potential treatment. Institutional and organizational support for interdisciplinary communication should produce great benefit.
The current relative isolation of investigators in this area might also be addressed by taking advantage of current technology to create a “virtual” research network. This could be seen as a very interesting experiment in scientific communication. Mainline cancer research is facilitated by frequent interchanges of ideas and new data among research groups at large institutions, and it is reasonable to assume that this facilitates research progress. Such a virtual network, using current Internet technology, could support frequent video research exchanges, postings of preliminary data, and collective hypothesis generation. It could also sponsor exchanges between clinicians (defining the problems, sharing observations) and basic, behavioral, and health research scientists. It could explore the potential utility of patient and family interchanges with researchers and provide data from patients’ experiences with existing and new symptom-related therapies.
THE PROBLEM The clinical trial database that covers end-of-life care, palliative care, and symptom control is very small. Most guidelines for management of symptoms depend heavily on “expert” opinion because of this deficit, and treatment is often empirical for the same reason. Few active clinical trials deal with single or multisymptom interventions or with practice change interventions. In studies examining single symptoms, pain is the best studied in clinical trials, but many of the trials are industry sponsored, with very few trials of off-patent medications such as morphine that are used routinely in the care of seriously ill patients.
Fatigue is an excellent example of an area in need of clinical trials. We know that some cancer-related fatigue is due to anemia and that anemia can be treated in some patients. Yet anemia is just one of the many causes of fatigue, and little if any clinical or basic science research is being done to discover the causes of this fatigue or to advance new treatments. Many oncologists are using methylphenidate (Ritalin) to treat patients with cancer-related fatigue, but there is not one published randomized trial (although one is now recruiting patients) that examines the effectiveness of this drug, the appropriate doses, or the indications for use. Dyspnea, psychological distress, poor appetite, wasting, psychological distress, nausea and vomiting, and cognitive impairment are all on the list of potential candidates for clinical trials that could be under way. As has been seen, there are few active trials in any of these areas.
Several NCI collaborative groups have attempted symptom management clinical trials, but with mixed results, and several potentially informa-