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Fatigue and malignant pleural effusions

Dear Editors We completely agree with Twose et al that until now the primary focus in both clinical practice and trials has been on interventions in malignant pleural effusions (MPEs), tailored to mitigating breathlessness and preventing admissions, with little consideration of other factors potentially of greater priority to the patient. We were encouraged to see that constitutional symptoms such as fatigue and anorexia were investigated, but disappointed that the effects of aspiration were not sustained at 7 days. Our interest lies in fatigue in MPEs. Cancerrelated fatigue is well described and is a subjective symptom experienced by patients at all stages of disease and can occur during treatment, in advanced disease and in diseasefree survivors. Approximately 40% of patients with cancer experienced fatigue at the time of diagnosis and up to 90% experience this symptom during radiotherapy or chemotherapy. Preliminary data from 30 consecutive patients with confirmed or presumed MPE presenting to the pleural clinic in Northumbria Healthcare NHS Foundation Trust showed high levels of fatigue using the validated FACITF (Functional Assessment of Chronic Illness Therapy – Fatigue) questionnaire. The median patient age 74.8 years, range 46–87. Diagnoses were 15 pleural mesotheliomas, 9 lung, 4 breast and 2 ovarian cancers. There was a wide range of comorbidities, for example, hypertension (commonest), previous myocardial infarctions, diabetes and previous resected cancers with 5 having more than 2 comorbidities Median body mass index was 26.5, range 21.3– 34.3. All haemoglobin and kidney function were normal with (Eastern Cooperative Oncology Group) ECOG performance status between 1 and 3 (1: n=16, 2: n=12, 3: n=2). This has led to a prospective feasibility study: ‘Do Interventions for Malignant Pleural Effusions (MPE) impact on patient reported Fatigue levels? A questionnairebased pilot study (IMPEF study)’ [supplementary files attached] [IRAS ID: 276 451 and CPMS ID 46430]. It involves completing the FACITF questionnaire prior to any pleural procedure and then a phone call to repeat the same questions at 7, 14 and 30 days. Recruitment is underway for patients with MPE undergoing any type of intervention (aspiration, chest drain or indwelling pleural catheter insertion, thoracoscopy), although this has been significantly hampered by the current COVID-19 pandemic and the high attrition rate for patients with MPE. The primary outcome is to determine if pleural interventions performed to treat MPE impact on fatigue and whether the effects are sustained. It will be important to determine if any confounding factors affect fatigue and so the following data are being gathered: sex, diagnosis (site/type of cancer and whether metastatic), comorbidities (esp. lung disease), time since cancer diagnosis, time since last anticancer therapy/if currently having chemotherapy or radiotherapy, Integrated Patient Outcome Score to assess symptom burden and screen for depression, size of pleural effusion, whether unilateral/bilateral, amount of fluid drained, performance status, haemoglobin and creatinine levels. The final outcome is to determine if a larger statistically powered study could be conducted. We understand that fatigue in the Twose et al study was not improved, and perhaps the timing of the interview was too soon. We hope that our study will complement the development of a symptomdriven personalised approach in MPE management, considering symptoms other than dyspnoea. We would gladly collaborate in any further work that might be planned. Avinash Aujayeb , Donna Wakefield 2 Respiratory Department, Northumbria Healthcare NHS Foundation Trust, North Shields, UK Palliative Care Department, North Tees and Hartlepool NHS Foundation Trust, StocktonUponTees, UK