Practice review: Evidence-based quality use of corticosteroids in the palliative care of patients with advanced cancer

Abstract

Background: It would be unusual for a patient with advanced cancer not to be prescribed corticosteroids at some stage of their disease course for a variety of specific and non-specific indications. Aim: The aim of this practice review was to provide a pragmatic overview of the evidence supporting current practice and to identify areas in which further research is indicated. Design: A ‘state-of-the-art’ review approach was used to examine the evidence supporting the use of corticosteroids for the management of cancer-related complications and in symptom control, in the context of known risks and harms to inform quality use of this medicine. We developed ‘Do’, ‘Do not’, and ‘Don’t know’ recommendations based on current literature and identified areas for future investigation and research. Data sources: We searched MEDLINE, EMBASE and the Cochrane library from inception to 14th October 2020. Our initial search limited to reviews, reviews of reviews, randomised controlled trials (RCTs) and controlled trials was supplemented by supporting literature as appropriate. Results: Evidence to support common practice in the use of corticosteroids is lacking for most indications. This is in the context of strong evidence for the potential for significant toxicity and poor quality use of medicine. Conclusion: Guidelines recommending the widespread use of corticosteroids should acknowledge the poor evidence base supporting much current dogma. Quality research is essential not only to define the role of corticosteroids in this context but to ensure good prescribing practice.

Treatment patterns and out-of-hospital healthcare resource utilisation by patients with advanced cancer living with pain: An analysis from the Stop Cancer PAIN trial

“…A recent study from New Zealand suggested corticosteroids are largely prescribed based on anecdotal and experiential evidence rather than on robust research [ 98 ]. Further investigation into the specific reasons for prescribing dexamethasone in the Australian setting using audit or qualitative methods is warranted given potential harms, absence of evidence for prolonged use of dexamethasone and limited information on why prescribers choose this medication [ 97 , 98 ].…”

Impact of Glucocorticoid Use in Oncology in the Immunotherapy Era

“…Clearly, corticosteroids have become well established in the management of patients with cancer at several levels although primarily in the management of cancer-related complications or treatment side effects. Nonetheless, it should be underlined that the use of a number of therapeutic approaches using GCs [ 72 ] lack a solid scientific rationale even though the side effects of GCs treatment are well known. This is all the more important to keep in mind since the advent of immunotherapy, which is quickly becoming a leading component of therapy in the majority of cancers.…”

Deprescribing in Palliative Cancer Care

“…However, the effect deteriorates during long-term use, and it is optimal to use for only shorter time-periods, e.g., 2 weeks. Interestingly, although the extensive use of corticosteroids, general guidelines for the use of this drug in palliative care is lacking [ 48 ]. Indeed, in two recent meta-analyses and reviews, it is shown that the evidence base for most indications of corticosteroids in palliative care were limited or non-existing [ 48 , 49 ].…”