The relationship between pro-inflammatory cytokines and pain, appetite and fatigue in patients with

16 Pages·2017·0.86 MB·English

RESEARCHARTICLE
The relationship between pro-inflammatory
cytokines and pain, appetite and fatigue in
patients with advanced cancer
ØrnulfPaulsen1,2*,BarryLaird1,3,NinaAass4,5,TorLea6,PeterFayers1,7,
SteinKaasa1,4,5‡,PålKlepstad1,8,9‡
1 DepartmentofCancerResearchandMolecularMedicine,EuropeanPalliativeCareResearchCentre,
NorwegianUniversityofScienceandTechnology(NTNU),Trondheim,Norway,2 PalliativeCareUnit,
a1111111111 TelemarkHospitalTrust,Skien,Norway,3 EdinburghCancerResearchCentre,UniversityofEdinburgh,
a1111111111 Edinburgh,UnitedKingdom,4 FacultyofMedicine,UniversityofOslo,Oslo,Norway,5 Departmentof
a1111111111 Oncology,OsloUniversityHospital,Oslo,Norway,6 DepartmentofChemistry,BiotechnologyandFood
Science,NorwegianUniversityofLifeSciences,Ås,Norway,7 DepartmentofPublicHealth,Universityof
a1111111111
Aberdeen,Aberdeen,UnitedKingdom,8 DepartmentofCirculationandMedicalImaging,Norwegian
a1111111111
UniversityofScienceandTechnology(NTNU),Trondheim,Norway,9 DepartmentofAnesthesiologyand
IntensiveCareMedicine,StOlavsHospital,TrondheimUniversityHospital,Trondheim,Norway
‡Theseauthorsarejointseniorauthorsonthiswork.
*[email protected]
OPENACCESS
Citation:PaulsenØ,LairdB,AassN,LeaT,Fayers
Abstract
P,KaasaS,etal.(2017)Therelationshipbetween
pro-inflammatorycytokinesandpain,appetiteand
fatigueinpatientswithadvancedcancer.PLoS
ONE12(5):e0177620.https://doi.org/10.1371/ Background
journal.pone.0177620
Systemicinflammationisassociatedwithreducedqualityoflifeandincreasedsymptomsin
Editor:CelenaScheede-Bergdahl,McGill patientswithadvancedcancer.Theaimsofthisstudyweretoexaminetherelationships
University,CANADA
betweeninflammatorybiomarkersandthePatientReportedOutcomeMeasures(PROMs)
Received:October16,2016 ofpain,appetiteandfatigue;andtoexplorewhetherlevelsofbaselinebiomarkerswere
Accepted:May1,2017 associatedwithchangesinthesePROMsfollowingtreatmentwithcorticosteroids.
Published:May25,2017
Materialandmethods
Copyright:©2017Paulsenetal.Thisisanopen
accessarticledistributedunderthetermsofthe Anexploratoryanalysiswasdoneonatrialexaminingtheanalgesicpropertiesofcorticoste-
CreativeCommonsAttributionLicense,which roidsinpatientswithadvancedcancer.Inclusioncriteriawere:>18years,takingopioidsfor
permitsunrestricteduse,distribution,and
moderateorseverecancerpain;pain(cid:21)4(numericalratingscale0–10).Serumwas
reproductioninanymedium,providedtheoriginal
extractedandlevelsofinflammatorybiomarkerswereassessed.PROMsofpain,appetite
authorandsourcearecredited.
andfatiguewereassessedusingtheEuropeanOrganisationforResearchandTreatment
DataAvailabilityStatement:Thedatabaseis
ofCancerQualityofLifeQuestionnaire-C30(EORTCQLQ-C30).Therelationshipsbetween
publishedatfigshare(DOI:10.6084/m9.figshare.
4981502)."PatientswithAdvancedCancer".The PROMsandinflammatorybiomarkerswereexaminedusingSpearmanRho-Rankandmul-
databasecontainsindividualleveldataandis tipleregressionanalysis.
availablefordownload(Excel).
Funding:Thisworkwasfundedbyunrestricted Results
grantsfromtheTelemarkHospitalTrustandthe
Datawereavailableon49patients.LevelsofsTNF-r1,IL-6,IL-18,MIF,MCP-1,TGF-β1,IL-
South-EasternNorwayRegionalHealthAuthority,
andisapartofØrnulfPaulsen’sPhDproject. 1ra,andC-reactiveprotein(CRP)andErythrocytesedimentationrate(ESR)wereelevated;
IL-1β,IL-2,IL-4,IL-8,IL-10,IL-12(p70),interferon-γ,MIP-1α,andTNF-αwerebelowthe
Competinginterests:SteinKaasahasservedasa
consultantonanAdvisoryboardfor,andhis levelofdetection.Thefollowingcorrelationswereobserved:appetiteandIL-6andCRP;
PLOSONE|https://doi.org/10.1371/journal.pone.0177620 May25,2017 1/16
Cytokinesandsymptomsinpatientswithadvancedcancer
institutionhasreceivedunrestrictedgrantsfrom, fatigueandIL-1ra(r :0.38–0.41,p<.01).Therewasnoassociationbetweenpretreatment
s
Helsinn.BarryLairdhasservedasaconsultanton biomarkersandeffectfromcorticosteroidtreatment.
advisoryboardsforChugaiandPfizer.Theother
authorshavenopotentialconflictsofinterestto
Conclusion
disclose.Thisdoesnotalterouradherenceto
PLOSONEpoliciesonsharingdataandmaterials.
Inpatientswithadvancedcancerandpain,somepro-inflammatorycytokineswererelated
toappetiteandfatigue.Inflammatorybiomarkerswerenotassociatedwithpainorwiththe
efficacyofcorticosteroidtherapy.Furtherresearchexaminingtheattenuationofthesys-
temicinflammatoryresponseandpossibleeffectsonsymptomswouldbeofinterest.
Introduction
Systemicinflammationhasbeendescribedastheseventh“hallmarkofcancer”[1];necessary
fortumorigenesisandmaintenanceandprogressionofthecancerstate.Symptomssuchas
pain,cachexia,fatigue,cognitiveimpairment,anxietyanddepressionarecommoninpatients
eitherinisolationorincombination,termedsymptomclusters.Thebiologicalbasisforthese
symptomclustershasbeenpostulatedasbeingdrivenbythetumour-hostinteractionviathe
systemicinflammatoryresponse[2]akintocytokine-inducedsicknessbehavior(asetofphysi-
ologicalandbehavioralresponsesobservedinsickindividualsaftertheadministrationof
infectiousorinflammatoryagentsorcertainpro-inflammatorycytokines)[3].
Cytokinesarekeymediatorsandprovidehomeostasisandimmunecontrolaspartofthe
innateimmunesystemthroughanintricateinterplaywithmutuallydependentpositiveand
negativefeedbackmechanisms[4].Inhealthyindividuals,equilibriumexistsbetweenpro-and
anti-inflammatorycytokines.Inadvancedcancer,however,complextumour-hostinteractions
disturbthisequilibrium.Datafrompatientswithadvancedcancershowacytokinepattern
indicatingastateofsimultaneousimmunostimulationandimmunosuppression.Pro-inflam-
matorycytokinespredominate,finallyresultinginincreasedconcentrationsofMacrophage
MigrationInhibitoryFactor(MIF),TumourNecrosisFactorα(TNF-α),interleukin(IL)-6,
IL-8,IL-10,IL-18,andTransformingGrowthFactorβ(TGF-β)inpatientswithadvancedcan-
cer[4].
Furthermore,studydatahaveshownassociationsbetweenserumconcentrationsofinflam-
matorybiomarkersandsymptomsincancerpatients.Toillustrate,elevatedlevelofC-reactive
protein(CRP)wasassociatedwithpain,anorexia,dyspnoea,andfatigueinpatientswithcan-
cer[5,6].Inanotherstudy,increasedserumconcentrationsofsolublereceptor1fortumor
necrosisfactor(sTNF-r1)andIL-6wererelatedtoanincreaseinthemeanscoreforall15
recordedsymptoms,andinthefivemostseveresymptoms,respectively,inpatientswithlung
cancerundergoingconcurrentchemoradiotherapy[7].Schubertandcoworkersfoundcancer
relatedfatiguetobeassociatedwithelevatedlevelsofbiomarkersIL-6,IL-1receptorantagonist
(IL-1ra)andneopterin[8].TwootherstudiesfoundthatincreasedlevelsofIL-6wereassoci-
atedwithmajordepressioninpatientswithlungcancer[9]andpancreaticcancer[10];thelat-
terstudyalsofoundanassociationbetweenthecytokinesIL-1β,IL-4,andIL-12(p70)andpain
intensity,andbetweenTGF-βandfatigue.Similarly,trialshaveindicatedassociationsbetween
inflammatorygenevariantsandseveralsymptoms.Forinstance,inastudyoflungcancer
patients,genevariantsforIL-8andIL-10wereassociatedwithpain,depressedmoodand
fatigue[11].
Sofar,theassociationsbetweensymptomsandspecificbiomarkershavenotbeenconsis-
tent,whichmayinpartbeduetouseofcross-sectionalstudydesigns,inconsistencyin
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Cytokinesandsymptomsinpatientswithadvancedcancer
measurements[12]andheterogeneouscancerpatientpopulations.Despitetheseinconsisten-
cies,therelationshipbetweensymptomsandpro-inflammatorycytokinesremainsofinterest
particularlyinthelightofrecentworkdemonstratingtheclearrelationshipbetweenPatient
ReportedOutcomeMeasures(PROMs)ofqualityoflifeandthesystemicinflammatory
response[13].Moreover,therelationshipbetweenindividualpro-inflammatorycytokinesand
PROMsofpain,appetiteandfatigueisofinterest,especiallyinthesettingofanti-inflamma-
torytreatmentwithcorticosteroids,whichmayhaveimplicationsforthemanagementofthese
symptoms.
Inclinicalpractice,anti-inflammatorydrugsareoftenusedforsymptomcontrol[14].In
particularcorticosteroidshavebeenshowntoimproveappetiteandfatigueinpatientswith
advancedcancer[15–17],anddatafromclinicaltrialssupporttheuseofcorticosteroidsfor
1–2weeksfortheseindications[15,18].Withregardtothetreatmentofpain,arandomized
controlledtrialfoundnoanalgesiceffectofcorticosteroidsincancerpatientstakingopioids
[17],whereastwostudieshaveshowedananalgesiceffect[19],ortemporarilyincreasedpain
control[16].Ameta-analysisinarecentlypublishedCochranereviewconcludedthatcortico-
steroidscouldprovideameanreductionofpainintensityof0.84onanumericratingscale
(NRS0–10)(confidenceinterval,(CI)-1.38to-0.3)afteroneweekoftreatment[20].The
mechanismsofactionarenotwelldefined,butarethoughttobemediatedbytheiranti-
inflammatoryeffects.
Thecurrentstudywasasecondaryexploratoryanalysisofabiobankestablishedaspartofa
randomized,controlledtrialassessingtheanalgesiceffectsofmethylprednisolone32mgdaily
inpatientswithcancerpainonopioids[17].
Therefore,theprimaryaimofthisstudywastoexaminetherelationshipbetweeninflam-
matorybiomarkers(cytokinesandmarkersoftheinflammatoryresponse)andPROMsof
pain,appetiteandfatigueinpatientswithadvancedcancerreceivingopioids.Asecondaryaim
wastoexplorewhetherlevelsofbaselineinflammatorybiomarkerswereassociatedwith
changesinpain,appetiteandfatiguefollowingtreatmentwithcorticosteroids.
Materialsandmethods
Overalldesign
Anexploratoryanalysiswasundertakenondatafromarandomized,double-blind,placebo
controlledtrialexaminingtheanalgesicefficacyofcorticosteroidsinpatientswithadvanced
cancertakingopioids[17].Forty-ninepatientswererandomizedtomethylprednisolone16
mgtwicedailyorplacebo;25wereevaluatedinthecorticosteroidarm,22wereevaluatedin
theplaceboarm.Thirteenpatientsrandomizedtoplaceboreceivedcorticosteroidsonanopen
basisaftertheinterventionperiod.PROMsfromthesepatientswereincludedintheanalyses
atfollowupaftercorticosteroidtreatment.Ethicalapprovalwasgivenfortheprimarystudyby
theRegionalCommitteeforMedicalResearchEthicsCentralNorway(4.2007.846)andthe
NorwegianDirectorateofHealth;ClinicaltrialinformationNCT00676936,EudraCTNo
2007-005617-19.ProcedureswereconductedinaccordancewiththeDeclarationofHelsinki,
asrevisedin1983.Allpatientsprovidedwritteninformedconsenttotheirdatabeinganalysed
inlinewiththepresentstudy.
Eligiblepatientsmetthefollowingcriteria:>18yearsofage,takingopioidsformoderateor
severecancerpain;cancerdiagnosis;pain(cid:21)4(ona0–10NumericalRatingScale(NRS))at
inclusion;expectedsurvival>4weeks.Exclusioncriteriaincludeddiabetesmellitus,peptic
ulcerdisease,andconcurrentuseofnon-steroidalanti-inflammatorydrugs(NSAIDs)[17].
Inflammatorybiomarkerswereassessedatbaseline,i.e.beforecorticosteroidtreatment.
PROMs,wereassessedatbaselineandatfollowupafter7daysofcorticosteroidtreatment
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Cytokinesandsymptomsinpatientswithadvancedcancer
usingtheEuropeanOrganisationforResearchandTreatmentofCancer—QualityofLife
Questionnaire—C30(EORTCQLQ-C30)[21].TheEORTCQLQ-C30scoreswerecalculated
accordingtotheEORTCscoringmanual[22],scoresrangefrom0to100;ahigherscorecorre-
spondstoabetterhealth-relatedqualityoflifeinthefunctionscales(“better”),whereasa
higherscorerepresentsahigherlevelsofsymptoms(“worse”)inthesymptomscales.The
EORTCQLQ-C30hasbeenextensivelyvalidatedinthecancerpatientpopulationandwas
completedbetween08:00and17:00hoursinallstudypatients.
Theinflammatorymarkersandcytokinesselectedforthepresentstudyincludedhighsensi-
tivityCRP,erythrocytesedimentationrate(ESR),IL-1β,IL-1ra,IL-2,IL-4,IL-6,IL-8,IL-10,
IL-12(p70),IL-18,interferon-γ,TGF-β1,MIF,TNF-α,MacrophageInflammatoryProtein-1α
(MIP-1α),MonocyteChemoattractantProtein-1(MCP-1)andsolubleTumorNecrosisFactor
receptor-1(sTNF-r1).sTNF-r1waschosenbecauseitreflectsTNF-α-activity,sinceTNF-αis
amongthemostunstablecytokines[8,23].Thecytokineswerechosenonthebasisofprevious
researchoncancerrelatedinflammationandsymptoms[7,24,25].Theseraunderwentone
freeze-thawcycle.
HighsensitivityCRPanalysiswasperformedatFu¨rstlaboratories,Oslo.Thecytokineanal-
yseswereperformedattheNorwegianUniversityofLifeSciences,Ås,usingmultiplextechnol-
ogy(MultiplexSystem,Bio-RadLaboratoriesInc.,Austin,Texas)inwhichserumcytokine
concentrationsaremeasuredinhigh-sensitivityassays.Allsampleswereassayedinduplicate
andtheassaysperformedaccordingtomanufacturer’sinstructionsbylaboratorypersonnel
blindedtotherestofthedata.BioRadHumanInflammationpanels6plexkitcontainingIL-8,
IL-12(p70),IL-2,IL-10,interferon-γ,andsTNF-r1;BioRadhumangroup1and29plexkit
containingIL-1β,IL-1ra,IL-4,IL-6,MCP-1,MIP-1α,TNF-α,IL-18,andMIF;andBioRad
singleplexkitTGF-β1wereused.Inonepatientoneoftheparallelsinthe6plexkitshowed
veryhighvaluesascomparedtotheotherparallel(coefficientofvariation:%CV137–140
betweentheduplicates)andtheotherbiomarkersfromthesamepatient.Thisparallelwas
thereforeexcludedfromtheanalysis.Exceptfromthis,nosignificantvariationwasnoted
betweenduplicatesforanysample.Theintra-assayCVwas<10%.Cytokine/chemokinecon-
centrationswereinterpolatedfromanappropriatestandardcurve.Ifthebiomarkerconcentra-
tionwasbelowthelowestpointonthestandardcurve,weusedthelowestvalue.
Statisticalanalyses
Asthiswasanexploratoryanalysisnoformalsamplesizecalculationwasperformed.Where
appropriate,alldataarereportedasmeanswith95%confidenceintervals(CIs),ranges,medi-
answithinterquartileranges(IQRs),orfrequencies.Asthecytokineswerenotnormallydis-
tributed,SpearmanRho-Rankwasappliedforthecorrelationanalyses.Basedonprevious
research[26],sex,BMI,andagewereexploredaspossibleconfoundingfactorsinamultiple
regressionmodel.SexorBMIwereassociated(p<.05)withPROMsoffatigue,appetite,and
dyspnoea,andphysicalandrolefunctionscales,butdidnotchangetheresults(datanot
shown).Associationsbetweenpre-treatmentinflammatorybiomarkerlevelsandchangesin
pain,appetite,andfatiguefollowingcorticosteroidusewereexploredusingmultipleregression
analyses.SexandBMIwereincludedascovariates.Inordertogivesomeprotectionformulti-
pletesting,asignificancelevelwassettop=.01.SPSSv21.0(Chicago,IL)wasusedforallsta-
tisticalanalyses.
Results
Patientdemographics,paincharacteristicsandanalgesicuseareshowninTable1(n=49).
Themeanagewas63.9years(CI:61.2–66.8),meanKarnofskyPerformanceStatusscore(KPS)
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Cytokinesandsymptomsinpatientswithadvancedcancer
Table1. Demographicsandmedicalcharacteristicsofthestudyparticipants.
Numberofpatients(n=49) Mean Median CI
Sex Female 24
Male 25
Age Years 63.9 64.8 61.2–66.8
Weight kg 68.3 67.0 63.8–72.9
BMIa kg/m2 23.0 22.3 21.6–24.5
Ethnicity Caucasian 49
KPSb 66 70 62–70
Survival(days) 185 86 39–197(IQR)c
Cancerdiagnosis Gastrointestinal 14
Lung 11
Gynaecological 10
Prostate 6
Breast 2
Other 8
Metastases Liver 17
Bone 15
Lung 7
CNS 2
Other 33
Nometastases 2
Oralopioiddosemg/24h mg(OME)d 230 135 165–296
Baselineopioid
Morphine 15 185 80 58–312
Oxycodone 19 148 110 98–198
Fentanyl 13 368 420 215–522
Other 2 459 459 -4198–5115
Corticosteroidmedication n=38
Methylprednisolone 34
Dexamethasone 2
Prednisolone 2
Dexamethasoneequivalent mg 5.5 Range:1.5–8
Concomitantdisease 29
Cardiovascular 18
Lung 7
GI/Hepatic 5
Other 18
Otherdrugs
Pepticulcer/Ulcerprophylaxis 19
Sleepmedication 15
Anticoagulants 14
Acetylsalicylicacid 8
Cardiovascular 6
Statins 4
Hormones 3
Antidepressants 8
Antibiotics 1
Antifungalagents 3
(Continued)
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Cytokinesandsymptomsinpatientswithadvancedcancer
Table1. (Continued)
Numberofpatients(n=49) Mean Median CI
Ongoingcancertreatment
Radiotherapy 0
Chemotherapy 7e
Hormonaltherapy 6
None 36
aBMI:Bodymassindex,
bKPS:KarnofskyPerformanceStatusScore,
cIQR:Interquartilerange,
dOME:OralMorphineEquivalents,
ePaclitaxel(n=1),Gemcitabine(n=1),Pemetrexed(n=1),Fluorouracil(n=1),FluorouracilandIrinotecan(n=1),FluorouracilandLeucovorin(n=1),
CapecitabineandTemozolomide(n=1).
https://doi.org/10.1371/journal.pone.0177620.t001
was66(CI:62–70),mediansurvivalwas86days(IQR:39–197),meanbodymassindex(BMI)
was23.0(CI:21.6–24.5),andmeanopioidconsumption259mg/day(oralmorphineequiva-
lents)(CI:178–339).Sixpatientsreceivedchemotherapy(Table1).Datawereavailableon49
patientsatbaselineandon38patientsatfollowuphavingreceivedmethylprednisolone
(n=34),dexamethasone(n=2)orprednisolone(n=2).Meandexamethasoneequivalent
dosewas5.5mg/day[27].
MeanPROMsatbaseline(EORTCQLQ-C300–100)areshowninTable2.MeanEORTC
QLQ-C30scoreswereabove65pointsforpain,appetiteandfatigueindicatingseveresymp-
tomintensity.Role,physical,andsocialfunctionandglobalhealthwerebelow45points,indi-
catingimpairmentinthesefunctiondomainsandhealth-relatedqualityoflife.
Table3showsthemedianserumconcentrationofinflammatorybiomarkers(cytokines,
CRPandESR)atstudybaseline.IL-1β,IL-2,IL-4,IL-8,IL-10,IL-12(p70),TNF-α,interferon-
γ,andMIP-1αvalueswerebelowthelowerlimitofdetection.MedianCRPandESRwere44
Table2. EORTCQLQ-C30measurementsatbaseline.
Mean Median CI
Physicalfunction 39.3 40 33.8–44.8
Rolefunction 24.8 16.7 18.4–31.2
Emotionalfunction 73.9 75.0 67.0–80.8
Cognitivefunction 68.8 66.7 60.7–76.8
Socialfunction 44.1 50.0 35.5–52.7
Generalhealth 40.5 41.7 34.8–46.1
Fatigue 72.7 77.8 66.1–79.2
Appetiteloss 68.0 66.7 59.3–76.8
Pain 78.9 83.3 74.1–83.7
Nauseaandvomiting 31.0 16.7 23.0–39.0
Dyspnoea 47.6 33.3 39.1–56.1
Sleep 27.8 33.3 18.6–37.0
Constipation 46.5 50.0 34.8–58.3
Diarrhoea 22.2 0,0 13.0–31.4
CI:95%confidenceinterval
https://doi.org/10.1371/journal.pone.0177620.t002
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Cytokinesandsymptomsinpatientswithadvancedcancer
Table3. Biomarkersandobservedserumconcentrations.
I Concentration(pg/mL)median Interquartilerange(IQR) LLOQa
CRP 44 19.8–122.5
ESR 42 18–83.8
IL-1ra 21.7 21.7–126.8 21.7
IL-6 2.33 2.33–26.0 2.33
IL-18 103.2 73.4–164.3 1.1
MCP-1 64.1 46.9–107.3 1.5
MIF 134.9 85.4–334.2 4.8
sTNF-r1 10917 7223–15257 27.1
TGF-β1 45145 36714–52636 1.2
aLLOQ:Lowerlimitofquantification.
https://doi.org/10.1371/journal.pone.0177620.t003
and42,respectively,andcytokinesIL-1ra,IL-6,IL-18,MCP-1,MIF,sTNF-r1andTGF-β1
wereincreasedasevidenceofsystemicinflammation.
Table4showsrelationshipbetweenbiomarkersandpain,appetiteandfatigueatstudybase-
line.ModeratecorrelationsweredemonstratedbetweenappetiteandCRPandIL-6;and
fatigueandIL-1ra(r =.38-.41,p<.01).Painwasnotsignificantlycorrelatedwithanybio-
s
markers.FortheotherEORTCPROMs,lowcorrelationswereobserved.
FortheEORTCfunctiondomains,strongcorrelationswerefoundbetweenphysicalfunc-
tionandCRP,IL-6andsTNF-r1;androlefunctionandCRP,IL-6,ESR,sTNF-r1(r>.50,
s
p<.001).ModeratecorrelationswerefoundbetweenphysicalfunctionandESR,andIL-18;
betweenrolefunctionandIL-18andMIF;andbetweencognitivefunctionandTGF-β1(r =
s
.40-.50,p<.01).
Table5showstherelationshipbetweenserumconcentrationsofbiomarkersatbaselineand
improvementinPROMsfollowingtreatmentwithcorticosteroids.Serum-concentrationof
MCP-1wascorrelatedwithpainintensity(β=-.38)(explainedvariabilityR2=0.13,p=.016),
andsTNF-r1wascorrelatedwithappetite(β=—.43)(explainedvariabilityR2=0.16,p=.012)
aftercorticosteroidtreatment,notsignificantwhenallowingformultiplecomparisons.
TherelationshipsbetweenindividualinflammatorymarkersareshowninTable6.Strong
correlationswerefoundbetweenCRPandESR,andIL-6;sTNF-r1andIL-18,andMIF;IL-6
andIL-1ra,andMIF;andMCP-1andIL-18,allcorrelationsr >.50(p<.001).Anumberof
s
moderatecorrelationswereobserved(r =.39-.50,p<.01).
s
Discussion
Thepresentstudydemonstratesthatbiomarkersofthesystemicinflammatoryresponseare
relatedtoappetiteandfatigueinpatientswithadvancedcancerwithpainwhoaretakingopi-
oids.Morespecifically,decreasedappetitewascorrelatedwithincreasedlevelsofIL-6and
CRP,andincreasedfatiguewascorrelatedwithincreasedIL-1ra.Incontrast,painwasnotcor-
relatedwithanyoftheinvestigatedbiomarkers.Nosignificantpredictorforeffectofcortico-
steroidtreatmentwasidentified.
Theinflammatorybiomarkerpanelincludedinthepresentstudyshowedincreasedserum
concentrationsofIL-6,IL-8,MIF,sTNF-r1,andTGF-β1inpatientswithadvanceddisease.
Interestingly,thispatterncorrespondstothecytokinepatterndescribedinpatientswith
advancedcancerbyLippitz[4].Itisalsoconsistentwithpreviousreportsshowingthatsys-
temicinflammationisrelatedtomultiplequalityoflifeandsymptomvariables[6,13].Inthis
study,IL-6andCRPwererelatedtodeterioratingappetite,andanimalstudieshavealso
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Cytokinesandsymptomsinpatientswithadvancedcancer
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selineand Rolefunction -0.89** -0.53** -0.52** -0.35 -0.59** -0.23 -0.43* -0.41* -0.24 (n=3)and
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EORTCQLQ-C30measurementsat FatigueAppetitePainPhysicalfunction 0.260.380.16-0.55*** 0.080.270.30-0.47* 0.170.220.20-0.55** 0.410.340.16-0.38* 0.200.410.20-0.51*** 0.180.320.09-0.20 0.130.280.15-0.45* 0.150.040.20-0.33 0.020.020.20-0.19 1, 001BloodsamplesforESR(n=1),C org/10.1371/journal.pone.0177620.t004
Table4. CRP ESR sTNF-r1 IL-1ra IL-6 MCP-1 IL-18 MIF TGF-1β =p.0*< =p.**< https://doi.
PLOSONE|https://doi.org/10.1371/journal.pone.0177620 May25,2017 8/16
Cytokinesandsymptomsinpatientswithadvancedcancer
Table5. Fatigue,appetiteandpainintensityandresponsetocorticosteroidtherapy.
Fatigue Appetite Painintensity
β Sig R2 β Sig R2 β Sig R2
CRP 0.07 .00 0.16 .02 -0.07 .00
ESR -0.06 .00 -0.04 .00 -0.17 .03
sTNF-r1 -0.18 .03 -0.43 p=.012 .16 -0.34 p=.033 .10
IL-6 0.07 .00 -0.10 .01 -0.21 .04
MCP-1 -0.10 .01 -0.20 .03 -0.38 p=.016 .13
IL-18 -0.15 .02 -0.04 .00 -0.29 .08
MIF -0.08 .01 -0.17 .03 -0.33 p=.034 .10
TGF-β1 -0.10 .01 -0.16 .02 0.02 .00
β=standardizedbeta.Multipleregressionanalysis:fatigueday7dependent;fatigueday0,sex,andBMIas
covariates.BiomarkersCRP,IL-6,IL-18,MCP-1,MIF,andTGF-β1werelog-transformed.Bloodsamples
weremissingforCRP(n=3)andforcytokines(n=6).
https://doi.org/10.1371/journal.pone.0177620.t005
proposedalinkbetweenlossofappetiteandsystemicandregionalexpressionofthepro-
inflammatorycytokinesIL-1,TNF-αandIL-6[28].Inotherstudiesinpatientswithcancer,
associationshavebeenshownbetweenappetitelossandIL-1β,IL-6andIL-8[29]andwith
genepolymorphismscodingforTNF-α[30],IL-1β[31],andIL-10[32].Inourdata,increasing
IL-6wasthemostprominentbiomarkerforappetitelosswithexplainedvariabilityR2=0.16.
Thepresentstudyalsoobservedamoderatecorrelation(r =.41)betweenfatigueandthe
s
anti-inflammatorycytokineIL-1ra.IL-1raisaphysiologicalinhibitorofIL-1β,itsproduction
isstimulatedbyIL-1βandIL-6[33].IL-1raisexpressedinhigherconcentrationsinserumas
comparedtoIL-1β,whichhasashorthalf-lifeandisdegradedduringstorage[34].Thus,IL-
1raservesasamarkerforIL-1activity[26,35].
Worktodatehassuggestedthatcancer-relatedfatigueislinkedtoinflammatory,metabolic,
neuroendocrine,andgeneticbiomarkers[12].However,resultsforindividualbiomarkersare
inconsistentwhichmaybedueinparttomethodologicalissues[12].Inpatientswithadvanced
disease,severalstudieshaveshownanassociationbetweenfatigueandCRP[6,13,36,37].
However,inanothertrialthisassociationdidnotpersistaftercorrectionforcovariates[38].In
oneofthecitedstudies,IL-1raandIL-6wereassociatedwithfatigueinpatientswithadvanced
cancer[36];althoughthiswasnotfoundforIL-6,IL-1β,IL-8orTNF-αinanotherstudy[29].
Table6. Correlationsbetweentheanalysedcytokines.
CRP ESR sTNF-r1 IL-1ra IL-6 MCP-1 IL-18 MIF
CRP 1
ESR 0.70** 1
sTNF-r1 0.38 0.45* 1
IL-1ra 0.32 0.28 0.21 1
IL-6 0.69** 0.49* 0.37 0.55** 1
MCP-1 -0.00 0.00 0.38 0.20 0.28 1
IL-18 0.39* 0.41* 0.59** 0.49* 0.45* 0.52** 1
MIF 0.31 0.40* 0.63** 0.32 0.54** 0.50* 0.31 1
TGF-β1 0.25 0.09 0.12 -0.12 0.16 0.15 -0.19 0.25
*=p<.01,
**=p<.001
https://doi.org/10.1371/journal.pone.0177620.t006
PLOSONE|https://doi.org/10.1371/journal.pone.0177620 May25,2017 9/16
Cytokinesandsymptomsinpatientswithadvancedcancer
Inpatientswithadvancedcancer,intensityoffatiguehasbeenassociatedwithothersymp-
toms,inparticularpain,dyspnoea,anorexia,psychologicaldistress,andinsomnia[39].Fatigue
iscommonlydescribedinsymptomclusterswithpain[40,41],andindeedtheprimarytrial
wasapaininterventiontrial.Ourresultsshowedthatpainintensitywasassociatedwith
fatigue,r =.38(p<.01)(resultsnottabulated).Inaregressionmodel,painandIL-1rawere
s
bothindependentlyassociatedwithfatigue,withanexplainedvariabilityofR2=0.12andR2=
0.13,respectively.Inthreesmallclinicaltrials,IL-6blockers[42,43],andIL-1ra-treatment
[44],wereeffectiveindecreasingdiseaseactivityandinalleviatingfatiguewhenusedfortreat-
ingIL-6-mediatedCastleman’sdisease.Dataalsoindicatethattreatmentwithrecombinant
IL-1ramayalleviatefatigueinpatientswithrheumatoidarthritisandSjo¨gren’ssyndrome[45,
46].
Inthecaseofpain,thepositiveassociationsbetweenpainandCRP[5,6,13]reportedprevi-
ouslywerenotobservedinthepresenttrial.Moreover,interventiontrialsassessingeffectsof
corticosteroidsoncancerpainhavealsoshownconflictingresults.Theprimarytrialfoundno
evidenceofananalgesiceffectofmethylprednisolone32mgdailyforcancerpain[17].
Anothertrialfoundonlyatemporaryeffectofsystemiccorticosteroidsonpainintensity[16,
47].Thisisincontrasttoapreviouscross-overtrial[19],inwhich28patientswithpredomi-
nantlybonelocalizedpain(n=16),visceral(n=7)ornervecompressionpain(n=5)andlow
levelofopioidsshowedresponseinpainintensityandanalgesicconsumptiontomethylpred-
nisolone32mgdaily.Theseobservationssuggestthatcancerpainmightbelessassociated
withsystemicinflammationthanappetiteandfatigue.However,theconflictingresultsmay
alsosuggestthattherearesubgroupsofcancerpainthatmayrespondbettertocorticosteroid
treatment.Cancerinducedbonepainmightbesuchasubgroup.Inthisrespectitisworth
mentioningthatpatientswithelevatedpre-treatmentserum-concentrationsofMCP-1were
morelikelytohaveanimprovementinpainfollowingtreatmentwithcorticosteroids(Table4)
(explainedvariabilityR2=0.13,p=.016,notsignificantwhenallowingformultiplecompari-
sons).Correctingforthepresenceofcancerinducedbonepaindidnotinfluencethisresult.
ThisobservationcorrespondstopreviousworkthatMCP-1playsaroleinchronicpain
facilitationviaitsreceptor,C-Cchemokinereceptortype2(CCR2)[48,49].Animaldatashow
thatMCP-1expressioninspinalneuronsalsoisincreasedinanimalswithcancerinduced
bonepain.Moreover,MCP-1inducedhyperalgesiaandanti-MCP-1orCCR2agonistattenu-
atedhyperalgesiainanimalswithbonecancerwhenappliedintrathecally[50,51].Further-
more,corticosteroidsareshowntodecreaseMCP-1[52].Additionally,experimentalanimal
studiessuggestthatlocallyappliedsustainedreleasemethylprednisoloneimprovedhyperalge-
siainratswithcompressionradicularpain.Thispainimprovementwasassociatedwitha
decreasednumberofinfiltratingmacrophagesatthesciaticnerve,andreducedMCP-1expres-
sioninthenerve[53].Inpatientswithcancerpain,MCP-1wasoneoffivecytokinesthatwas
significantlycorrelatedwithpainreliefinastudyonacutechangesincytokineserumconcen-
trationsduringthreehoursofopioidtreatmentforpain[54].Basedonthisbasicsciencework,
theobservationthatMCP-1mightbeabiomarkerforpainresponsefromcorticosteroidsis
interestingandshouldbetestedinfuturestudies.
AnumberofcorrelationswereobservedbetweenbiomarkersandEORTCfunction
domains,inparticularfordeterioratingphysicalandrolefunctionwhichwereassociatedwith
increasingCRP,IL-6,sTNF-r1,ESR,IL-18,andMIF.Multipleregressionanalysesshowedthat
CRPwasthemoststronglycorrelatedbiomarkerforrolefunction,andIL-6forphysicalfunc-
tion,withexplainedvariabilityR2 =0.34and0.28,respectively.Rolefunctioncomprises
adjusted
twoitems,i.e.abilitytoperformworkortopursuehobbyactivity,whilephysicalfunction
itemsfocusonphysicalcapabilityandstrength.Roleandphysicalfunctionitemsareclosely
related[55]anddoprobablyexpressthesameconstruct.Moreover,poorrolefunctionmay
PLOSONE|https://doi.org/10.1371/journal.pone.0177620 May25,2017 10/16