Table 2. Centrally Acting Stimulants for Adult Cancer Patients continued...
On the basis of limited clinical experience and acknowledging a lack of evidence in randomized controlled trials, it might be reasonable to consider a psychostimulant such as methylphenidate or modafinil for the treatment of severe fatigue, particularly for short periods of time (a couple of weeks) in patients with advanced disease. When the use of these medications is being considered, it is important to obtain informed consent, with careful discussion of risks, benefits, and alternatives. Continuous monitoring of cardiovascular parameters is crucial when these medications are used, especially in patients with preexisting cardiovascular issues and in patients being treated with known cardiotoxic chemotherapeutic regimens (e.g., anthracyclines). In certain cases, consulting with cardiology services might be necessary. Longer-term psychostimulant therapy is not advisable at this time because there is limited information about its potential negative effects and longer-term benefits.
Treatment of Anemia
Anemia in patients with cancer is best managed by treatment of the underlying cause. When the cause is obscure or there is no specific remedy, then treatment is supportive. Nutritional interventions, including the intake of nutrient-rich foods and supplements should be considered in addition to other treatment modalities. Transfusion of packed red blood cells is the most widely used and most rapid way to alleviate symptoms in cancer patients with symptomatic anemia. The likelihood of success in raising the level of hemoglobin is very high with transfusion, and the risks of complications are low. Nevertheless, repeated transfusions can be cumbersome, and the risks of blood-borne infection can be worrisome for patients. Other risks include an acute transfusion reaction, transfusion-associated graft-versus-host disease, subtle immune modulation that occurs with transfusion, and iron overload for those with repeated transfusions.
Several large, community-based studies have examined the effectiveness of epoetin alfa and darbepoetin alfa [Level of evidence: I];[Level of evidence: I] in the treatment of cancer-related anemia in patients undergoing chemotherapy.[Level of evidence: II];[Level of evidence: III];[Level of evidence: I] A few of the studies of epoetin alfa employed an open-label, nonrandomized design and included objective endpoints (hemoglobin response, transfusion requirements) and subjective evaluation of fatigue and quality of life. In this setting, epoetin alfa has been effective at increasing hemoglobin levels and decreasing transfusion requirements. In addition, epoetin alfa was associated with improvement in functional status and quality of life, independent of tumor response. Several studies of epoetin alfa and darbepoetin alfa employed a randomized, controlled design. These studies varied in terms of dosing and frequency of medication administration. A review and meta-analysis of randomized and open-label studies concluded that these agents are effective in the management of CRF  but also raises serious concerns about safety data and adverse outcomes associated with these agents. The review concludes that these agents should not be used for the treatment of fatigue in patients with cancer. The authors argue that the risks associated with these agents outweigh their benefits for the treatment of CRF.