Modafinil to Improve Fatiguability (MODIFY)

Cancer-related fatigue (CRF) and cancer-related cognitive impairment (CRCI) are among the most commonly reported disabling symptoms experienced by patients with advanced cancer. However, there are currently limited evidence-based pharmacologic interventions available. The investigators will conduct a Vanguard Randomized Clinical Trial (RCT) to estimate the effect of modafinil in managing CRF and CRCI, and to test the feasibility of carrying out the study.

Background: Patients with advanced cancer often experience various disabling symptoms. Cancer-related fatigue (CRF) and cancer-related cognitive impairment (CRCI) are among the most common reported symptoms, yet the availability of evidence-based pharmacologic interventions is limited. CRF can be defined as a "distressing, persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning." CRF is experienced by over 75% of patients with advanced cancer. CRCI is defined as a decline in one or more areas of cognitive function, including attention and concentration, executive functioning, information processing speed, language, visuospatial skill, psychomotor ability, and memory. It is estimated that up to 40% of patients experience CRCI prior to any treatment; up to 75% during their treatment; and up to 60% upon completion of therapies. Modafinil is a psychostimulant that has been studied in the context of CRF and daytime sleepiness. Its mechanism of action is not clear, but it is thought to promote wakefulness through dopaminergic neurotransmission which has been hypothesized to play a role in CRF. Study Hypothesis: Modafinil will improve CRF and CRCI Study Objectives: To estimate the effect size of modafinil in managing CRF and CRCI To test the feasibility of carrying out the study (recruitment, etc.) Study Design: Randomized, placebo-controlled, double-blind, single-centre vanguard trial Sample Size & Study Population: Approximately 40 outpatients presenting ≥4/10 on the fatigue score of their screening questionnaire will be recruited. Eligible patients must be 18-75 years old with advanced cancer who have not received cytotoxic chemotherapy for at least one month. Intervention: Subjects will be randomized to receive 200 mg of modafinil or placebo once daily for one week. Study Outcome Measures: Using validated questionnaires and a digital tool, the investigators will assess the patient's fatigue (CRF), cognition (CRCI), and quality of life before and after the intervention. In addition, patients will report their global impression of change. Finally, if patients experience any adverse events (headache, nausea, vomiting, anxiety, etc.), they will report them using a standard questionnaire. Adverse events (AEs) and Serious Adverse Events (SAEs) will be documented. Expected Outcomes: Positive results should provide justification to prolong the study to complete a phase III trial. This study is important because fatigue remains a cause of suffering amongst palliative patients with cancer. Modafinil has the potential to improve patients' fatigue, cognition, and quality of life.

The number of patients approached, total participants screened for eligibility, and reason for ineligibility or refusal to participate will be documented. We will consider the study successful if we can enroll 40 participants over a 1-year study period, with a recruitment rate of 15%.

We will consider the intervention to be feasible if at least 75% of enrolled participants complete the full intervention protocol.

We will consider the intervention to be feasible if at least 75% of enrolled participants complete all assessments at 1- week follow-up.

Change in cognition score evaluated using electronic cognitive assessment tool COVID-19 Assessment Battery.

Change in quality of life score evaluated using McGill Quality of Life Questionnaire-Revised (MQOL-R).

Daily patient-reported adverse effects with specific focus on headache, nausea and vomiting and anxiety, evaluated using the Common Terminology Criteria for Adverse Events (CTCAE).

Inclusion Criteria: Stage III or IV cancer diagnosis; Has been off cytotoxic chemotherapy for at least 1 month; Eastern Cooperative Oncology Group (ECOG) score of 0-2; Experiencing CRF, defined as score of 4 or greater on the Fatigue item of the Edmonton Symptom Assessment System-revised (ESAS-r); Prognosis of at least 3 months; Able to understand and communicate in English and/or French; Able to give first-person informed consent. Exclusion Criteria: Allergy to modafinil; Has been on stable dose of prednisone and/or dexamethasone for at least 3 days without dosing adjustments; Received blood transfusion in the past week; Hemoglobin lower than 100g/L for females or 110 g/L for males (measured in past month or at investigator's discretion); Thyroid Stimulating Hormone (TSH) above normal range (measured in past month or at investigator's discretion); Untreated or symptomatic brain metastasis or primary brain tumours; Documented dementia diagnosis; Documented major psychiatric illness including major depressive episode, bipolar disorder, or schizophrenia; Uncontrolled hypertension, defined as blood pressure higher than 140/80; Inability to ingest oral capsule; Pregnant or lactating.

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