Symptom Management: War Problems, Moonshot Solutions?

Dubbed the “war on cancer” by President Nixon, the National Cancer Act of 1971 charged the Director of the National Cancer Institute with developing “an expanded, intensified, and coordinated cancer research program” (1). While the ultimate victory of a cancer cure remains elusive, advances in cancer screening, diagnosis, and treatment have dramatically improved survival for people with many forms of cancer. Those gains, however, have been accompanied by the collateral damage of often severe symptoms such as the neuropathy, pain, and fatigue experienced to some degree by many cancer patients (2). These are but three of the approximately 800 toxicities included in the standard tool for reporting adverse events in oncology clinical trials (3). Such symptoms are a serious concern because they can require shifts to potentially less effective therapeutic regimens and dramatically reduce quality of life for cancer patients and survivors. In this issue of the Journal, Miaskowski et al. present expert panel recommendations intended to move from studying symptoms in isolation from one another to a more robust examination of co-occurring symptoms known as clusters (4). The panel defined a cluster as two or more concurrent symptoms that persist over time and for which there may be shared mechanisms and outcomes. However, the panel’s first of five key recommendation areas highlights the need for a more refined definition and a conceptual framework to serve as a foundation for future symptom cluster research. The remaining four recommendation areas call for research aimed at improving measurement of clusters, developing new analytic techniques, investigating underlying pathophysiologic mechanisms, and evaluating targeted interventions. Each area includes an ambitious set of specific research priorities. Much of the published literature focuses on cancer patients, suggesting that scientists studying this group may be more prepared to address these priorities than scientists studying other chronic conditions. Advancing symptom cluster research in the cancer context will require consideration of the implications of molecularly targeted therapies. The high likelihood of a therapeutic response in patients whose tumors express an alteration known to be a target of a study drug allows for designs that require many fewer participants than traditional trials (5). The success of ongoing US Food and Drug Administration efforts to accelerate drug approval has shortened the time from trial completion to market release (6). These trends toward smaller trials with shorter follow-up may create substantial challenges in detecting individual treatment–related symptoms unless they are frequently experienced and occur within a few weeks or months of treatment initiation. New strategies for studying individual symptoms may need to be developed before or in parallel to an expansion of symptom cluster research. The importance of considering clinical application across all phases of symptom cluster research is another topic that may merit additional consideration. Clinical staff in oncology care delivery settings face tremendous time pressure as the complexity of cancer treatment increases, reimbursement mechanisms shift, and care delivery models change (7). Implementation and use of electronic medical records continue to disrupt clinical work flow (8). The incorporation of palliative care specialists and principles into oncology care remains challenging despite widespread recognition that patients may benefit from this approach (9). Sophisticated measurement approaches and rigorously evaluated interventions are likely to be adopted only if they are clearly beneficial to patients, readily incorporated into practice, and fully reimbursed. Achieving those goals will require symptom cluster researchers to fully engage frontline clinicians, administrators, and insurers as partners in developing, conducting, and reporting on their studies. The Cancer Moonshot created by President Obama and led by Vice President Biden may offer a unique opportunity to address both these cancer-specific issues and the priorities described by Miaskowski et al. (4). A Blue Ribbon Panel created to identify Moonshot research priorities has recently selected symptom management research as one of 10 potentially highimpact topics poised to meet the goal of achieving in five years