Physician's Weekly Article - Opening Communication Lines in Chemotherapy-Induced Anemia

       Physicians may need to modify their vocabulary and incorporate validated fatigue instruments into exams in order to better prevent and treat chemotherapy-induced anemia.

      It is estimated that chemotherapy-induced anemia occurs in roughly half of people who receive cytotoxic chemotherapy, and the condition has been shown to adversely affect health-related quality of life. “Patients at risk for chemotherapy-induced anemia include older individuals, those with significant comorbidities, and individuals who are bone marrow compromised prior to starting chemotherapy,” explains David Cella, PhD. “The most common symptom of chemotherapy-induced anemia is fatigue, one that’s not always on the radar screen for physicians. Typically, fatigue occurs within the first few cycles of chemotherapy. It’s non-specific, so while it’s not a good marker for anemia, it can help drive decisions about when to treat”

      Fatigue is the most prevalent symptom associated with cancer, and it can be life-disruptive. Regardless of its cause, fatigue can be difficult to discuss efficiently and effectively with patients. “We have much data on the connection between fatigue and anemia,” says Dr. Cella. “It’s important to recognize and treat fatigue with exercise, diet, iron, or erythropoietic agents. It’s also difficult to establish clinically defined endpoints to ensure proper treatment. Treatment usually involves a decision algorithm consisting of a review of symptoms and laboratory data. To help assess fatigue, many instruments have been created and tested to validate the impact of anemia and fatigue treatments on quality of life for patients. However, it remains to be seen whether or not these instruments are useful in assisting patients and doctors in making treatment decisions.”

      Doctor-Patient Communication is Key

      In a study published in the January 2007 Journal of Supportive Oncology, Dr. Cella and colleagues evaluated how discussions of anemia and related fatigue transpired based on accepted methodologies from sociolinguistics and linguistic anthropology. “We designed the study to capture naturally-occurring conversations between clinicians and patients undergoing chemotherapy,” he says. “Our analysis focused on a close analysis of all discourse in the exam room. We observed differences in patterns of communication between patients and oncologists as well as other allied health professionals.”

      Despite the fact that more than half of visit time was spent discussing side effects and symptoms of treatments, the study showed that most discussions of anemia and fatigue lacked the specificity necessary to determine their true impact on patients’ lives (Figure 1). “When physicians asked about fatigue, the discussions tended to be too brief to elicit the patients’ chief concerns,” Dr. Cella says. “When chemotherapy-induced anemia is discussed between doctors and patients, the conversations tended to be in a closed-loop format, impeding further discussion of fatigue and reducing the likelihood that clinicians and patients will collaborate to discuss available interventions. We also found that the vocabulary used when speaking about anemia and related fatigue was variable and imprecise, and no fatigue assessment instrument was used or referenced in any visit.”

      In light of the study findings, Dr. Cella says that community-based oncologists should be encouraged to modify their vocabulary when treating chemotherapy-induced anemia (Table 1). “They should also consider incorporating a brief, validated fatigue instrument—either within or before the consultation—to improve the quality of communication. Additionally, the Joint Commission on Accreditation of Healthcare Organizations requires that clinicians ask their patients about pain. We should consider adopting this practice with fatigue because it severely affects quality of life. Furthermore, physicians should refer to available guidelines for chemotherapy-induced anemia—several professional organizations have produced them—because they provide clear and explicit recommendations.”

      Measure Hemoglobin Levels Regularly

      Dr. Cella says that physicians should be sure to review hemoglobin levels during patient visits at the initiation of therapy and look for downward trends before and after starting treatment. “Regular hemoglobin measurements can identify the warning signs of fatigue. The hemoglobin trend—not just the number at one particular visit—is important to monitor. Carefully tracking these numbers and monitoring patients for fatigue over the long haul can help avoid chemotherapy-induced anemia. No clinician can determine how tired a patient is by looking at hemoglobin levels alone. Measuring the patient’s fatigue is as important to their lives as measuring their hemoglobin.”

      Take More Time Whenever Possible

      The time that doctors and patients have to communicate about all aspects related to cancer treatments is limited, according to Dr. Cella. He says “chemotherapy-induced anemia and fatigue are not even discussed during most visits. Until physicians and providers are equipped with more automated tools that can quickly and accurately track patient symptoms, it will be challenging to improve the ability to identify fatigue that triggers chemotherapy-induced anemia. More careful monitoring of patients should also be advocated and it’s important to understand that therapies are available to significantly improve the quality of life in our patients."

      David Cella, PhD has indicated to Physician’s Weekly that he has or has had the following financial interest: Consultant to Amgen Inc. and Ortho Biotech Products, LP.