selection of participating PCPs could consider seniority and interest for public and private practice, respectively. Proposed adoption incentives included increased renumeration for private PCPs and work recognition for public PCPs. Public PCPs further proposed integrating shared care elements to their existing family medicine clinics. CONCLUSIONS: PCPs perceived shared care favorably as it echoed principles of primary care to provide holistic and well-coordinated care. Contextual factors should be considered when adapting implementation recommendations to Asian settings like Singapore. With limited competitive pressure, the government is then pivotal in empowering primary care participation in survivorship shared care delivery.

Reporting adherence, validity and physical activity measures of wearable activity trackers in medical research: A systematic review.

BACKGROUND: Wearable activity trackers are gaining traction in medical research, providing both real-time and remote monitoring of physical fitness. Activity trackers offer an excellent source of personalized physical activity data from patients, as well as healthy individuals, that would provide insights into healthcare analytics and user-feedback on health status. In addition, these activity trackers would also allow researchers to monitor symptom severity and assist clinicians in providing their patients a more holistic care. Despite the promise of wearable device technology, there is still a lack of standardization in the medical literature regarding the analysis and reporting of adherence, validity and physical activity data generated by these activity trackers. OBJECTIVE: We performed a systematic review to identify the activity tracker-derived measures and evaluate the relations of reported adherence, validity, and physical activity types across currently available literature. METHODS: The searches were performed using Pubmed and Embase databases. Studies enrolling at least 1,000 human subjects regardless of health or disease status, using activity trackers of any brand used to track step count, distance, heart rate, energy expenditure or activity intensity, were included. Studies have been published between 2009 to March 2021, with editorials, systematic reviews, meta-analysis, grey literature, validation studies, study protocols and studies using smartphone trackers being excluded. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: A total of 27 studies met the eligibility criteria and were included in the review, with a total of 514,418 and 1,186,530 subjects recruited in observational and interventional studies, respectively. Apart from ActiGraph (n = 11, 41%), Fitbit (n = 4, 15%) and Axivity (n = 3, 11%) were found to be the most commonly used activity trackers in both types of studies. The wear duration of activity trackers ranged from 1 day to 59 months, with 1 week being the most common length (n = 16, 59%). The most frequently collected physical activity measure was activity intensity (n = 21, 78%), followed by step count (n = 9, 33%) and energy expenditure (n = 2, 7%). Most studies defined a valid day as wear-time of at least 10 h within 1 day (n = 10, 37%), and a valid interval as a week with at least 3 valid days (n = 8, 30%). CONCLUSIONS: This systematic review reveals the diverse analysis and reporting of activity tracker data in the medical literature. Future studies will need to evaluate the feasibility on adopting minimum reporting thresholds of data generated by wearable activity trackers.

Prescribing patterns in breast cancer survivors: A Korean National Health Insurance Service cohort study.

PURPOSE: Breast cancer survivors often manifest comorbidities that require medication management. This study aimed to investigate the prescription patterns of drugs prescribed frequently among breast cancer survivors and to provide data to monitor adverse effects using other covariates in these patients. MATERIALS AND METHODS: We analyzed a Korean national sample cohort database. The diagnosis of breast cancer, survival, survival duration, and frequency of drug prescription were first defined and extracted. We then analyzed the frequency of drug prescription in breast cancer by survival duration. Factors associated with drug prescribing patterns were analyzed using logistic regression analysis. RESULTS: Among 2,410 breast cancer survivors, anti-hormonal agents, gastrointestinal drugs, calcium, and anxiolytics were most frequently prescribed. Gastrointestinal disturbance and depression are most commonly observed among breast cancer survivors. Survivors who were 3 to < 5 years post treatment were frequently prescribed calcium. In addition to gastrointestinal drugs, anxiolytics were frequently prescribed among survivors manifesting comorbidities. In addition to anti-hormone agents, which were frequently prescribed to breast cancer patients, gastrointestinal drugs were the second most frequently prescribed, and anxiolytics were often co-prescribed. Calcium was also frequently co-prescribed in patients requiring anti-depressants. CONCLUSION: In the Korean National Cohort, gastrointestinal drugs, calcium, and anxiolytics were frequently prescribed to older patients, suggesting that older patients diagnosed with cancer experience a wide array of toxicities requiring supportive care.

A study protocol for HEalth-Related quality of life-intervention in survivors of Breast and other cancers experiencing cancer-related fatigue using TraditionAL Chinese Medicine: the HERBAL trial.

BACKGROUND: Cancer-related fatigue (CRF) is a debilitating condition which commonly affects cancer survivors. The management of CRF remains a challenge due to the lack of effective pharmacological interventions. Traditional Chinese medicine (TCM) could be a potential therapeutic option for CRF. The modified Xiang Bei Yang Rong Tang (XBYRT) is a TCM herbal decoction, formulated to improve fatigue symptoms in cancer survivors. This clinical trial aims to evaluate the efficacy and safety of XBYRT in improving CRF and quality of life (QOL) of cancer survivors. METHODS: This is a single centre, randomized, double-blind, placebo-controlled, parallel trial. Eighty cancer survivors will be recruited and randomized to receive the XBYRT or placebo decoction, in a ratio of 1:1. Participants will consume the XBYRT/placebo decoction daily for 8 weeks and undergo assessments at baseline and 4, 8 and 10 weeks after baseline. The participants will be assessed for patient-reported outcomes (PRO), blood biomarkers and adverse events at each time point. The primary outcome is the overall health and QOL status, at 8 weeks follow-up. The secondary outcomes are the effects of XBYRT on fatigue levels, cancer-related cognitive impairment and QOL, as assessed by PRO. The incidence of adverse events and the effects of the XBYRT decoction on blood biomarkers associated with CRF will also be evaluated. DISCUSSION: Efficacy and safety outcomes from this trial will provide important clinical data to guide future large-scale randomized controlled trials, and the evaluation of the objective blood biomarkers can help to delineate the biological mechanisms of CRF. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT04104113 . Registered on 26 September 2019.

A longitudinal analysis of phenotypic and symptom characteristics associated with inter-individual variability in employment interference in patients with breast cancer.

PURPOSE: A breast cancer diagnosis has a substantial economic impact. Study aims were to evaluate for inter-individual differences in cancer's level of interference with employment and identify phenotypic and symptom characteristics associated with higher levels of interference. METHODS: Patients (n = 387) were enrolled prior to breast cancer surgery and followed for 12 months. Interference with employment was measured using a 0 (no problem) to 10 (severe problem) numeric rating scale. Hierarchical linear modeling (HLM) was used to evaluate for inter-individual differences in trajectories of employment interference and characteristics associated with employment interference at enrollment and over 12 months. RESULTS: Patients' mean age was 55.0 (±11.7) years and the majority underwent breast conservation surgery (80.6%). Mean employment interference score was 3.2 (±3.7). Unconditional model for employment interference demonstrated a decreasing linear trend (-.076/month). Younger age, lower income, higher pain intensity, and having an axillary lymph node dissection were associated with higher pre-surgical interference scores. Having a sentinel lymph node biopsy was associated with ongoing employment interference scores. Higher sleep disturbance scores were associated with both initial and ongoing employment interference scores. Receipt of chemotherapy, use of complementary or alternative therapies, and re-excision or mastectomy following surgery were significant time varying covariates. CONCLUSION: This study is the first to use HLM to describe inter-individual differences in the trajectories of cancer's interference with employment and associated factors prior to and for 12 months following breast cancer surgery. Patients with the identified risk factors warrant ongoing assessments of employment interference and appropriate referrals.

Applicability of the National Comprehensive Cancer Network/Multinational Association of Supportive Care in Cancer Guidelines for Prevention and Management of Chemotherapy-Induced Nausea and Vomiting in Southeast Asia: A Consensus Statement.

A meeting of regional experts was convened in Manila, Philippines, to develop a resource-stratified chemotherapy-induced nausea and vomiting (CINV) management guideline. In patients treated with highly emetogenic chemotherapy in general clinical settings, triple therapy with a serotonin (5-hydroxytryptamine-3 [5-HT3]) antagonist (preferably palonosetron), dexamethasone, and aprepitant is recommended for acute CINV prevention. In resource-restricted settings, triple therapy is still recommended, although a 5-HT3 antagonist other than palonosetron may be used. In both general and resource-restricted settings, dual therapy with dexamethasone (days 2 to 4) and aprepitant (days 2 to 3) is recommended to prevent delayed CINV. In patients treated with moderately emetogenic chemotherapy, dual therapy with a 5-HT3 antagonist, preferably palonosetron, and dexamethasone is recommended for acute CINV prevention in general settings; any 5-HT3 antagonist can be combined with dexamethasone in resource-restricted environments. In general settings, for the prevention of delayed CINV associated with moderately emetogenic chemotherapy, corticosteroid monotherapy on days 2 and 3 is recommended. If aprepitant is used on day 1, it should be continued on days 2 and 3. Prevention of delayed CINV with corticosteroids is preferred in resource-restricted settings. The expert panel also developed CINV management guidelines for anthracycline plus cyclophosphamide combination schedules, multiday cisplatin, and chemotherapy with low or minimal emetogenic potential, and its recommendations are detailed in this review. Overall, these regional guidelines provide definitive guidance for CINV management in general and resource-restricted settings. These consensus recommendations are anticipated to contribute to collaborative efforts to improve CINV management in Southeast Asia.

Exercise improves quality of life in androgen deprivation therapy-treated prostate cancer: systematic review of randomised controlled trials.

Men receiving androgen deprivation therapy (ADT) for prostate cancer (PCa) are likely to develop metabolic conditions such as diabetes, cardiovascular disease, abdominal obesity and osteoporosis. Other treatment-related side effects adversely influence quality of life (QoL) including vasomotor distress, depression, anxiety, mood swings, poor sleep quality and compromised sexual function. The objective of this study was to systematically review the nature and effects of dietary and exercise interventions on QoL, androgen deprivation symptoms and metabolic risk factors in men with PCa undergoing ADT. An electronic search of CINAHL, CENTRAL, Medline, PsychINFO and reference lists was performed to identify peer-reviewed articles published between January 2004 and December 2014 in English. Eligible study designs included randomised controlled trials (RCTs) with pre- and post-intervention data. Data extraction and assessment of methodological quality with the Cochrane approach was conducted by two independent reviewers. Seven exercise studies were identified. Exercise significantly improved QoL, but showed no effect on metabolic risk factors (weight, waist circumference, lean or fat mass, blood pressure and lipid profile). Two dietary studies were identified, both of which tested soy supplements. Soy supplementation did not improve any outcomes. No dietary counselling studies were identified. No studies evaluated androgen-deficiency symptoms (libido, erectile function, sleep quality, mood swings, depression, anxiety and bone mineral density). Evidence from RCTs indicates that exercise enhances health- and disease-specific QoL in men with PCa undergoing ADT. Further studies are required to evaluate the effect of exercise and dietary interventions on QoL, androgen deprivation symptoms and metabolic risk factors in this cohort.

Medication use by early-stage breast cancer survivors: a 1-year longitudinal study.

PURPOSE: The aim of this study is to characterize the patterns of medication use by early-stage breast cancer (ESBC) survivors from diagnosis to 1 year post-chemotherapy. METHODS: A single-center longitudinal study was conducted with ESBC patients diagnosed between December 2011 and June 2014. Data on the medication use of individual patients were retrieved from prescription databases, supplemented by records from the National Electronic Health Records. The data covered the period from ESBC diagnosis to 1 year post-chemotherapy. Medication types were classified according to the World Health Organization's Anatomical Therapeutic Chemical classification system, and medication for chronic diseases was created by adapting a list of 20 chronic diseases provided by the U.S. Department of Human and Health Services. RESULTS: Of the 107 patients involved in the study (mean age 51.1 ± 8.4 years; 78.5 % Chinese), 46.7 % manifested non-cancer comorbidities, of which hypertension (24.3 %) was the most prevalent, followed by hyperlipidemia (13.1 %) and diabetes (5.6 %). Calcium channel blockers (12.1 %) and lipid-modifying agents (11.2 %) were the most common chronic medication types used before chemotherapy, and their use persisted during chemotherapy (10.3 and 11.2 %, respectively) and after chemotherapy (11.2 and 13.1 %, respectively). Hormonal therapy was the predominant post-chemotherapy medication (77.6 %). A statistically significant increase (p < 0.0001) was observed in the mean number of chronic disease medication classes prescribed to patients between the pre-chemotherapy (0.53 ± 1.04) and chemotherapy (0.62 ± 1.08) periods and between the chemotherapy and post-chemotherapy (1.63 ± 1.35) periods. CONCLUSIONS: There is an increase in trend of chronic medication usage in breast cancer survivors after cancer treatment. This study provides important insights into the design of medication management programs tailored to this population. Future studies should incorporate a control population to improve the interpretation of study results.

The Effect of Ginger (Zingiber officinale) on Platelet Aggregation: A Systematic Literature Review.

BACKGROUND: The potential effect of ginger on platelet aggregation is a widely-cited concern both within the published literature and to clinicians; however, there has been no systematic appraisal of the evidence to date. METHODS: Using the PRISMA guidelines, we systematically reviewed the results of clinical and observational trials regarding the effect of ginger on platelet aggregation in adults compared to either placebo or baseline data. Studies included in this review stipulated the independent variable was a ginger preparation or isolated ginger compound, and used measures of platelet aggregation as the primary outcome. RESULTS: Ten studies were included, comprising eight clinical trials and two observational studies. Of the eight clinical trials, four reported that ginger reduced platelet aggregation, while the remaining four reported no effect. The two observational studies also reported mixed findings. DISCUSSION: Many of the studies appraised for this review had moderate risks of bias. Methodology varied considerably between studies, notably the timeframe studied, dose of ginger used, and the characteristics of subjects recruited (e.g. healthy vs. patients with chronic diseases). CONCLUSION: The evidence that ginger affects platelet aggregation and coagulation is equivocal and further study is needed to definitively address this question.

Trajectory and risk factors for chemotherapy-induced nausea and vomiting in Asian patients with head and neck cancer.

BACKGROUND: The purpose of this study was to analyze the trajectory of and risk factors for chemotherapy-induced nausea and vomiting in Asian patients with head and neck cancer. METHODS: Adult patients with head and neck cancer scheduled to receive cisplatin-based chemotherapy were recruited for the study. Clinical events were collated from standardized diaries. RESULTS: Two hundred thirty-five patients were included in the analyses. The majority (75.7%) was men, Chinese (81.7%), and manifested nasopharyngeal cancer (83.4%). The overall incidence of significant nausea and vomiting was 73.7% and 24.7%, respectively, with single-day cisplatin regimens of 48.9% and 28.9%, respectively, with the multiple-day cisplatin regimen. Patients using complementary alternative medicine were less likely than others to achieve a complete response to antiemetics. CONCLUSION: Although postchemotherapy vomiting is relatively well controlled in Asian patients with head and neck cancer, postchemotherapy nausea remains problematic in this population.

Conservative management of L-asparaginase-induced hypertriglyceridemia in an adult patient: a case report and review of the literature.

BACKGROUND: L-Asparaginase (L-Asp) may induce hypertriglyceridemia; however, this has been mainly observed among pediatric patients. Treatment for L-Asp-induced hypertriglyceridemia is not standardized, ranging from fasting and diet restriction to the invasive plasmapheresis procedure. CASE REPORT: We describe a 53-year-old male patient who presented with L-Asp-induced severe hypertriglyceridemia. He was receiving L-Asp as part of his chemotherapy regimen for natural killer T-cell lymphoma. After the 20th dose, his serum triglyceride level was 3,552 mg/dl, with a total cholesterol of 418 mg/dl. Despite the high triglyceride, the patient did not present with acute pancreatitis symptoms. Treatment comprising fasting, fenofibrate, and omega-3 fatty acids was initiated. Triglyceride levels dropped rapidly to 1,000 mg/dl within 2 days, and to 268 mg/dl after 10 days. The chemotherapy regimen was subsequently switched to exclude L-Asp. CONCLUSION: L-Asp-induced severe hypertriglyceridemia may occur in adults and may be conservatively managed with fasting, fibrates, and omega-3 fatty acids. Plasmapheresis or continuous insulin infusion may be used for symptomatic patients with high triglyceride levels. Lipidlowering agents should be continued for patients previously treated for hyperlipidemia. Regular monitoring of lipid levels for patients receiving L-Asp is important, especially for those with a prior history of dyslipidemia. Re-challenge with L-Asp can be undertaken on an individual basis.

Clinical outcomes for cancer patients using complementary and alternative medicine.

CONTEXT: Over half of cancer patients in Singapore use some form of complementary or alternative medicine (CAM) to improve their immunity and general health status. The effectiveness of CAM, however, in reducing acute complications is currently unknown. Concerns also exist as to whether CAM may cause toxic effects in patients with cancer. OBJECTIVE: To investigate the changes in general health status, immunity, and organ function over a 6-month period in CAM and non-CAM users with cancer. DESIGN: The authors designed a single-center, retrospective cohort study. The patients had participated previously in a cross-sectional prevalence survey about the types of oral CAM they were using in addition to chemotherapy. The authors used the data from the survey and clinical and medication-use information from patients' medical and pharmaceutical records to complete the current study. SETTING: The study occurred at the National Cancer Centre Singapore (NCCS), which is the largest ambulatory cancer center in Singapore and treats two-thirds of the solid-tumor patients in Singapore. The study excluded patients if their medical records were incomplete and/or if the patients had not received any cytotoxic or targeted therapies at the time of survey. PARTICIPANTS: The authors reviewed the records of a total of 403 patients and excluded 46 patients because their records were missing (n=20) or because they had not received any form of anticancer treatment at the time of survey (n=26). They included 357 patients in the current study. The authors did not contact patients for this follow-up study. OUTCOME MEASURES: The authors collected data on clinical characteristics for each patient and assessed the differences between each characteristic at baseline (at the time of the survey) and at 6 months after baseline measurement. The authors evaluated clinical characteristics using the National Cancer Institute's Common Terminology Criteria for Adverse Events version 3. RESULTS: As a whole, CAM use provided an absolute reduction of infection episodes by 11.9% (P=.045) and of antibiotic use by 10.3% (P=.022). Subgroup analysis showed a reduction of documented infection by 17.9% (P=.02) and a 13% decrease in hospitalizations due to infections (P=.043) among metastatic cancer patients who used CAM. CAM usage was not associated with significant changes of hepatic and renal function. CONCLUSION: CAM use in patients with cancer was associated with a reduction in hospitalizations and requirements for antibiotics. CAM use was not associated with significant changes in hepatic and renal function. There is a need for well-designed, prospective clinical studies to confirm these findings.

Utilizing mobile networks for the detection of clinically relevant interactions between chemotherapy regimens and complementary and alternative medicines.

OBJECTIVES: Patients with cancer who use complementary and alternative medicines (CAMs) in conjunction with chemotherapy treatment are at risk of manifesting anticancer drug-CAM interactions (DCIs), which may lead to negative therapeutic outcomes. This article describes a novel iPhone application developed for the Mobile Internet, called OncoRx-MI, which identifies DCIs of single-agent and multiple-agent chemotherapy regimen (CReg) prescriptions. METHODS: Drug-, CAM-, and DCI-related information was compiled from various hardcopy and softcopy sources, and published literature from PubMed. Overall management plans for the CRegs were then developed. The iPhone Web documents were constructed using Adobe software and programming scripts, and mounted onto a third-party server. DCI searches are based on CReg acronyms, and OncoRx-MI is designed to fit the iPhone screen configuration for improved usability. A small usability study was also carried out and the user feedback presented. RESULTS: OncoRx-MI is able to detect over 2700 interactions between 256 CRegs and 166 CAMs, making up a total of over 4400 DCI pairs. The CAMs are classified into seven categories based on their uses in supportive care, and non-cancer-related CAMs are also included. The majority of the DCIs are pharmacokinetic in nature (79%), involving the induction and inhibition of the cytochrome P450 isozymes and p-glycoprotein. Pharmacodynamic DCIs include hepatotoxicity (39%), altered corticosteroid efficacies (30%), and increased risks of hypoglycemia (4%), hypertensive crisis (2%), bleeding, and serotonin syndrome (1% each). CONCLUSIONS: OncoRx-MI is the first mobile application of its kind that allows searching of DCIs for CRegs through 3G networks, and is intended to improve pharmaceutical care of patients with cancer by assisting health care practitioners in managing CReg interactions in their clinical practices.

Impact of erythropoiesis-stimulating agent prescribing at an Asian cancer center, after release of safety advisories.

BACKGROUND: Erythropoiesis-stimulating agents (ESAs) provide symptom relief and decrease blood transfusion support among patients with chemotherapy-induced anemia. However, due to increased cardiovascular events associated with off-labeled usage of ESAs, the FDA incorporated black box warnings in 2007 to include the following key points: (a) ESAs should be used only to treat anemia due to concomitant chemotherapy of a noncurative intent and (b) target hemogloblin level should not exceed 12 g/dL. Thus, this study was designed to compare the prescribing of epoetin alfa at National Cancer Centre Singapore before and after FDA black box updates. The secondary objective of this study was to evaluate the appropriateness of efficacy and toxicity monitoring of epoetin alfa. METHODS: This was a retrospective, single-centered, drug utilization review. Patients who received at least one dose of epoetin alfa were included in this study. Utilization of epoetin alfa was segregated into two time periods: January 1, 2005 to October 15, 2007 (S1, Pre-safety advisories changes) and October 16, 2007 to December 10, 2009 (S2, Post-safety advisories changes). RESULTS: A total of 171 patients were prescribed epoetin alfa at NCCS during the two time periods. However, only 139 patients were eligible for analysis, with 91 and 48 patients in S1 and S2 respectively. After safety advisory changes, there were more (18.2%) metastatic patients and fewer (19.1%) patients with cardiovascular co-morbidities who were prescribed epoetin alfa, the mean hemogloblin level when epoetin alfa was initiated was lowered by 0.46 g/dL, more (43%) dose adjustments were made for 'excessive' responders and more (40.7%) patients had fewer blood transfusions after epoetin alfa therapy (p < 0.05). However, blood pressure control, iron studies, and supplementation did not improve (p > 0.05). CONCLUSION: This study suggested that oncologists have generally adopted the new ESA safety warnings and adjusted prescribing habits.

Clinically-relevant chemotherapy interactions with complementary and alternative medicines in patients with cancer.

Complementary and alternative medicines (CAMs), in particular herbal medicines, are commonly used by cancer patients in conjunction with chemotherapy treatment for their anticancer properties and supportive care. However, the effects of many of these herbs are not well-documented due to limited studies done on them. Severe herb-drug interactions (HDIs) have been recorded in some cases, and failure to recognize these harmful HDIs can lead to dire consequences in cancer patients. This study discusses clinically-relevant interactions between anticancer drugs (ACDs) and herbs classified into 7 categories: cancer treatment and prevention, immune-system-related, alopecia, nausea and vomiting, peripheral neuropathy and pain, inflammation, and fatigue. Some promising patents which contain these herbs and thus may manifest these interactions are also presented in this article. Pharmacokinetic interactions involved mainly induction or inhibition of the cytochrome P450 isozymes and p-glycoprotein, while pharmacodynamic interactions were related to increased risks of central nervous system-related effects, hepatotoxicity and bleeding, among others. Clinicians should be vigilant when treating cancer patients who take CAMs with concurrent chemotherapy since they face a high risk of HDIs. These HDIs can be minimized or avoided by selecting herb-drug pairs which are less likely to interact. Furthermore, close monitoring of pharmacological effects and plasma drug levels should be carried out to avoid toxicity and ensure adequate chemotherapeutic coverage in patients with cancer.

An onco-informatics database for anticancer drug interactions with complementary and alternative medicines used in cancer treatment and supportive care: an overview of the OncoRx project.

PURPOSE: Cancer patients are at high risk of manifesting interactions from use of anticancer drugs (ACDs) and complementary and alternative medicines (CAMs). These interactions can result in sub-therapeutic effects or increased toxicities which may compromise the outcome of chemotherapy. It is important for practitioners to gain convenient access to ACD-CAM interaction information so as to make better-informed decisions in daily practice. This paper describes the creation of an oncology database (OncoRx) that documents ACD-CAM interactions, including traditional Chinese medicines (TCMs) that are commonly used for cancer treatment, prevention, and supportive care therapy. METHODS: Information regarding ACDs, CAMs, and drug interactions were collated from 14 sources, inclusive of hardcopy and online resources, and input into a modified web server with a database engine and a programming interface using a combination of software and programming scripts. RESULTS: OncoRx currently contains a total of 117 ACDs and 166 CAMs. Users are able to search for interactions based on various CAM uses: cancer treatment or prevention, immune-system-related, alopecia, nausea, and vomiting, peripheral neuropathy and pain, inflammation, fatigue, and non-cancer related. Pharmacokinetic data on ACDs and CAMs, characteristics of CAMs based on TCM principles, and drug interaction parameters such as effects, mechanisms, evidences, and proposed management plans, are shown in the search results. CONCLUSION: OncoRx is an oncology database which detects ACD interactions. It is currently able to detect interactions with CAMs. It is hoped that OncoRx will serve as a useful resource to clinicians, educators, trainers, and students working in the oncology setting.