Fatigue and psychostimulant use in patients with advanced cancer in an oncology palliative care clinic: A retrospective cohort study.

Abstract

12069 Background: Cancer-related fatigue (CRF) is the most common symptom experienced by patients with cancer but is underreported and undertreated. Psychostimulants are prescribed for CRF despite limited evidence; data on real-world use of these medications for CRF is scant. We aimed to describe the prevalence and predictors of CRF and psychostimulant use, and the association of psychostimulant use with CRF improvement in an oncology palliative care clinic (OPC). Methods: We conducted a retrospective review of new consultations in the Princess Margaret Cancer Centre OPC from Jan 1, 2018 - Jul 30, 2025. Demographic and clinical characteristics, including Palliative Performance Scale (PPS) and Edmonton Symptom Assessment System (revised, with constipation and sleep, ESAS-rCS) scores were recorded. Psychostimulant prescriptions were extracted from Epic, the electronic medical record system as of Jun 4, 2022. We calculated prevalence of fatigue in the total cohort and psychostimulant prescription following initial OPC visit in the subcohort seen on/after Jun 4, 2022. For the latter group, we reviewed charts to assess adherence, CRF severity, patient perception of efficacy and adverse effects. Multivariable logistic regression evaluated baseline factors associated with moderate-severe fatigue (≥4/10 on ESAS-rCS) and psychostimulant prescription. We compared pre- and post-psychostimulant fatigue scores by Wilcoxon signed rank test. Results: 8,439 patients (5,812 with complete ESAS-rCS) were seen in the OPC from Jan 1, 2018 - Jul 30, 2025; 74.4% and 40.6% reported fatigue ≥4/10 and ≥7/10, respectively. Moderate-severe fatigue was independently associated with lower PPS ( < 60 vs ≥60, OR 1.66, 95% CI 1.15-2.38, p < 0.01) and worse ESAS-rCS scores for pain, drowsiness, appetite, dyspnea, depression, and wellbeing (p < 0.0001). Among 3,623 patients seen on/after Jun 4, 2022, 140 (3.9%) were prescribed a psychostimulant by the OPC; no baseline patient factors were associated with psychostimulant prescription. Of these 140 patients, 139 were prescribed methylphenidate at a maximum total daily dose ≤10 mg; 77 adhered to treatment and had follow up notes reporting effects. Of evaluable patients, 53 (68.8%) reported improved fatigue, 12 (15.6%) no benefit, and 12 (15.6%) had conflicting notes regarding effectiveness; 3 (3.9%) reported non-serious adverse events related to methylphenidate. Median (interquartile range) fatigue scores pre- and post-psychostimulant treatment were 7 (5-8) and 6 (3-7), respectively (p < 0.01). Conclusions: Nearly 3/4 of patients with advanced cancer receiving outpatient palliative care experienced fatigue, yet few were treated with psychostimulants. Most patients reported improvement in fatigue with low-dose methylphenidate. Future studies should address knowledge gaps in assessment and management of CRF and the role of psychostimulants.