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Corticosteroids can be useful but are not devoid of 51 U/L) while thyroid, hepatic and renal function were
major side effects. Some evidence supports the use of normal. Serological tests for hepatitis B virus, hepatitis
methylphenidate over placebo, but its use is limited by C virus, human immunodeficiency virus, Epstein-
side effects, and it should be administrated only under Barr virus and cytomegalovirus were negative. Chest
expert supervision. One placebo-controlled trial on radiography, abdominal ultrasound, electrocardiography and
methylphenidate in prostate cancer showed a small benefit. echocardiography were all normal.
However, 37.5% of treated subjects dropped out for severe
drug-related adverse events. Secondly, the sample size was Diagnosis of CRF was established as a diagnosis of
quite small, and statistical analysis was not corrected for exclusion. CRF was assessed according to the Brief
multiple comparisons. [11] Fatigue Inventory (BFI), [17] and a score of 9 (BFI range,
0-10) was found.
Also, erythropoietin may be effective but a specific dose for
routine practice in CRF cannot be recommended. The aim Considering both the urinary incontinence and depression
of treatment should be to use the minimum required dose symptoms, we prescribed duloxetine at a starting daily dose
for the shortest duration. This is due to the theoretical of 30 mg and then, as per drug schedule, after 2 weeks, the
[12]
increase in the risk of thromboembolic side effects with dose was increased to 60 mg. Duloxetine was chosen due to
higher doses and protracted treatment with erythropoietin its efficacy against urinary incontinence at a similar dose
and possible cancer stimulation. [10] (dose range, 40-80 mg daily).

In some trials, antidepressants and psychostimulant drugs After 2 months of treatment at the dose of 60 mg, the BFI
showed a small little clinical benefit. Here, we report a case score was decreased to 2, urinary incontinence completely
[13]
of CRF treated with duloxetine. Duloxetine is a serotonin- resolved, and the patient returned to regular activities.
noradrenergic reuptake inhibitor, commonly used as an There were no side effects. Duloxetine was continued at
antidepressant. It has been recently approved for neuropathic the same dose for a further 2 months and then was
withdrawn because of alcoholism relapse, a disorder that
pain, chronic fatigue syndrome (at the dose range of 30-60 mg the patient and his relatives had omitted in medical history.
daily), fibromyalgia and it is also recommended for urinary
incontinence in Europe (40-80 mg daily). [14-16] After duloxetine discontinuation, the patient reported a
moderate CRF worsening over 6 months. However, 4
CASE REPORT months later, he maintained a 5 points-lower BFI score
than the initial one. At the same time, he was referred
A 74-year-old man presented to our clinic complaining of to our alcohol abuse center with a progressive reduction
more than 6 months of fatigue, which was exacerbated by of heavy-drinking days in a 6-month timeline follow-back.
activity and not relieved by rest. The patient had a history DISCUSSION
of advanced prostate cancer 3 years before, he underwent
a radical prostatectomy (Gleason score 4 + 4, pT3bN0; CRF is a major problem in prostate cancer management,
prostate-specific antigen (PSA) 21.1 ng/mL) followed by according to several studies, the prevalence of CRF
adjuvant radiotherapy. Following treatment, only mild regardless of intensity is about 74%. There is no
[4]
urinary incontinence was noted. Two years later, he had a “gold standard” treatment currently recommended, and
biochemical relapse, with a PSA doubling time < 6 months the commonly given therapies are poorly successful.
for which he started on daily bicalutamide, 50 mg and Only 2 drugs have shown some activity against CRF:
monthly luteinizing hormone-releasing hormone agonist. methylphenidate and erythropoietin, although their regular
After starting medical therapy, a progressive and significant use do have caveats. [10]
PSA normalization was observed. However, 6 months
later, he complained for recurrent moments of sadness, Our patient, who was not receiving chemotherapy,
loss of interest in daily activities, insomnia, concentration showed mild anemia, thus not presenting an indication for
problems and worsening urinary incontinence (from mild erythropoietin. Some data show that CRF can disappear
to moderate). spontaneously 6-8 weeks after the end of HT, but our patient
was receiving HT, and was to be continued until progression
On physical examination, he was not pale or jaundiced, or unacceptable toxicity, so that a medical withdrawal was
afebrile with normal heart rate and blood pressure. Heart, not indicated. Although the timing and modality of treatment
lung, abdominal and musculoskeletal examinations were of PSA-only recurrence after radical prostatectomy and
normal. No hepatomegaly, gynecomastia or neurological radiotherapy remains controversial, our patient had high-
signs were present. Eastern Cooperative Oncology Group risk disease deserving first-line treatment. [18]
performance status was 0-1. Laboratory tests, including
a complete blood count and electrolytes, showed mild In CRF pathophysiology, a relevant impairment of
anemia (hemoglobin 11.7 g/dL) and elevated transaminase neurotransmitter (serotoninergic, noradrenergic and
levels (alanine transaminase 83 U/L, aspartate transaminase dopaminergic) systems is present. The use of different

Journal of Cancer Metastasis and Treatment ¦ Volume 2 ¦ Issue 2 ¦ February 29, 2016 ¦ 65