9. Additional Therapies – Psycho-oncology
9.1 Psychopharmacotherapy
The treatment of cancer patients with psychopharmaceuticals should be embedded in an overall psycho-oncological treatment concept.
- Consensus
- Strong consensus (97%)
Change note
The treatment of tumor patients with psychopharmaceuticals should always be embedded in an overall oncological treatment concept. Before any psychopharmacological therapy, the medical causes or triggers of the psychological symptoms should be considered and included in the treatment concept. In particular, the following should be considered: optimal symptom control of pain, dyspnea, nausea, fatigue, etc.; correction of electrolyte disturbances the diagnosis and treatment of tumor-related causes (e.g., CNS metastases, CNS tumors, meningeosis, endocrine disorders, hypercalcemia) clarification of the influence of potentially depressiogenic drugs (e.g., steroids, interferon, etc.). (e.g., steroids, interferon, tyrosine kinase inhibitors) consideration of withdrawal states (e.g., opiates, benzodiazepines, alcohol) consideration and modification of potentially anxiety-inducing medication (e.g., corticosteroids, metoclopramide, benzodiazepines) diagnostic clarification of confusional states (e.g., delirium)Somatic, psychological, and social factors as well as the effects of the oncological disease and therapy should be taken into account before and during psychopharmacological treatment.
- Consensus
- Strong consensus (97%)
Change note
The treatment of tumor patients with psychopharmaceuticals should always be embedded in an overall oncological treatment concept. Before any psychopharmacological therapy, the medical causes or triggers of the psychological symptoms should be considered and included in the treatment concept. In particular, the following should be considered: optimal symptom control of pain, dyspnea, nausea, fatigue, etc.; correction of electrolyte disturbances the diagnosis and treatment of tumor-related causes (e.g., CNS metastases, CNS tumors, meningeosis, endocrine disorders, hypercalcemia) clarification of the influence of potentially depressiogenic drugs (e.g., steroids, interferon, etc.). e.g., steroids, interferon, tyrosine kinase inhibitors) consideration of withdrawal states (e.g., opiates, benzodiazepines, alcohol) consideration and modification of potentially anxiety-inducing medication (e.g., corticosteroids, metoclopramide, benzodiazepines) diagnostic clarification of confusional states (e.g., delirium) June 2021Psychopharmacotherapy for patients with ICD-10 diagnoses of a mental disorder shall be provided according to available guidelines (unipolar depression (AWMF registry number: nvl-005); trauma sequelae disorders (AWMF registry numbers: 051-027 and 155-001); anxiety disorders (AWMF registry number: 051-028); sleep disorders (AWMF registry number: 063-003)).
- Consensus
- Strong consensus (100%)
Change note
Psychopharmacotherapy of patients with ICD-10 diagnoses of a mental disorder should be carried out according to the available guidelines (AWMF Reg.No. nvl-005; AWMF Reg.No. 051/010; AWMF Reg.No.051/027). The somatic and social factors identified in the diagnostic process and their interactions should be taken into account.An effective treatment of depression, anxiety disorders and other psychological disorders in cancer patients requires close cooperation between the treating physicians, psycho-oncologists, and nurses, both in terms of diagnosis as well as an optimal treatment of somatic causes, possible triggers, and symptoms. All these factors should be taken into account when choosing the appropriate psychopharmacological therapy. In addition, the preferences of the patient with regard to psychotherapeutic and psychopharmacological treatment are to be taken into account when making treatment recommendations [857].
The treatment of cancer patients with psychopharmaceuticals should therefore always be embedded in an overall oncological treatment concept. Before any psychopharmacological or psychotherapeutic treatment, the medical causes or triggers should be taken into account and included in the treatment concept (see Chapter 7). These include, first and foremost, the diagnosis and treatment of tumor-related causes: symptom control (e.g., pain), CNS affections (e.g., tumors), endocrine or electrolyte disturbances, withdrawal symptoms, or medication side effects (see Table 10). An optimal symptom control of pain, dyspnea, nausea, or fatigue should be undertaken, as well as any necessary correction of electrolyte imbalances. The influence of potentially depressant medications (e.g., steroids, interferon, or tyrosine kinase inhibitors) should be assessed and, if appropriate, the corresponding medication should be discontinued if oncologically safe. The modification of potentially anxiety-inducing medications, which include corticosteroids, metoclopramide, or benzodiazepines, should also be considered in advance. Furthermore, withdrawal states from opiates, benzodiazepines or alcohol can play a role and should be diagnostically clarified, just as states of confusion (delirium) should also be taken into account.
Table 6: Contextual Factors Influencing Mental Health that Should be Considered Before and During Psychopharmacological Treatment
|
Optimized symptom control of tumor and tumor therapy sequelae:
|
|
Diagnosis and treatment of brain-organic tumor sequelae:
|
|
Psychotropic drug side effects:
|
The following sections focus on the most commonly cited indications for psychopharmacological treatment in cancer patients for the syndrome and diagnosis groups:
- Depressive symptoms and depression
- Anxiety and anxiety disorders
- Sleep disorders
9.1.1 Depressive Symptoms and Depression
Psychopharmacological treatment of subsyndromal disorders or as a preventative measure for depressive disorders should be given only in individual cases after strict indication, as insufficient evidence is available.
- Consensus
- Strong consensus (97%)
Change note
Medication therapy with an antidepressant or psychotherapy should be offered to treat an acute moderate depressive episode.Guidelines with a high level of evidence are available for the treatment of depressive disorders that fulfill the diagnostic criteria according to ICD-10 (also valid for DSM-IV, DSM-5 and ICD-11). Especially for unipolar depression, the „NVL Unipolar Depression“ provides a reference that also addresses somatic comorbidities (see Recommendation 9.2). For depressive episodes associated with bipolar disorder, in addition to the evidence from the general "S3-Guideline: Diagnostic and Therapy of Bipolar Disorders" (AWMF-Registernummer: 038-019), the general principles of psychopharmacological treatment with cancer should be followed (recommendations and background text from this Chapter 9.1).
On the question of the efficacy of psychopharmacological interventions in cancer patients with depression, other depressive disorders, or depressive symptoms without a formal diagnosis, a recent Cochrane Review by Ostuzzi et al. [858], [859] on antidepressants in cancer patients is available. The authors conclude that the quality of the available evidence for this group of patients is very low, but that there is no indication for an unfavorable safety profile of antidepressants. Based on similar studies, but also with longer study duration, the meta-analysis [860] found a weakly significant effect and a low quality of the studies as well, so that overall one can speak of an inhomogeneous study situation with a lack of high-quality RCTs regarding cancer. Another review by Grassi et al. (2018) [861] concludes that the use of antidepressants is recommended in cancer patients with major depressive disorder. Here, side effects and interactions with the cancer therapy as well as patient preferences should be considered. Cancer patients without significant depressive disorder in terms of major depression, e.g., with advanced cancer or with other, non-depressive symptoms (e.g., fatigue during chemotherapy) do not recognizably benefit from antidepressant therapy. The current scientific knowledge does not allow an evidence-based recommendation on the combined or additive effectiveness of antidepressant treatment in addition to or complementary to psychotherapy in cancer patients. With reference to the „NVL Depression“, however, a combination treatment with pharmacotherapy and psychotherapy is explicitly recommended for acute severe depressive episodes; for the treatment of acute moderate depressive episodes, psychotherapeutic treatment or pharmacotherapy is recommended.
For patients with depressive disorders without somatic comorbidity, the relationship between the initial severity of depression and the effectiveness of antidepressant or psychotherapeutic therapy is well established [862], [863], [864]. Therefore, these patients should be treated according to the recommendations of the „NVL Depression“.
9.1.2 Fears and Anxiety Disorders
The treatment of situational anxiety in cancer patients should be interdisciplinary and multimodal.
- Consensus
- Consent (86%)
Change note
The treatment of anxiety disorders and anxiety states in tumor patients should be interdisciplinary and multimodal. Psychopharmacological treatment should include benzodiazepines with a short duration of action, anxiolytic antidepressants and other anxiolytics.As a psychopharmacological treatment of situational anxiety in cancer patients, anxiolytic medications can be offered over a short duration if carefully indicated.
- Consensus
- Consent (86%)
Change note
The treatment of anxiety disorders and anxiety states in tumor patients should be interdisciplinary and multimodal. Psychopharmacological treatment should include benzodiazepines with a short duration of action, anxiolytic antidepressants and other anxiolytics.Effective treatment of anxiety and anxiety disorders in cancer patients requires close cooperation with the treating physicians and nurses, both from a diagnostic point of view and for the optimal treatment of somatic etiologies, triggers and symptoms, and for the determination of an individually appropriate psychopharmacological therapy. The treatment is carried out according to the current guidelines for anxiety and trauma sequelae disorders, or organic mental disorders. Antidepressants with anxiolytic effects (e.g., paroxetine, venlafaxine, mirtazapine) can be used for longer-term treatment, as well as for concomitant sleep disordersrs (see Chapter 8.1.3) [865], [866], [867]. In routine clinical practice, benzodiazepines with a rapid onset of action (e.g., alprazolam, lorazepam) can be used short-term for anxiety occurring in temporary and situational contexts. In the case of non-curable cancer, reference should also be made to the current "Extended S3 Guideline on Palliative Care for Patients with Non-curable Cancer" (AWMF Register Number: 128-001OL) which recommends the use of benzodiazepines under certain conditions and objectives. Because of the potential for dependency, care must be taken to ensure that the indications are well defined and that the duration of use is limited. Antipsychotics (haloperidol, possibly risperidone, olanzapine, or quetiapine) may also be used to treat delirium, pronounced nausea, and paradoxical reaction to benzodiazepines [865], [866], [868].
9.1.3 Sleep Disorders
In cancer patients, sleep disorders frequently occur as a result of psychological distress (e.g., fear of illness/recurrence) and side effects of treatment (e.g., after steroids, polyneuropathy), as well as the cancer disease itself (e.g., sleep apnea from head and neck tumors).
These shall be documented regularly and treated with a multimodal approach.
- Consensus
- Strong consensus (97%)
The indication for psychopharmacological treatment of sleep disorders in cancer patients should be reviewed and carried out under consideration of the current guideline recommendations (S3 guidelines "Sleep-related Respiratory Disorders" (AWMF register number: 063-001) and "Insomnia in Adults" (AWMF register number: 063-003)).
- Consensus
- Strong consensus (97%)
For general recommendations on sleep disorders, please refer to the corresponding S3 guideline (AWMF register number: 063-003). In this chapter, only special features of sleep disorders in cancer patients are detailed.
The cause of sleep disorders in cancer patients is multifactorial. Predisposing factors (e.g., female gender, older age, positive self- or family history) and perpetuating factors (e.g., excessive daytime sleeping) for sleep disorders exist regardless of the cancer disease and treatment [869]. However, there are a number of precipitating factors that are specific to cancer patients. These include antitumor treatments that affect the levels of inflammatory cytokines or disrupt circadian rhythms (e.g., corticosteroids), adverse side effects of antitumor treatments (e.g., hot flashes with anti-hormonal therapy), hospitalization, psychological distress, and somatic symptoms such as pain, nausea, dyspnea, and hot flashes [870], [869], [871], [872], [873].
25% to 80% of oncology patients suffer from disturbed sleep, with particularly high prevalences reported for the initial treatment period and the palliative stagestage [870], [874], [875], [876],[877], [878]. The most common forms of disturbed sleep in cancer patients are difficulty falling asleep and staying asleep [876]. A limiting observation regarding these epidemiological data is that the methodology has been criticized for poor operationalization of sleep disturbances – most studies do not differentiate between sleep disturbance as a symptom and sleep disturbance as a diagnostic category [874], [879]. The two large studies that diagnosed insomnia according to the diagnostic manuals found prevalences between 21% and 43% [875], [878]. With regard to the entity, there is evidence that sleep is most frequently disturbed in carcinomas of the respiratory tract (head and neck, lung) and the reproductive organs (breast, gynecological, prostate) [878],[875], [877], [870]. The latter are thought to be linked to hot flashes related to anti-hormone therapy [880], [881].
Sleep disturbances in cancer patients are closely associated with fatigue [882] as well as the quality of life [883]. They are mediators (the same as depressive symptoms) for the correlation between distress and quality of life [884] as well as between recurrent cancer and days of absence from work [881].
Despite this high clinical relevance, sleep disorders are underdiagnosed in cancer patients [873], [869]. In the outpatient setting, it has been found that sleep was addressed in conversation with health professionals in less than 1/5 of oncology patients with disturbed sleep [876] and in 2/3 of patients with significantly disturbed sleep [885]. A qualitative study confirmed the strong reluctance of cancer patients to discuss disturbed sleep with their oncologists. Patients believed that the doctor was not responsible for this symptom or would not be interested in it, and they did not want to „whine“ or disturb [886]. Pro-active, repeated screening of cancer patients for sleep disorders is therefore recommended [869].
If screening is positive, it is important to consider obstructive sleep apnea syndrome (OSAS) as a cause, as OSAS is associated with the development and progression of cancer [887]. In particular, a high prevalence of OSAS has been reported in patients following initial treatment of a head and neck tumors. Here, a meta-analysis of nine studies found a pooled prevalence of 71% (95% CI [48%; 86%], defined as apnea-hypopnea index ≥ 5, [888]. See also the "S3 Guideline Non-restorative Sleep/Sleep Disorder", Chapter „Sleep-related Breathing Disorders in Adults" (AWMF register number: 063-001) [889]. In several case reports, central sleep apnea syndrome (CSAS) occurred with and following brainstem tumors [890], [891], [892]. It is debated whether treatment with opioids can also lead to CSAS. The relevant data are sparse and inconsistent. For example, a meta-analysis of studies examining non-oncologic pain patients receiving opioids found increased prevalences of CSAS (33%, 95% CI [3 – 72] vs. 3%, 95% CI [1 – 6]) and an increased Central Apnea Index (CAI) compared to pain patients not receiving opioids [893]. These studies are limited, however, by the low methodological quality of the meta-analysis and the small number of included studies (e.g. the prevalence of CSAS in pain patients without opioid medication is based on only one study).
If somatic symptoms such as pain, nausea, dyspnea or hot flashes can be identified as (co-)causes of the sleep disorder based on the medical history, it is recommended to optimize the treatment of these symptoms first. Recommendations for this can be found in the "S3-Guideline Supportive Therapy for Oncological Patients " (AWMF-Registerummer: 032/054OL) and regarding hot flushes in the guidelines "S3-Leitlinie Prostate Cancer" (AWMF-Registerummer: 043/022OL) and "Interdisciplinary S3-Guideline for the Early Detection, Diagnosis, Therapy and Follow-up of Breast Carcinoma" (AWMF-Registerummer: 032/045OL).
While the efficacy of Cognitive Behavioral Therapy (CBT) for insomnia has also been shown in cancer patients [872], [894], there is little empirical research on the tolerability and efficacy of psychotropic drugs for sleep disorders in cancer patients [869], [895]. This is of particular concern since a relevant percentage of cancer patients take sleep medication. In a study of 124 breast cancer patients undergoing chemotherapy, 32.3% were prescribed a sleep medication, most commonly lorazepam and zolpidem [896]. In another study of 219 breast cancer patients undergoing chemotherapy, 12 – 23% reported taking a prescribed or over-the-counter sleep medication (depending on the agent and cycle of chemotherapy [897]).
A double-blind RCT with 53 breast cancer patients with sleep disturbances due to nocturnal hot flashes investigated 10 mg zolpidem vs. placebo for five weeks as an augmentation to pre-existing SSRI/SNRI medication, or 75 mg venlafaxine [898]. More patients in the augmentation group responded to treatment (40% vs. 14%, p=.035, defined as significant improvement on the Pittsburgh Sleep Quality Index and/or a reduction in wake time after sleep onset of ≥ 15 min as measured with an actigraph). Adverse side effects were reported by 60% in the augmentation group and 53.5% in the placebo group and were mild in severity, for example, nausea, fatigue, and dry mouth. Reliability of the findings is limited because a per-protocol analysis was performed and the placebo group in particular had a high dropout rate (43% vs. 12%).
A small RCT with 45 hematology patients with mucositis requiring opioids found self-reported improvement of duration, depth, and quality of sleep and reduced nocturnal awakenings when taking 2 – 3 mg eszopiclone (all p < .05) compared with the placebo over two days [899]. There were three participants per group who did not receive the second dose due to daytime sleepiness or confusion. No other adverse effects were reported
A double-blind RCT with 95 breast cancer patients after completion of active treatment found improved sleep while taking 3 mg melatonin compared with placebo (mean Pittsburgh Sleep Quality Index score -1.9 vs. -0.1) [900].
A double-blind phase III RCT with 227 cancer patients (mostly with breast cancer) on active antitumor treatment found good tolerability of 450 mg Valeriana officinalis (valerian) for eight weeks, but no difference in sleep quality [901].
An RCT with 96 cancer patients of different entities in remission over 47 days found no efficacy of 50 mg Armodafinil 2 x daily on the Insomnia Severity Index (ISI), neither as a monotherapy nor in combination with CBT (p=.174) [902].
9.1.4 Special Risks Regarding Side Effects and Interactions of Psychotropic Drugs in Cancer Patients
In the psychopharmacological treatment of cancer patients, an amplification of the side effects of underlying somatic disease and pharmacokinetic interactions with cancer treatment should be considered. In particular, seizure susceptibility can be enhanced, and the inhibition or induction of liver enzymes may affect the efficacy of anti-tumor subtances.
- Consensus
- Strong consensus (100%)
Consideration of side effects and interactions
Following the review by Grassi et al. [861], some of the side effects and interactions of antidepressant medications should be considered when determining the treament indication for cancer patients. The indication should always be determined in close consultation with the patient's treating oncologist/general practitioner and, if necessary, with the consultation of a specialist in psychiatry and psychotherapy. For example, anticholinergic side effects (dry mouth, constipation) are particularly relevant in patients receiving pain therapy with opioids. Some antidepressants have a relevant effect on the conduction of impulses in the heart (QT time), the electrolyte balance (hyponatremia) or in the form of organ toxicities (e.g., hepatotoxicity), so that regular controls or risk-benefit considerations are necessary for this purpose. Especially against the background of demographic changes and multimorbidity, these aspects are becoming increasingly important in the treatment of mental illnesses in patients with somatic illness. Detailed information on this can be found in standard medical texts [903] and specific reviews [904].
Tamoxifen in breast cancer
A special treatment situation arises in breast cancer patients taking tamoxifen, as the potential for an increase in mortality has been observed here. The group of SSRIs shows considerable differences in terms of interactions with the cytochrome P 450 system. Potent CYP2D6 inhibitors prevent the transformation of tamoxifen (TAM) to the biologically active endoxifen, thereby reducing antitumor efficacy. In addition to in vitro studies, clinical relevance was observed in a retrospective study based on increased cancer-related mortality in breast cancer patients taking TAM and paroxetine, whereas no effect of citalopram, sertraline, fluvoxamine and venlafaxine on cancer-related mortality was observed [905]. Breast cancer patients taking tamoxifen should therefore not receive SSRIs or other drugs with strong or moderate inhibitory activity [905], [906], [907], [908]. Psychotropic drugs with moderate to strong CYP2D6 inhibitory activity include the antidepressants paroxetine, fluoxetine, bupropion and duloxetine, as well as the antipsychotics thioridazine, perphenazine and pimozide [906].
Table 7: Overview of Significant and Important Interactions:
| P450 Inhibition or Induction: |
| Isoenzyme CYP2D6 is inhibited by several psychotropic drugs, particularly antidepressants. The decreased activation of tamoxifen was associated with increased mortality in breast cancer patients receiving antidepressants with moderate or high inhibitory activity [905]. |
| Anticholinergic side effects may affect opioid tolerance [903]. |
| Impaired cardiac conduction may require close monitoring – especially with electrolyte shifts in the scope of the cancer illness and treatment. |
| Pharmacodynamic interactions with cytostatics are not known, but antidepressants and antipsychotics may enhance the risk of seizures (and if there is another underlying disease as well). |
9.1.5 Psychopharmacotherapy for Individuals at Increased Risk for Epileptic Seizures due to Malignant CNS Tumors or Cerebral Metastases
Before psychopharmacological treatment of patients with malignant CNS tumors or cerebral metastases, the following constellations should be considered: (1) potential psychological side effects of a concomitant anticonvulsant therapy and (2) potential interaction of the psychopharmaca with existing anticonvulsant therapy. The risk of seizures is particularly increased with tricyclic antidepressants and maprotiline; bupropion is contraindicated.
- Consensus
- Strong consensus (100%)
Patients with malignant CNS tumors or cerebral metastases have a significantly increased risk for epileptic seizures. The risk depends on the location and histology of the tumor: especially tumors located in the parietal, temporal or frontal lobes of the cerebral cortex increase the risk. CNS tumors generally lead to a higher risk of seizures than metastases (see Table 10). Depending on the primary tumor, however, metastases may also be associated with a high risk of seizures, e.g., up to 67% risk of seizures in cerebral metastasized malignant melanoma [909].
Before starting psychopharmacological treatment, the following points should be considered: (1) possible causal significance of a concomitant anticonvulsant therapy for the psychiatric symptoms, (2) possible interaction of psychopharmaceuticals with concomitant anticonvulsant therapy, and (3) risk of triggering epileptic seizures from the psychopharma.cal.
Treatment with antidepressants
The overall risk of triggering epileptic seizures through treatment with antidepressants is low. Tricyclic antidepressants (mainly clomipramine and imipramine) and maprotiline are associated with an increased risk of triggering epileptic seizures. Bupropion increases the risk of epileptic seizures in a dose-dependent manner; there is a contraindication in patients with CNS tumors [Ratiopharm, 2019 SmPC: Bupropion], [Glaxo SmithKline, 2020 SmPC: Elontril]. SSRIs and other newer antidepressants may have more of an anticonvulsant effect at therapeutic doses [910], [911].
Treatment with antipsychotics
The effect of treatment with antipsychotics on seizure risk in patients with brain tumors has not been systematically studied. In a review of FDA phase II and III pivotal trials (non-oncology patients), clozapine (SIR 9.5; 95% CI 7.27 – 12.2), olanzapine (SIR 2.5; 95% CI 1.58 – 3.74), and quetiapine (SIR 2.05; 95% CI 1.21 – 2.03) were associated with an increased risk of epileptic seizures [912].
9.1.6 Risk of Bleeding Associated with Antidepressants
Patients with a high risk of bleeding should preferably receive antidepressants with low serotonin transporter affinity (e.g., bupropion, mirtazapine, trazodone, trimipramine) for the pharmacological treatment of depression.
- Consensus
- Strong consensus (100%)
Bleeding is a common complication, particularly in advanced cancers. Antidepressants may influence the risk of bleeding through several mechanisms. To date, no studies have examined the risk of tumor associated bleeding with antidepressant therapy or the influence of antidepressants on the bleeding risk specifically in cancer patients. Therefore, extrapolation from studies of the general population is necessary. The best studied risk is with serotonin reuptake inhibitors, especially SSRIs.
Serotonin reuptake inhibitors
Serotonin reuptake inhibitors impair hemostasis primarily by inhibiting the reuptake of serotonin in platelets, thereby interfering with platelet aggregation as well as vasoconstriction in response to vessel wall injury. Other mechanisms will be discussed [913].
In a meta-analysis of 11 case-control and 11 cohort studies, Laporte et al. [914] found an increased risk (OR 1.41; 95% CI 1.27-1.57) of clinically relevant bleeding with SSRI use. The risk was highest for gastrointestinal bleeding (OR 1.55; 95% CI 1.32-1.81) and lower for intracerebral hemorrhage (OR 1.16; 95% CI 1.01-1.33).
In a meta-analysis of 8 cohort studies, Singh et al. [915] examined the risk of postoperative bleeding when taking serotonergic antidepressants. They found no significantly increased risk of reoperation due to bleeding complications (OR 1.48; 95% CI 0.84-2.62), but an increased risk of bleeding requiring transfusion (OR 1.19; 95% CI 1.09-1.30).
The risk of bleeding depends on a number of additional factors. Regarding the use of SSRIs, it has been shown that the risk of gastrointestinal bleeding is higher when SSRIs and NSAIDs are combined than when only one of the drug classes is used, and, that in the treatment with SSRIs alone as well as SSRIs + NSAIDs combined, the risk could be reduced below the significant threshold level with the additional administration of PPIs [916].
Other antidepressants
In a meta-analysis from Na et al. [917], patients taking mirtazapine had a higher risk of gastrointestinal bleeding compared with patients not taking antidepressants (OR=1.17; CI = 1.01 – 1.38). In the same study, no significant difference in bleeding risk was found between mirtazapine and SSRIs or between bupropion and SSRIs.
In contrast, van Walraven et al. [918] and Wang et al. [919] found an association between the affinity of antidepressants for the serotonin transporter and the risk of gastrointestinal bleeding.
In summary, an increased overall risk of bleeding during treatment with serotonergic antidepressants is well established. Patients with other risk factors for bleeding should preferably be treated with antidepressants that have a low affinity for the serotonin transporter (e.g., bupropion, mirtazapine, trazodone, trimipramine). In particular, the individual risk for gastrointestinal bleeding should be considered and prophylactic administration of PPIs should be considered.
9.2 Occupational Therapy
Occupational therapy can be offered to cancer patients with limitations in the activities of daily living in order to improve quality of life.
- Consensus
- Strong consensus (100%)
Change note
Occupational therapy can be offered to patients with cancer who have limitations in their ability to function.The central task of occupational therapy is to maintain, stabilize, or restore a person's (client's) ability to function as a prerequisite for participation in the various areas of life.
Occupational therapy measures therefore always focus on activities that are important for the individual and which they need to manage everyday life (activities).
The most important methods in occupational therapy are specific activities (e.g. [I]ADL training, creative/design measures, [senso-]motoric or cognitive training, work-related measures); environmental modification/compensation/adaptation (provision of therapeutic aids, adaptation of the home, the workplace); and counseling/education/training (e.g. time, energy, stress management, instructing relatives, behavioral interventions).
Here, the intersection with psychoeducational, neuro-psychological and body-based therapies, such as physiotherapy, also becomes visible [920]. However, the main domain of occupational therapy is activation, both nationally and internationally [920]. Occupational therapy can be implemented in oncology in all disease phases and settings, including palliative care units [921]. It follows a client-centered, resource-oriented approach, and a bio-psycho-social understanding of health (International Classification of Functioning, Disability and Health, ICF).
Based on a systematic search conducted in the course of the first version of the S3 Guideline Psycho-oncology, four randomized controlled trials ([922], [923], [924], [925]), up to and including 2011 with a total of 95 participants (majority with breast cancer), reported initial positive effects of occupational therapy, e.g. on the management of concomitant symptoms (range of motion, fatigue), mood, and health-related quality of life.
For the current guideline, five additional RCTs ([926], [927], [928], [929], [930]) between 2011 and 2020 with a total of 543 participants were identified along with The Occupational Therapy AOTA Guideline [921] for the Rehabilitation of Adult Cancer Patients, which is based on two systematic reviews [931], [932].
Evidence exists for longer, i.e., multi-week, multimodal occupational therapy group programs that link multiple components (e.g., client-centered ADL training, shared leisure activities, education, relaxation training, teaching energy-management strategies, exercise, and creative arts activities).
Such a program improved overall quality of life in patients with breast cancer, including the role function, emotional functioning, fatigue, and sleep (all subscales of the EORTC QOQ-C30), as well as breast symptomatology and the side effects of therapy. Involvement in meaningful activities also improved significantly [929].
Patients with metastatic prostate cancer receiving ongoing hormone therapy also had better quality of life after such a program and showed significant improvements in carrying out activities important to them and being satisfied with them (in the Canadian Occupational Performance Measure/COPM). Concomitant symptoms of therapy (relating to sexual activity, incontinence) were also significantly reduced [927].
Several RCTs investigated occupational therapy group programs to reduce fatigue as a primary endpoint:
Here, a multi-week program for breast cancer patients proved to be effective, significantly reduced fatigue, and promoted a healthy lifestyle. It included education; the planning/teaching/evaluation of energy-management strategies; activity/break management, daily structuring, and homework (monitoring symptoms, prioritizing activities) [928].
One study examined at what point fatigue management/education produced the best results in people receiving radiation therapy for various cancers. The group program consisted of: a one-time education session, a manual, a goal-setting sheet, and a diary to document one's progress, as well as two follow-up calls. The control group also received: a one-time individual educational intervention about the radiation therapy process and their individual diagnosis, a flyer on fatigue, and standard written information about radiation therapy. The study found no improvements or differences in fatigue between groups or between time points. However, participants who received the intervention prior to radiation participated significantly more in moderate and vigorous physical activities (participation) during the radiation phase, whereas participation decreased in participants who did not receive the program prior to radiation [926].
In acute care, occupational therapy interventions, e.g. after surgery, can also be provided on a visiting basis at the patient's bedside. The focus at this time is, for example, practicing self-care skills (activities of daily living/ADL, such as dressing and personal hygiene); adapting the patient's (immediate) environment; planning any necessary modifications in the home environment; developing/practicing strategies to compensate for limited bodily functions and/or skills (e.g., through the use of assistive devices). Here, for example, strategies for problem-solving can be developed which improve the patient's participation in daily life and have a stabilizing effect on their mental state [923].
One RCT [930] investigated a short occupational therapy program (strategy teaching/training) in the home environment for people with different oncological diagnoses in advanced stages compared to standard care. This did not result in significant improvements in ADL performance, quality of life, or autonomy and participation compared to standard outpatient care (home or palliative care, or outpatient rehab including occupational therapy if needed). The majority of participants received only one home visit (77 of 113) and one phone call (62 of 113) as part of the intervention.
The American Occupational Therapy Association (AOTA) Guideline reports strong evidence for improvement in function and participation through multidisciplinary rehabilitation programs (including occupational therapy) [932]. This is valid regardless of the entity and stage of the cancer or the age of the patient.
Moderate evidence also exists for the use of cognitive interventions within integrated rehabilitation programs to improve attention, cognitive performance, and quality of life [921], [932].
For reducing symptoms (such as shortness of breath, fatigue, or pain) associated with cancer or its treatment, the AOTA Guideline reports moderate to strong evidence that exercise programs, cognitive-behavioral therapy, and techniques that train patients to use their resources are effective intervention components [921].
In addition, there is strong evidence that psychosocial strategies, including cognitive-behavioral therapy and educational interventions (e.g., problem solving, knowledge about the disease, and side effects), can reduce anxiety >3 months and depression 1-3 months after treatment [932].
Moderate evidence exists for the effectiveness of a variety of psychosocial interventions (including mindfulness-based interventions, brief life review with terminally ill patients, stress management program, or expressive writing in breast cancer survivors) on improving quality of life, well-being, psychosocial adjustment, and reducing anxiety and depression [921]; [932].
Limited evidence exists for occupational therapy interventions that focus on social participation and vocational reintegration regarding quality of life and the return to work after breast cancer [921]; [932]. Measures for reintegration and returning to work (e.g., job coaching, workplace counseling) are an important concern for cancer survivors (see [933]; [239]; [934]; [932]).
Problems following adjuvant oncological therapy, such as neuropathies in the hands and feet or limited range of motion (e.g., in breast cancer), can be treated with sensorimotor-perceptual approaches [935].
In addition to regaining the greatest possible independence in activities of daily living, the reentry into working life – when possible – (e.g., through brain performance training, counseling on dealing with fatigue, vocational preparation measures) and the resumption of desired social roles are also initiated.
Particularly important, especially in post-acute care, is how a person can optimally cope with existing difficulties and possible long-term limitations, e.g., due to neuropathies/CIPN, fatigue, or neuropsychological deficits; how they can continue to perform desired activities in a way that provides meaning and satisfaction; whether and how contextual factors can be adapted (e.g., living space, workplace, involvement of relatives); and what skills and abilities can be relearned in order to lead a life as self-determined as possible with maximum quality of life and social participation in all areas of their life.
In the palliative situation, methods and aids can be offered to maintain the highest possible level of quality of life, self-determination and (spiritual) well-being, especially with regard to depression and anxiety reduction.
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