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Cancer-related Fatigue and Sleep Disorders, Part2
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Professional Oncology Education
Cancer-related Fatigue and Sleep Disorders, Part2
Time: 28:57
Dave Balachandran, M.D.
Associate Professor, Pulmonary Medicine
The University of Texas MD Anderson Cancer
Center
Hello, my name is Dave Balachandran. I’m an
Assistant Professor in the Department of Pulmonary
Medicine at the UT MD Anderson Cancer Center.
Today, I’d like to talk to you and continue on the topic
that you just may have heard about, on cancerrelated fatigue and sleep disorders. This is the
second part of that program and we’re going to be
discussing a few cases that may help us better
explain the relationship between cancer-related
fatigue and sleep disorders. So, let’s begin.
Spanish Translation
Fatiga y trastornos del sueño relacionados con el
cáncer, parte 2
Transcripción del video
Educación Oncológica Profesional
Fatiga y trastornos del sueño relacionados con el
cáncer, parte 2
Duración: 28:57
Dr. Dave Balachandran
Profesor Asociado, Medicina Pulmonar
MD Anderson Cancer Center de la Universidad de
Texas
Hola. Mi nombre es Dave Balachandran y soy
profesor adjunto en el Departamento de Medicina
Pulmonar del MD Anderson Cancer Center de la
Universidad de Texas. Hoy continuaremos hablando
sobre la fatiga y los trastornos del sueño relacionados
con el cáncer. En esta segunda parte del programa
evaluaremos algunos casos que nos ayudarán a
explicar mejor la relación entre la fatiga y los
trastornos del sueño relacionados con el cáncer.
Comencemos.
1
The relationship between cancer-related fatigue and
sleep disorders and circadian rhythms is a novel one
and it’s one that we are actively investigating here at
The UT MD Anderson Cancer Center.
En el MD Anderson Cancer Center de la UT estamos
investigando activamente esta novedosa relación
entre la fatiga y los trastornos del sueño relacionados
con el cáncer y los ritmos circadianos.
Let’s start by presenting a few cases of patients who
may help us explore some of these concepts. The
first patient is a 35-year-old woman with breast
cancer treated approximately 5 years ago. She was
treated with chemotherapy and surgery and is now
cancer flee --- free. She was seen in the Sleep
Disorders Clinic for severe cancer-related fatigue and
insomnia. She has excessive daytime sleepiness,
also known as hypersomnolence. She sleeps 6 to 9
hours per day, but still awake --- awakens
unrefreshed. Her Epworth Sleepiness Scale Score,
which is a measurement of daytime sleepiness, and
any score over 10 is considered excessive daytime
sleepiness, is elevated at 14. She also notes an
approximately 40-pound weight gain since her
chemotherapy. She denies any witnessed apneas,
snoring or other sleep symptoms. However, her
father was recently diagnosed with sleep apnea.
Comencemos presentando casos de pacientes que
nos pueden ayudar a explorar algunos de estos
conceptos. La primera paciente es una mujer de 35
años con cáncer de mama tratado hace unos 5 años.
Recibió quimioterapia y cirugía, y ya no tiene cáncer.
Fue tratada en la Clínica de Trastornos del Sueño por
fatiga e insomnio graves relacionados con el cáncer.
Tiene somnolencia diurna excesiva, también conocida
como hipersomnolencia. Duerme de 6 a 9 horas por
día, pero se despierta cansada. Obtuvo una
puntuación de 14 en la escala de Epworth, que evalúa
la somnolencia diurna y considera excesiva una
puntuación mayor de 10. También observó que subió
unas 40 libras desde su quimioterapia. Niega haber
presentado apneas, ronquidos u otros síntomas
durante el sueño, pero su padre fue diagnosticado
recientemente con apnea del sueño.
2
Her past medical history, as stated before, is
significant for breast cancer, mild neuropathy,
hypothyroidism, and adult-onset diabetes. Her
medications include Nexium, Synthroid and
Vasotec. She is a judge. She is single without
children and does not smoke or drink alcohol. Her
physical exam is remarkable for her mild obesity with
a BMI of 31. She is not hypertensive nor febrile. Her
Mallampatti exam, which is an examination of the
oropharynx, reveals a fairly normal airway. There
are no large tonsils. The lungs are clear to
auscultation and her neuro exam is nonfocal at this
time.
Su historia médica indica cáncer de mama,
neuropatía leve, hipotiroidismo y diabetes de
aparición en edad adulta. Sus medicamentos incluyen
®
®
®
Nexium , Synthroid y Vasotec . Es jueza, soltera y
sin hijos; no fuma ni bebe alcohol. Su examen físico
es excepcional a pesar de su obesidad leve y un IMC
de 31. No es hipertensa ni tiene estado febril. Su
prueba de Mallampati, que evalúa la orofaringe,
revela una vía respiratoria normal. No tiene las
amígdalas agrandadas. La auscultación pulmonar no
indica obstrucciones y su examen neurológico no es
focal.
We took this patient, because of her symptoms of
excessive daytime sleepiness, to our sleep lab at
The MD Anderson Cancer Center. We are fortune at
The MD Anderson Cancer Center to have one of the
few sleep labs located within a cancer center. During
the sleep study, which is shown in front of you, the
patient slept fairly well. As you can see, she had a
high sleep efficiency of 97% and slept more than a
total of 6 --- of a total of 7 hours. What you see
before you is a description of her nighttime sleep and
what you can see is that she processes through the
stages of sleep fairly normally with adequate REM
sleep. She had no significant hypopneas or apneas
and she had no significant leg movements, which
would --- could disturb her sleep. In essence, this is
a fairly normal sleep study and does not explain her
significant daytime sleepiness.
Llevamos a esta paciente con síntomas de
somnolencia diurna excesiva a nuestro laboratorio del
sueño en el MD Anderson Cancer Center, uno de los
pocos situados en un centro oncológico. Durante el
estudio, la paciente durmió relativamente bien. Tuvo
una eficiencia de sueño del 97% y descansó más de
7 horas. Esta es una descripción de su sueño durante
la noche y vemos que atraviesa las etapas del sueño
de manera relativamente normal, con un sueño REM
adecuado. No presentó hipopneas o apneas
significativas ni movimientos de piernas considerables
que perturbasen su sueño. Se trataba de un estudio
del sueño relativamente normal que no explica su
somnolencia diurna.
3
So, let’s examine why a person who has fairly normal
sleep may still have significant cancer-related fatigue
and hypersomnia, and the relationship between
these two.
Examinemos por qué una persona con un sueño
relativamente normal puede tener fatiga e
hipersomnia significativas relacionadas con el cáncer,
y qué relación existe entre ambas condiciones.
One of the ways we can measure excessive daytime
sleepiness or hypersomnolence in the sleep lab is by
doing a test called a Multiple Sleep Latency test.
What the Multiple Sleep Latency does is provides
information objectively about daytime sleepiness. In
essence, it actually measures how quickly someone
falls asleep. A patient is given an opportunity to
sleep in 4 to 5 nap periods. These are spread out
two hours apart throughout the day after they wake
up from their nocturnal sleep. What we measure is
how many minutes it takes them to fall asleep and
whether during any of these 20-minute periods
whether they have REM sleep, which would indicate
a pathology. An increased sleep latency, that is,
more minutes to fall asleep indicates increased
alertness or normal alertness. A decrease in sleep
latency, or a decrease in the number of minutes it
takes to fall asleep, indicates increased sleep --sleepiness and that’s our objective finding.
Una manera de medir la somnolencia diurna
excesiva, o hipersomnolencia, en el laboratorio del
sueño es mediante la prueba de latencia múltiple del
sueño. Esta prueba provee información objetiva sobre
la somnolencia diurna, pues mide cuánto tarda una
persona en conciliar el sueño. El paciente debe
dormir 4 o 5 siestas cada dos horas durante el día,
luego de despertarse de su sueño nocturno. Medimos
cuántos minutos tardan en conciliar el sueño y si en
alguno de estos períodos de 20 minutos tienen sueño
REM, lo que indicaría una patología. Un aumento de
la latencia del sueño, o cuanto más tarda en dormirse,
indica un mayor estado de alerta o un estado de
alerta normal. Una disminución en la latencia del
sueño o en los minutos que tarda en conciliar el
sueño indica un aumento de la somnolencia. Ese es
nuestro hallazgo objetivo.
4
Here is the initial study that validated the Multiple
Sleep Latency Test. As you can see normal control
patients who did not report sleepiness had a sleep
latency of about 12 to 15 minutes. Patients with
narcolepsy, who by definition are excessively sleepy,
had a sleep latency less than 4 minutes. And based
on these findings it was decided that a sleep latency
less than 8 minutes is considered hypersomnolent
and less than 5 minutes is more consistent with
narcolepsy.
Este es el primer estudio que validó la prueba de
latencia múltiple del sueño. Los pacientes con
resultados normales que no informaron somnolencia
tuvieron una latencia del sueño de 12 a 15 minutos
aproximadamente. Los pacientes con narcolepsia,
que por definición son excesivamente somnolientos,
tuvieron una latencia del sueño inferior a 4 minutos.
Con base en estos hallazgos se decidió que una
latencia del sueño inferior a 8 minutos se considera
hipersomnolencia, y menos de 5 minutos es más
consistente con la narcolepsia.
This is a hypnogram, again of our patient, when she
actually had her Multiple Sleep Latency test. You
can see on the right side that she, on all of her naps,
fell asleep in less than 6 minutes indicating that she
is objectively very sleepy despite sleeping completely
normally as you saw in the priv --- previous slide of
approximately 7 hours. Despite an adequate night’s
sleep that was not interrupted by obstructive sleep
apnea or by leg movements, this patient is
impressively sleepy despite a normal night’s sleep.
Este es un hipnograma de la paciente cuando realizó
su prueba de latencia múltiple del sueño. A la derecha
vemos que en todas sus siestas se quedó dormida en
menos de 6 minutos, lo que indica que objetivamente
tiene mucho sueño a pesar de dormir normalmente.
Aunque la noche de sueño no se vio interrumpida por
una apnea del sueño obstructiva o por movimientos
de las piernas, esta paciente es llamativamente
somnolienta.
5
So what explains this? We’ll come to that in a
minute. The patient was titrated with modafinil,
based on these Multiple Sleep Latency results, and is
doing much better and is able to perform better at
work…
¿Cómo se explica esto? En breve lo analizaremos.
Con base en los resultados de la prueba de latencia,
la paciente fue tratada con modafinilo. Su estado
mejoró y tiene un mejor desempeño en el trabajo.
…and this slide reviews the use of modafinil in
cancer-related fatigue. I should mention that there is
no FDA approval for the use of modafinil in cancerrelated fatigue. In this --- in these studies, you can
see that they primarily looked at patients with breast
cancer and ones that use patients with brain tumors.
And they used modafinil either 200 or 400 mg dose,
used primarily during the morning and measured
their fatigue scores before and after treatment, and
there is improvement seen in some of the studies in
their fatigue scores with the use of modafinil.
Esta diapositiva analiza el uso del modafinilo en la
fatiga relacionada con el cáncer, aunque no está
aprobado por la FDA para tratarla. En estos estudios
se observó principalmente a pacientes con cáncer de
mama o tumores cerebrales. Se administraron dosis
de modafinilo de 200 o 400 mg, principalmente por la
mañana, y se midieron sus puntuaciones de fatiga
antes y después del tratamiento. En algunos estudios
se observaron mejoras con el uso de modafinilo.
6
Well, going back to our case, let us try to understand
a little bit why this patient with a normal night’s sleep
still has significant cancer-related fatigue and
daytime sleepiness. We think that this may be
related to abnormalities in circadian rhythms that
exist within cancer patients. And now we will review
some of the evidence for this belief that we have.
Queremos comprender por qué esta paciente duerme
bien durante la noche, pero sufre fatiga y somnolencia
diurnas relacionadas con el cáncer. Creemos que
puede obedecer a anomalías en los ritmos
circadianos de los pacientes con cáncer. Analicemos
la evidencia de esta afirmación.
Let’s start by defining what circadian rhythms are.
Circadian rhythms are the natural rhythms, or the
biological clock, that informs pretty much every
activity of our daily life including how we think, when
we’re best coordinated, when we sleep, when we
eat. All of these things are pretty much mediated
very cyclically by our circadian rhythms. Many
physiological variables also rotate on a very
predictable circadian rhythm including blood
pressure, body temperature, hormonal levels and
even things like bowel movements actually have a
very normal circadian rhythm. And circadian rhythms
are fairly preserved throughout all life species on
earth.
Los ritmos circadianos son los ritmos naturales, o el
reloj biológico, que informan casi todas las
actividades de nuestra vida cotidiana: cómo
pensamos, cuándo estamos mejor coordinados,
cuándo dormimos y cuándo comemos. Todo esto es
medido cíclicamente por nuestros ritmos circadianos.
Muchas variables fisiológicas suceden también con
un ritmo circadiano muy predecible, como la presión
arterial, la temperatura corporal, los niveles
hormonales… Incluso los movimientos intestinales
tienen un ritmo circadiano muy normal y estos ritmos
se preservan en todas las especies de la Tierra.
7
Circadian rhythms are actually modulated through a
very small set of neurons in the area of the brain
called a suprachiasmatic nucleus pictured on this
diagram. The suprachiasmatic nucleus contains
genes that turn off and on in a very cyclical pattern,
which modulates when a certain behavior or a
physiologic parameter is activated or decreased.
And we went over some of those physiologic and
behavioral mod --- models and one of the most
important ones, at least for the topic today, is sleep
and wakefulness. Light, as you can see, is a very
important time setter for the circadian pacemaker in
the suprachiasmatic nucleus. And the daily cycles of
the sun moving through night and day is really what
entrains the circadian rhythm in humans to about 24
hours a day.
Los ritmos circadianos se modulan a través de un
pequeño conjunto de neuronas en el núcleo
supraquiasmático del cerebro que contiene genes que
se encienden y se apagan en un patrón cíclico, y que
modula cuándo se activa o disminuye un parámetro
conductual o fisiológico determinado. Entre todos
esos modelos fisiológicos y de comportamiento, uno
de los más importantes es el de sueño y vigilia. La luz
es un regulador de tiempo muy importante para el
marcapasos circadiano del núcleo supraquiasmático y
los ciclos diarios del sol —el día y la noche— son lo
que realmente marca el ritmo circadiano de los seres
humanos de 24 horas por día.
Well what about other physiologic parameters?
Well, we talked about some of them. Here is a
diagram that actually shows the fluctuations in core
body temperature, heart rate, plasma cortisol, and
even mood in patients based on their circadian
rhythms. We often use plasma melatonin, which is
secreted by a part of the brain called a pineal
gland, which is activated by inputs from the
suprachiasmatic nucleus. Melatonins are a very
useful marker for the circadian rhythms in humans.
And we use that to determine whether a patient
has a normal circadian rhythm or an abnormal
circadian rhythm. And you can see before you in
the green line there’s a demonstration of a normal
circadian rhythm throughout the course of the day.
¿Qué sucede con otros parámetros fisiológicos? Ya
hemos mencionado algunos. Este diagrama muestra
variaciones en temperatura corporal, ritmo cardíaco,
cortisol en plasma e incluso el estado de ánimo de los
pacientes, que dependen de sus ritmos circadianos. A
menudo medimos los niveles de melatonina en
plasma, que es secretada por la glándula pineal del
cerebro, la cual se activa con aportes del núcleo
supraquiasmático. La melatonina es un marcador muy
útil en los ritmos circadianos de los seres humanos y
permite determinar si un paciente tiene un ritmo
circadiano normal o anormal. El trazo verde marca un
ritmo circadiano normal en el transcurso del día.
8
There are few studies looking at plasma melatonin
levels and circadian rhythms in patients with cancerrelated fatigue. Before you is one that was done in
2007 by Ryan and colleagues. On the --- in the
diagram labeled A, you can see different fatigue
measures plotted against possible circadian
measures. The blue lines represent patients who
had less robust circadian rhythms and the green bars
those who had normal – or normal circadian rhythms.
And you can see their fatigue scores measure --measured here were higher in the patients who had
less robust circadian rhythms compared to those who
had more robust circadian rhythms.
When
interventions were used in figure B to promote sleep
hygiene and better circadian rhythm, in general, you
can see the fatigue scores decreased in patients who
achieved a more regular circadian rhythms, noted in
the green bars, and actually worsened, the fatigue
scores worsened in patients who had less robust
circadian rhythms noted in the blue bars.
Actigraphy is also a way to measure circadian
rhythms. An actigraph is a small little device usually
worn on the nondominant wrist, which measures
movement. And the idea is that, when you are active,
you are moving, and when you are sleeping, you are
not. And you can use those counts to actually plot a
person’s circadian rhythm. What you have before
you is the actigraphic analysis of a patient
undergoing chemotherapy. In figure A, what you see
is the patient is fairly active until his bedtime
somewhere around 2 or 3 o’clock and then actually
having a few arousals, but actually a fairly
consolidated time or period in those blank spaces
where he is awake. And you could see diffuse
activity surrounding it, which represents the patient
being wakeful --- of being awake. What you see in
figure B, however, is that the patient has a much
longer period of time where he was trying to actually
sleep, but that sleep itself is much more interrupted.
There’s a lot more activity during the sleep periods
and there’s even one period, perhaps around, oh,
20:00 hours or so, where you can see the patient had
a small area of less activity. This may represent a
nap for instance. And what these diagrams show is
that, as the patient goes through cancer therapy their
Son pocos los estudios que analizan los niveles de
melatonina en plasma y los ritmos circadianos en los
pacientes con fatiga relacionada con el cáncer. Este
fue realizado en 2007 por Ryan y su equipo. En el
diagrama A vemos diferentes mediciones de fatiga
graficadas con mediciones circadianas. Las barras
azules representan pacientes con ritmos circadianos
menos intensos y las verdes, pacientes con ritmos
circadianos normales. Comparando los resultados, las
puntuaciones de fatiga son más altas en los pacientes
con ritmos circadianos menos intensos. En la figura B
intervenimos para promover la higiene del sueño y un
mejor ritmo circadiano, y las puntuaciones de fatiga
disminuyeron en los pacientes con ritmos circadianos
más normales —indicados en verde— y empeoraron
en aquellos con ritmos circadianos menos intensos —
señalados en azul—.
Los ritmos circadianos también pueden medirse
utilizando la actigrafía. El actígrafo es un pequeño
dispositivo que se lleva en la muñeca no dominante y
mide el movimiento. Cuando se está activo hay
movimiento, y no lo hay durante el reposo. Estas
mediciones permiten graficar el ritmo circadiano de
una persona. Este es el análisis actigráfico de un
paciente en tratamiento con quimioterapia. En la
figura A, el paciente se mantiene relativamente activo
hasta su hora de dormir, las 2 o 3 de la mañana, y
luego tiene algunos despertares; es decir, en ese
período hubo momentos en los que estuvo despierto.
Esto se indica en las zonas difusas circundantes. En
la figura B vemos que tiene un mayor período durante
el cual intenta dormir, pero que el sueño en sí es más
interrumpido. Hay mucha más actividad durante los
períodos de sueño y hay un breve período cerca de
las 20:00 horas con menos actividad, que puede
representar una siesta, por ejemplo. Estos diagramas
muestran que, a medida que el paciente atraviesa la
terapia oncológica, los períodos de sueño se
extienden, pero no duerme bien durante ellos. Es otra
indicación de que el paciente tiene insomnio:
permanece en la cama por más tiempo, pero no
duerme tan bien durante los períodos de sueño. Es
9
sleep period becomes longer, but they sleep less
well during that period. And that’s another way for
just saying that the patient has insomnia. They’re
staying in bed longer, but they’re not sleeping as well
during the time they are actually asleep. Plus they
may be recruiting other hours of the day to try to fall
asleep, and those are the nap periods that we may
see. And we see this pattern very commonly in
patients undergoing chemotherapy or even who
simply have a cancer diagnosis, as their sleep
pattern seem to worsen with their cancer diagnosis
and throughout their therapy.
What you see in this fairly complicated slide is a
study that actually tried to correlate cancer-related
fatigue symptoms as well as circadian strength and
circadian rhythms. In the first column, there are
three measures of circadian rhythm. Let me go
over what they mean. The first one here, Mesor,
represents the actual time --- the medium point in
the patient's circadian rhythm. If the Mesor is high,
that indicates a very robust circadian rhythm and
as the Mesor is low, that read --- indicates a less
robust circadian rhythm. Amplitude, as you can
imagine, is the difference between the peak and
trough of the circadian rhythm and a higher
amplitude also indicates a more robust circadian
rhythm. Peak activity is when the circadian rhythm
during the course of the day is at its height. And so
you might see some phase shifting based on the
patient's sleep patterns. In the next column,
indicated here as the Daily Fatigue Intensity, you
can see that all the numbers correlated with their
circadian parameters are negative. That indicates
an inverse correlation between fatigue and the
robustness of the circadian rhythm. So, in other
words, the more regular or the more strong the
circadian rhythm is, the less fatigue that the patient
is to experience. In the last column, you can see
how patients felt when they woke up from sleep,
how alert they felt. And you can see that there is a
positive correlation between the strength of the
circadian rhythm and your symptoms of feeling
more alert and active during the day. So what this
represents is a very nice trial that showed that the
strength of the circadian rhythm in a cancer patient
posible que esté utilizando horas adicionales del día
para dormir y esos son los períodos de siesta que
vemos. Este patrón es muy común en los pacientes
tratados con quimioterapia o con diagnóstico de
cáncer, y empeora luego del diagnóstico y durante su
tratamiento.
Esta diapositiva muestra un estudio que intentó
correlacionar los síntomas de la fatiga relacionada
con el cáncer y la intensidad de los ritmos
circadianos. En la primera columna hay tres
mediciones de ritmo circadiano. El primero, el
promedio MESOR, representa el punto medio en el
ritmo circadiano del paciente. Si el MESOR es alto,
indica un ritmo circadiano muy intenso, y si es bajo,
menos intenso. La amplitud es la diferencia entre el
máximo y el mínimo del ritmo circadiano. A mayor
amplitud, más intenso el ritmo circadiano. El pico de
actividad ocurre cuando el ritmo circadiano alcanza su
pico durante el día. Es posible ver desplazamientos
de fase según los patrones de sueño del paciente. En
la siguiente columna, intensidad de la fatiga diaria, se
observa que todos los números correlacionados con
los parámetros circadianos son negativos, lo que
indica una correlación inversa entre la fatiga y la
intensidad del ritmo circadiano. En otras palabras,
cuanto más regular o intenso es el ritmo circadiano,
tanta menos fatiga experimenta el paciente. La última
columna indica qué tan alertas se sintieron los
pacientes al despertar. Hay una correlación positiva
entre la intensidad del ritmo circadiano y el hecho de
sentirse más alerta y activo durante el día. Este
ensayo demostró que la intensidad del ritmo
circadiano en un paciente con cáncer se correlaciona
muy bien con sus síntomas de fatiga y estado alerta.
10
actually correlates very nicely with their symptoms
of fatigue and their symptoms of alertness
So, where does this relationship come from? How
does the circadian rhythm pick up on the fact that the
patient may have cancer or that there’s some other
fluctuations in the body, perhaps due to the
chemotherapy or radiation therapy. And how does
that affect cancer-related fatigue? Well we believe
that this may be related to an active inflammatory
response in patients with cancer, and also patients
with cancer who undergo certain therapies, and that
correlates with their cancer-related fatigue. So, let’s
go over the evidence for that.
What you see here is evidence for the correlation
between abnormal --- an abnormal inflammatory
response and cancer-related fatigue and insomnia.
In this study, they were able to correlate levels of
Interleukin-6 and TNF-α with symptoms of
insomnia as --- with symptoms of insomnia and
daytime fatigue. What you see here in the solid
blue line under IL-6 is the normal circadian rhythm
for IL-6. And here in this diagram the blue line is
the normal circadian rhythm of TNF- α. In patients
with cancer-related fatigue and insomnia, what you
see here, in the dotted green line, is an incomplete
inversion of the normal parameters for IL-6 and an
absolute increase in tet --- TNF- α throughout the
cycle in patients with cancer-related fatigue and
insomnia. This represents a complete modulation
of the inflammatory response, which correlates
very well with symptoms, as you can see here
pointed out.
¿De dónde surge esta relación? ¿Cómo afecta al
ritmo circadiano el hecho de que el paciente pueda
tener cáncer o que haya fluctuaciones en el cuerpo,
tal vez debido a la quimioterapia o la radioterapia? ¿Y
cómo afecta a la fatiga relacionada con el cáncer?
Creemos que puede tratarse de una respuesta
inflamatoria activa en los pacientes con cáncer y
también en aquellos que reciben determinados
tratamientos, y eso se correlaciona con la fatiga
relacionada con el cáncer. Analicemos la evidencia.
Aquí se observa evidencia de la correlación entre una
respuesta inflamatoria anormal y la fatiga y el
insomnio relacionados con el cáncer. En este estudio
se correlacionaron niveles de interleucina 6 y TNF-α
con los síntomas de insomnio y fatiga diurnos. La
curva azul indica el ritmo circadiano normal para la
interleucina 6. En este otro diagrama, la curva azul
marca el ritmo circadiano normal del TNF-α. La curva
verde de trazos indica una versión incompleta de los
parámetros normales de interleucina 6 y un aumento
del TNF-α durante el ciclo en los pacientes con fatiga
e insomnio relacionados con el cáncer. Esto
representa una modulación completa de la respuesta
inflamatoria, que se correlaciona muy bien con los
síntomas.
11
In this study done here at MD Anderson, researchers
were able to correlate IL-6 levels and cancer-related
symptoms in patients undergoing hematopoietic stem
cell transplant or bone marrow therapy. What you
can see here is, as the patient loses their counts with
therapy and they get to their white cell nadir, there’s
actually a peak of IL-6 and this correlates very well
with the peak of their cancer-related symptoms as
well. The symptoms that they scored using the
MDASI index were --- included pain, fatigue, sleep
disturbance, drowsiness, poor appetite, and dry
mouth. What you can see [is] that three out of the
top six symptoms, fatigue, sleep disturbance, and
drowsiness all go along with sleep and lack of sleep
and lack alertness. So, these seem to be the most
important symptoms that a lot of patients complain
about and they seem to be very well correlated with
this peak in IL-6.
Here’s a summary diagram of some of the cytokines
that are elevated in patients with cancer-related
fatigue as well as insomnia. Here we see IL-1, TNFα, IL-6 and normally during the night indicated by the
star, these level -- IL-1 levels, TNF-α levels and IL-6
levels are elevated. What you can see in patients
with cancer-related fatigue is an inversion of that
where their levels go down at night and peak during
the day and this inversion in these levels seems to
correlate very well with their symptoms.
En el estudio realizado en el MD Anderson, los
investigadores pudieron correlacionar los niveles de
interleucina 6, o IL-6, y los síntomas relacionados con
el cáncer en pacientes trasplantados con células
madre hematopoyéticas o terapia de médula ósea.
Vemos que a medida que los recuentos del paciente
se reducen con terapia y alcanzan su nivel mínimo de
glóbulos blancos, se observa un pico de IL-6 que
coincide con el pico de sus síntomas. Los síntomas
detectados con el índice MDASI son dolor, fatiga,
trastornos del sueño, somnolencia, falta de apetito y
sequedad bucal. Tres de los seis síntomas principales
—fatiga, trastornos del sueño y somnolencia— están
relacionados con la falta de sueño y de estado alerta.
Estos son los síntomas más mencionados por los
pacientes y parecen estar bien correlacionados con el
pico de IL-6.
Este es un diagrama que resume las citocinas
elevadas en los pacientes con fatiga e insomnio
relacionados con el cáncer. Estas mediciones
normales tomadas durante la noche —indicada por la
estrella— revelan niveles elevados de IL-1, TNF-α e
IL-6. En los pacientes con fatiga vemos una inversión
de niveles: bajan durante la noche y se elevan
durante el día, lo que parece correlacionarse con los
síntomas.
12
Many researchers have speculated that there is a
very complex relationship as well as a reciprocal
relationship between the circadian rhythm between
sleep and the immune system and the perturbations
in one system, say sleep, has impact on the other
ones and vice versa. When the immune system is
irregular, there is abnormal sleep and circadian
rhythms and when the circadian rhythm or sleep are
abnormal there is impact on the immune system with
inputs from the autonomic nervous system as well as
the neuroendocrine system. And what these have is
an impact on the --- on the ability on the immune
system to protect us from infections as well as
malignancy. And that’s why we think here at MD
Anderson investigating patients sleep and their
fatigue is so important to understanding how this
complex relationship works.
Let’s go on to another case of a patient to
understand how another sleep disorder affects
cancer-related fatigue. Patient #2 is a 59-year-old
woman with a history of breast cancer diagnosed in
2002, treated with surgery and chemoradiation who
is now cancer-free. Her past medical history is
significant for hypertension, hypothyroidism, a mood
disorder, hyperlipidemia, and severe fatigue that
originated with her breast cancer therapy. She’s also
had a weight gain of about 20 pounds in the last five
years, but she has symptoms of loud snoring,
gasping and choking arousals throughout the night.
However, because she sleeps alone, there are no
witnessed apneas. This patient sleeps quite a lot.
She sleeps nine hours at night although she does not
nap during the day. She has excessive daytime
sleepiness or hypersomnolence or here abbreviated
as EDS and her Epworth Sleepiness Scale Score is
elevated at 12.
Muchos investigadores han especulado que existe
una relación muy compleja y recíproca entre el ritmo
circadiano, el sueño y el sistema inmunológico. Las
perturbaciones en el sistema de sueño, por ejemplo,
afectan a los otros sistemas y viceversa. Cuando el
sistema inmunológico tiene alguna irregularidad, el
sueño y los ritmos circadianos son anormales, y
cuando esto sucede, el sistema inmunológico recibe
aportaciones del sistema nervioso autónomo y del
sistema neuroendocrino, lo cual afecta la capacidad
del sistema inmunológico para proteger de
infecciones y enfermedades. Por eso, en el MD
Anderson creemos que investigar el sueño y la fatiga
de los pacientes es importante para comprender el
funcionamiento de esta relación tan compleja.
Analicemos otro caso para comprender cómo otro
trastorno del sueño afecta la fatiga relacionada con el
cáncer. La paciente número 2 es una mujer de 59
años con cáncer de mama diagnosticado en 2002 y
tratado con cirugía y quimiorradiación. Actualmente
está libre de cáncer. Su historia clínica muestra
hipertensión,
hipotiroidismo,
trastornos
del
comportamiento, hiperlipidemia y fatiga grave que se
originó con el tratamiento oncológico. Subió alrededor
de 20 libras en los últimos cinco años y presenta
ronquidos, jadeos y despertares por asfixia durante la
noche. Debido a que duerme sola, no tiene apneas
confirmadas. Esta paciente duerme nueve horas
durante la noche y no toma siestas durante el día.
Padece somnolencia diurna excesiva —EDS o
hipersomnolencia— y obtuvo 12 puntos en la escala
de Epworth.
13
Her medications are numerous and include several
psychotropic medications including Lexapro,
Wellbutrin, Ambien, and lithium, all of which may
contribute to her daytime sleepiness. She is actually
obese with a BMI of 37. She does have some mild
hypertension. She has a thick neck, but otherwise a
fairly unremarkable exam --- exam except for some
truncal obesity.
Toma varios medicamentos y psicotrópicos, incluidos
®
®
®
Lexapro , Wellbutrin , Ambien y litio, que pueden
contribuir a su somnolencia diurna. Es obesa y tiene
un IMC de 37. Sufre hipertensión leve. Tiene el cuello
engrosado y su examen es relativamente normal,
excepto por su obesidad troncal.
We put this patient also through our Sleep Center
here at the MD Anderson Sleep Center. And what
you can see at the beginning of her study is that
there are numerous breathing events, numerous
apneas, periods where she actually stops breathing
at night. And during that time, her sleep is
remarkable for an absence of REM sleep and pretty
much staying in a very light form of sleep with a num
--- numerous amount of arousals. This patient was
actually treated for sleep apnea or sleep-disorder
breathing with a treatment called CPAP, which we
will discuss.
And when she was started on
continuous positive airway pressure or CPAP, what
you can see is an improvement in the number of
apneas that she had during the course of the night
and a restoration of REM sleep is seen here in this
black line, indicating that she is going to have deeper
sleep or more restorative sleep during the second
half of the night, with the treatment for the episode of
sleep apnea.
La llevamos al Centro del Sueño del MD Anderson. Al
comienzo del estudio se observaron numerosos
eventos respiratorios, apneas y períodos nocturnos
donde deja de respirar. Durante ese tiempo, hubo una
notable ausencia de sueño REM y su reposo fue más
ligero debido a la gran cantidad de despertares.
Recibió tratamiento de ventilación de presión positiva
continua, o CPAP, para la apnea o trastorno
respiratorio del sueño, y hubo una mejora en la
cantidad de apneas durante la noche y una
restauración del sueño REM —señalado por el trazo
negro—. Esto indica que, con el tratamiento de la
apnea, la paciente logró un sueño más profundo y
reparador durante la segunda mitad de la noche.
14
Here is some of the data from her sleep study. You
can see that before starting treatment for sleep
apnea, her sleep efficiency, the time she was actually
sleeping while she was in bed, was about 75%. After
treatment, that went up to 92%. She had no REM or
rapid eye movement sleep during the first half of the
night. After treatment, she actually had 35% REM
sleep, which we called REM rebound because that is
an excess of what you would normally see because
this REM sleep was suppressed in the early part of
the night. This patient had very severe sleepdisordered breathing. She actually had 80 apnea
events per hour of sleep, which is quite remarkable.
Her oxygen saturation went down to 87%. After
treating her with continuous positive airway pressure,
we were able to bring her apnea-hypopnea index of
80 down to 10 and her oxygen saturation stayed
above 90%. So this indicates a successful treatment
of her obstructive sleep apnea.
Three months later, when the patient was seen in the
Sleep Clinic, she said she was very pleased with the
results and said she sleeps through the night instead
of being interrupted so often. And she notes an
improvement in her mood. She is baking more and
actually is off her antidepressant medications at this
time. Nine months later, when she was seen by her
breast cancer physicians, they noted in their report
that she feels so much better since she started
CPAP, that she feels full of energy and feels very
positive when she wakes up in the morning, so again
a successful treatment.
Estos son algunos datos de su estudio. Antes de
comenzar el tratamiento de la apnea, el tiempo de
sueño en la cama era del 75%. Después del
tratamiento subió al 92%. No tuvo sueño REM o
movimiento ocular rápido durante la primera mitad de
la noche. Después del tratamiento tuvo un 35% de
sueño REM, o rebote de REM porque es un exceso
con respecto a lo normal, y es sueño REM suprimido
en la primera parte de la noche. Tenía trastornos
respiratorios del sueño muy graves. Presentaba 80
episodios de apnea por hora de sueño. Su saturación
de oxígeno se redujo al 87%. Después de tratarla con
CPAP pudimos reducir su índice de apnea o hipopnea
de 80 a 10, y su saturación de oxígeno se mantuvo
por encima del 90%. Esto indica un tratamiento
exitoso para la apnea del sueño obstructiva.
Tres meses más tarde, cuando fue atendida en la
Clínica del Sueño, dijo estar muy satisfecha con los
resultados y que ahora dormía toda la noche, en lugar
de despertarse con frecuencia. Observó una mejora
en su estado de ánimo. Ahora cocina con más
frecuencia y ha dejado de tomar antidepresivos.
Nueve meses más tarde, sus médicos de cáncer de
mama reportaron que con la CPAP la paciente se
siente mucho mejor y llena de energía, y tiene una
actitud positiva cuando se despierta por la mañana.
Este ha sido otro tratamiento exitoso.
15
Well this study indicates the relationship between a
sleep disorder, obstructive sleep apnea and cancerrelated fatigue and how that identifying and treating
this in certain patients can be very important.
Este estudio indica la relación entre un trastorno del
sueño —la apnea del sueño obstructiva— y la fatiga
relacionada con el cáncer, y por qué identificar y tratar
estas condiciones es tan importante en algunos
pacientes.
Sleep-disordered breathing has been linked in
cancer. There are studies that show that patients
who had opioid therapy, which is a number of our
cancer patients, actually are more likely to have
sleep-disordered breathing. Up to 79% to 91% of
patients with head and neck tumors actually have
sleep apnea. And there are many cases where
actually sleep apnea is the presenting case --symptom of the patient’s tumor.
Los trastornos respiratorios del sueño han sido
relacionados con el cáncer. Existen estudios que
demuestran que los pacientes que recibieron terapia
con opioides —como una gran cantidad de nuestros
pacientes con cáncer— son más propensos a los
trastornos respiratorios del sueño. Del 79% al 91% de
los pacientes con cáncer de vías respiratorias y
digestivas altas tienen apnea del sueño. En muchos
casos, esta apnea es el síntoma de presentación del
tumor.
16
Sleep apnea occurs because of an abnormality of the
upper airway. Here you see a normal airway. When
a patient takes a breath, you would expect air to
enter the trachea and then go into the lungs. In
patients with sleep apnea, especially when they lie
on their back, gravity causes the uvula and the soft
palate, perhaps the tongue and epiglottis, to move
backwards into the oropharynx and actually cause an
obstruction.
La apnea del sueño se produce debido a una
anomalía en las vías respiratorias altas. Estas son
unas vías respiratorias normales. Cuando un paciente
respira, el aire ingresa en la tráquea y luego se dirige
a los pulmones. En los pacientes con apnea del
sueño, especialmente cuando están acostados boca
arriba, la gravedad hace que la úvula y el paladar
blando, y tal vez la lengua y la epiglotis, se desplacen
hacia atrás dentro de la orofaringe y provoquen una
obstrucción.
Some of the symptoms of obstructive sleep apnea
during the nighttime include snoring, gasping or
choking arousals, wak --- witnessed apneas,
nighttime sweating, dry mouth, nocturia, and
gastroesophageal reflux. During the daytime, the
patients may present with excessive daytime
sleepiness, morning headaches, attention deficits,
poor judgment or mood disturbances such as
irritability.
Algunos de los síntomas de la apnea del sueño
obstructiva son ronquidos, jadeos o despertares por
asfixia, apneas confirmadas, sudoración nocturna,
sequedad bucal, nocturia y reflujo gastroesofágico.
Durante el día, los pacientes pueden presentar
somnolencia diurna excesiva, dolores de cabeza
matutinos, déficit de atención, falta de juicio o
alteraciones del estado de ánimo, como irritabilidad.
17
We talked a little about the therapy for obstructive
sleep apnea and the therapy really is positive airway
pressure. That’s usually delivered through a small
mask either over the nose or perhaps over the nose
and mouth that’s connected to a small device that
actually moves air into the patient’s airway. And
causes --- and that air pressure causes the airway to
remain open treating the obstructive sleep apnea and
preventing the blockages in the airway that we just
discussed.
Mencionamos que la apnea del sueño obstructiva se
resuelve con ventilación de presión positiva que se
administra a través de una mascarilla pequeña que se
coloca sobre la nariz, o sobre la nariz y la boca,
conectada a un dispositivo que introduce aire en las
vías respiratorias. La presión hace que las vías
respiratorias permanezcan abiertas. De este modo se
trata la apnea y se evitan las obstrucciones en las
vías respiratorias.
Interestingly enough, sleep apneas [have] now been
associated with a number of disorders. The patients
with sleep apnea are more likely to have
hypertension, to have arrhythmias especially atrial
fibrillation. As we have shown, they’re more likely
to be sleepy during the day. They’re more likely to
have mood disturbances such as depression.
They’re more likely to do poorly on neurocognitive
tests and actually this can contribute to dementia.
They’re more likely to be diabetic. They’re more
likely to have heart disease and they’re more likely to
have a stroke. So, it’s important for our patients with
cancer to find if they have sleep apnea because
treating the cancer obviously is not enough, we have
to treat the whole patient and make sure they don’t
develop some of these other illnesses.
Curiosamente, las apneas del sueño han sido
asociadas con una serie de trastornos. Los pacientes
con apnea son más propensos a hipertensión,
arritmias y fibrilación auricular. Hemos mencionado
que suelen sentir somnolencia durante el día y
trastornos del estado de ánimo, como depresión. Son
más susceptibles a un mal rendimiento en las
pruebas neurocognitivas, lo que puede contribuir a la
demencia. Tienen mayor probabilidad de sufrir
diabetes, enfermedades cardíacas y accidentes
cerebrovasculares. Es importante determinar si un
paciente tiene apnea del sueño. El tratamiento
oncológico no basta, pues debemos realizar un
tratamiento integral y asegurarnos de que no
desarrolle otras enfermedades.
18
Sleep apnea has been shown to improve daytime
sleepiness and here you can see in this com --- the
meta-analysis, when combined, there is an
improvement in the Epworth Sleepiness Scale Score,
which measures daytime sleepiness in patients
treated for their sleep apnea with continuous positive
airway pressure.
Se ha demostrado que el tratamiento de la apnea del
sueño mejora la somnolencia diurna. En el
metanálisis observamos una mejora en la puntuación
de Epworth, que mide la somnolencia diurna en los
pacientes con apnea tratados con ventilación de
presión positiva continua.
Well the simp --- the story isn’t as simple as just a
mechanical fix for sleep apnea. What with --- the
researchers have actually shown is that sleep apnea
is actually inflammatory as well. And it actually
impacts the same kyto --- cytokines that we
mentioned earlier that impact – that correlate with
daytime sleepiness and fatigue. And what you can
see here, here being normal patients without sleep
apnea in the bottom lines, that both IL-6 and TNF-α
increase in patients with sleep apnea whether they’re
obese or not obese. And these elevations contribute
to their dee --- daytime sleepiness just as we showed
earlier it does in cancer. So treating sleep apnea
may be one way to bring down these IL-6 and TNF- α
levels.
El tratamiento de la apnea del sueño no es una
simple solución mecánica. Los investigadores han
demostrado que la apnea es en realidad inflamatoria
y afecta las mismas citocinas que se correlacionan
con la somnolencia y la fatiga diurnas. Los trazos
inferiores corresponden a pacientes normales sin
apnea del sueño. En los pacientes con apnea, los
niveles de IL-6 y TNF-α aumentan, sean obesos o no,
lo que contribuye a la somnolencia diurna, de modo
que tratar la apnea del sueño puede ser una manera
de reducir los niveles de IL-6 y TNF-α.
19
So, I would like to conclude with what we are doing
here at MD Anderson to try to better understand this
very complicated system that I have shown you of
how sleep and cancer-related fatigue and circadian
rhythms all work together and how we can try to
piece out these --- the aspects of these and try to find
out ways to improve patients’ symptoms.
Concluiré mencionando qué estamos haciendo en el
MD Anderson para comprender mejor este
complicado sistema de cómo el sueño, la fatiga
relacionada con el cáncer y los ritmos circadianos
funcionan juntos, y cómo resolver estos aspectos
para mejorar los síntomas de los pacientes.
While as I mentioned to you, that sleep disorders --sleep disorders, including sleep apnea, have been
associated with a variety of diseases, including heart
disease, diabetes, obesity, and neurological
diseases. And what has been shown in most of
these diseases, that by treating the sleep disorder
you can improve symptoms, neurocognitive function,
quality of life, the disease itself, and even impact
mortality in certain instances. Well what is not known
is whether treating and identifying a sleep disorder
will actually help in treating cancer and provide the
same sorts of benefits. Those are the questions that
we’d like to answer here at MD Anderson. We’ve
chosen three areas in particular to begin our quest.
And we wanted to focus on patients with head and
neck tumors because, as I showed you, a very high
percentage of these patients have obstructive sleep
apnea. We focused on breast cancer because many
of our patients with breast cancers, up to 80% to
90%, complain of poor quality of sleep, and finally
focus on the symptoms of cancer-related fatigue
because it is probably that, along with pain, are the
number 1 and 2 causes of --- of quality of life loss in
patients with cancer.
Mencionamos que los trastornos del sueño, incluida la
apnea del sueño, están asociados con una variedad
de males, como las enfermedades cardíacas, la
diabetes, la obesidad y las enfermedades
neurológicas. Se ha demostrado que, en la mayoría
de ellas, tratar el trastorno del sueño puede mejorar
los síntomas, la función neurocognitiva, la calidad de
vida y la enfermedad en sí, y, en ciertos casos, puede
incluso afectar la mortalidad. Aún se desconoce si
tratar e identificar un trastorno del sueño realmente
ayuda a tratar el cáncer y aporta los mismos
beneficios. Esas son las preguntas que queremos
responder aquí en el MD Anderson. Para comenzar,
hemos escogido tres áreas: analizamos pacientes con
cáncer de vías respiratorias y digestivas altas porque
un alto porcentaje tiene apnea del sueño obstructiva;
nos concentramos en el cáncer de mama, porque del
80% al 90% de nuestras pacientes con esta
enfermedad padecen una mala calidad de sueño; y
abordamos los síntomas de la fatiga relacionada con
el cáncer porque, junto con el dolor, son las
principales causas de la pérdida de calidad de vida en
los pacientes con cáncer.
20
So, let’s go over the first. Let us look at the
relationship between sleep apnea and head and
neck cancer.
En primer lugar, veamos la relación entre la apnea del
sueño y el cáncer de vías respiratorias y digestivas
altas.
We began our study by looking at our first 16 patients
with head and neck cancer; 13 of them have
completed therapy, three are on active therapy and
you can see their medium BMI is not particularly high
at 27. We put these patients through our sleep lab
and we actually found that the median AHI in these
patients was fairly high at 26, with 10 being the
normal for a sleep study.
Comenzamos analizando a nuestros primeros 16
pacientes con cáncer de vías respiratorias y
digestivas altas; 13 de ellos completaron el
tratamiento y 3 se encuentran en terapia activa. Se
observa que el promedio de IMC de 27 no es
particularmente alto. Los llevamos al laboratorio del
sueño y descubrimos que su índice de apnea o
hipopnea promedio era de 26; bastante alto si
consideramos que 10 es lo normal para estudios del
sueño.
21
This is actually an enumeration of our patients and,
as you can, see almost all of them had obstructive
sleep apnea with an AHI greater than 10, except for
actually one of these patients. What was interesting
is that this syndrome is definitely related to their
anatomy, as when these patients lie down flat, the
number of apnea/hypopneas they have increases
significantly as you can see here.
Esto es una enumeración de nuestros pacientes y,
con la excepción de un paciente, todos tenían apnea
del sueño obstructiva con un índice superior a 10. Lo
interesante es que, sin duda, este síndrome está
relacionado con su anatomía, ya que cuando se
recuestan el número de apneas o hipopneas aumenta
significativamente.
In patients with --- let’s move on to the relationship
between sleep apnea and breast cancer and what
we are doing to investigate that very interesting
relationship.
Ahora analizaremos la relación entre la apnea del
sueño y el cáncer de mama.
22
We looked at 68 patients with breast cancer, 24 who
have completed therapy, 10 who are receiving
chemotherapy actively, and 34 of them are still on
hormonal therapy. Fifty-one of these patients were
referred to us because of daytime sleepiness and the
mean Epworth Sleepiness Scale Score was elevated
at 12. We did polysomno --- polysomnography on
these patients and we actually found that their AHI
wasn’t particularly elevated. Their mean AHI was
approximately 10, which is not much different than
the general population without sleep-disordered
breathing. Very few of them had a sleep-disordered
breathing problem. So although we did find sleepdisordered breathing in some of these patients,
many, if not most of these patients, did not have a
primary sleep disorder. Yet they did complain of
extreme daytime sleepiness just like the very first
patient that I showed you.
So, that brings up the point as to why these patients
who do not have a primary sleep disorder but do
have --- still have significant cancer-related fatigue as
well as daytime sleepiness or hypersomnia.
Evaluamos a 68 pacientes con cáncer de mama: 24
completaron su tratamiento, 10 están recibiendo
quimioterapia activa y 34 aún están bajo terapia
hormonal. Cincuenta y una de ellas fueron referidas
debido a su somnolencia diurna y a una puntuación
promedio de 12 en la escala de Epworth. Realizamos
polisomnografías y descubrimos que su índice no era
particularmente elevado. Tenían un promedio de 10,
que no es muy diferente al de la población general sin
trastornos respiratorios del sueño. Muy pocas
presentaban trastornos respiratorios. Aunque
detectamos algunos casos, la mayoría no tenía un
trastorno primario; sin embargo, al igual que la
primera paciente, se quejaban de somnolencia diurna
extrema.
Esto nos hace preguntarnos por qué estas pacientes
sin trastorno primario del sueño tienen fatiga
relacionada con el cáncer y somnolencia diurna o
hipersomnia.
23
We’re proposing to do a study to investigate just that
problem, and we’re going to focus on breast cancer
survivors. We’re going to put them through an
assessment of their sleep and fatigue. And those
who feel --- we feel need to be seen for a
polysomnogram will go on to be seen by one of our
sleep physicians and then have a polysomnogram. If
they do have a primary sleep disorder, as I showed
you in the second case, such as sleep-disordered
breathing, we will treat that. And then we will
remeasure their fatigue and see if we can see
objective improvements. If they do not have a sleepdisordered breathing diagnosis or another primary
sleep disorder, we will put them through that MSLT
test that I told you about, the Multiple Sleep Latency
Test and we’ll actually try to objectively measure
whether they had daytime sleepiness and then treat
the daytime sleepiness and then again remeasure
sleep and fatigue. What this study will allow us to do,
is first of all, get a prevalence of how common this
problem is in our patients; how much they have
fatigue; try to understand how much sleep disorders
contribute to cancer-related fatigue; and see if we
can treat these problems and make a difference in
these patients lives.
So to end up, our goal here at MD Anderson, in
trying to understand this relationship with cancerrelated fatigue and symptoms, is to really fill-in this
column here, to try to understand what kind of sleep
disorders patients with cancer have, and whether
what --- what treatments and how we can best
identify these patient to impact these symptoms and
to build the same case for cancer that already exists
for many other disorders. Thank you very much for
your attention today and I hope you will take the time
to come back to us to see how we may help you in
the future.
Hemos propuesto realizar un estudio para investigar
ese problema, concentrándonos en las sobrevivientes
de cáncer de mama. Realizaremos una evaluación
del sueño y la fatiga, y si consideramos necesaria una
polisomnografía, serán evaluadas por nuestros
médicos del sueño y luego realizarán el
procedimiento. Si tienen un trastorno primario, como
trastornos respiratorios del sueño, las trataremos y
luego volveremos a medir su fatiga para determinar si
ocurrieron mejoras objetivas. Si no tienen un
diagnóstico de trastornos respiratorios del sueño u
otro trastorno primario, deberán realizar una prueba
de latencia múltiple del sueño para determinar
objetivamente si tienen somnolencia diurna. Luego las
trataremos y volveremos a medir el sueño y la fatiga.
Este estudio nos permitirá, en primer lugar, calcular la
prevalencia de este problema en nuestras pacientes y
cuánta fatiga tienen, comprender en qué medida los
trastornos del sueño contribuyen a la fatiga
relacionada con el cáncer, y ver si podemos tratar
estos problemas para marcar una diferencia en su
vida.
Por último, el objetivo del MD Anderson al estudiar la
relación entre la fatiga relacionada con el cáncer y
sus síntomas es completar este recuadro y
comprender qué trastornos presentan los pacientes
con cáncer, y si el tratamiento de esos síntomas
puede aplicarse a otros cánceres y trastornos.
Muchas gracias por su atención. Si considera que
podemos brindarle asistencia, no dude en
consultarnos.
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