Highlight
- The MePFAC randomized controlled trial rigorously tested methylphenidate against placebo for cancer-related fatigue in advanced cancer patients under palliative care.
- No clinically meaningful reduction in fatigue was observed with methylphenidate at 6 weeks despite prior meta-analyses suggesting potential benefit.
- Methylphenidate was found to be safe and well tolerated with no significant difference in adverse events compared to placebo.
- The study’s findings suggest methylphenidate should not be recommended routinely for fatigue management in this patient population.
Study Background
Cancer-related fatigue is a prevalent and debilitating symptom among patients with advanced malignancies, significantly impairing quality of life and daily functioning. Despite its high prevalence, effective pharmacological treatments remain limited. Methylphenidate, a central nervous system stimulant commonly used for attention-deficit disorders, had been hypothesized and preliminarily supported by earlier meta-analyses as a potential agent to alleviate cancer-related fatigue, especially in palliative care settings where symptom management is paramount. However, evidence remains inconsistent, and previous studies were often heterogeneous in design and populations.
Study Design
The MePFAC trial was a phase III, randomized, double-blind, placebo-controlled, parallel-group multicenter study conducted across 17 palliative care services in England from June 2018 to April 2023. The study enrolled adults with advanced cancer experiencing fatigue, fulfilling strict inclusion and exclusion criteria that ensured the safety of methylphenidate use and minimized confounding factors.
Participants were randomly assigned (1:1) to receive either oral methylphenidate starting at 5 mg twice daily or matching placebo. The dose was titrated over six weeks to a maximum of 12 tablets per day depending on tolerability and clinical response. Randomization was stratified by center, concomitant treatments, depression status, and baseline fatigue severity. Both patients and outcome assessors were blinded to treatment allocation.
Endpoints
The primary endpoint was the change in fatigue severity at six weeks (±2 weeks) measured by the Functional Assessment of Chronic Illness Therapy – Fatigue Scale (FACIT-F), a validated measure for fatigue in chronic illness populations. Secondary endpoints included fatigue measurements at other time points, quality of life, activities of daily living, appetite, anxiety, depression, patient satisfaction, overall survival, and need for additional medications.
Key Findings
A total of 162 patients were randomized, with 75 analyzed in the methylphenidate group and 72 in the placebo group for the primary outcome. At six weeks, there was no statistically or clinically significant difference in fatigue scores between the groups. The mean FACIT-F score difference was 1.97 points higher in the methylphenidate group (95% CI: -0.95 to 4.90; p = 0.186), which does not meet the predefined minimal clinically important difference of 5 points.
Across the study duration, methylphenidate showed a nominally significant but clinically insufficient improvement of 2.20 points in FACIT-F (95% CI: 0.39 to 4.01), indicating a subtle trend without meaningful clinical impact. Secondary outcomes mostly showed no significant differences, except for depression scores that were modestly reduced in the methylphenidate group (difference of -1.35; 95% CI: -2.41 to -0.30), suggesting a potential psychotropic benefit.
Safety and Tolerability
Safety profiles were comparable between groups. Serious adverse events were balanced with 25 events in 20 methylphenidate recipients and 25 events in 16 placebo recipients. No suspected unexpected serious adverse reactions occurred. Mortality within 75 days post-randomization was not significantly different (6 in methylphenidate vs. 2 in placebo; p = 0.278). Overall, methylphenidate was well tolerated without any signals of increased harm.
Limitations and Considerations
The trial included a highly selected patient population due to multiple exclusion criteria, which may limit generalizability to broader palliative care patients. The threshold of a 5-point FACIT-F difference as clinically meaningful, while grounded in prior literature, may be debated, although it remains a standard benchmark. The maximal dose titration and duration of treatment might also influence observed effects.
Expert Commentary
Despite prior meta-analytic hints suggesting methylphenidate’s utility for cancer-related fatigue, this robust randomized trial demonstrates no clinically relevant benefit in advanced cancer patients receiving palliative care. The rigorous double-blind design and multicenter recruitment strengthen the validity of these findings.
The modest improvement in depressive symptoms might hint at methylphenidate’s neuropsychiatric effects rather than fatigue amelioration, warranting further exploration. Additionally, due to the strict population and exclusion criteria, results should be cautiously extrapolated to other cancer populations or less advanced stages.
Conclusion
This well-conducted phase III trial establishes that methylphenidate does not significantly reduce fatigue severity compared with placebo in patients with advanced cancer under palliative care, although it is safe and tolerable. These findings suggest that methylphenidate should not be routinely recommended for cancer-related fatigue in this context. Future research may focus on different populations, indications, or potential synergistic approaches for symptom control.
Funding and Trial Registration
This independent research was funded by the UK National Institute for Health and Care Research (NIHR) Health Technology Assessment programme, award number 15/46/02.
References
Stone P, Minton O, Richardson A, Buckle P, Enayat ZE, Marston L, Freemantle N. Methylphenidate versus placebo for fatigue in patients with advanced cancer: the MePFAC randomised controlled trial. Health Technol Assess. 2025 Jul;29(36):1-47. doi: 10.3310/GJPS6321. PMID: 40755226; PMCID: PMC12376206.
