We have described the results of the analysis of 665 consecutive patients with advanced cancer seen in our PCC, including detailed exploration of symptoms and opioid usage for the first consecutive 100 CAGE+
and 100 CAGE−
The CAGE questionnaire is routinely administered to all patients seen by our team at the time of consultation. We have found that CAGE was documented in the majority of the medical records (90%). However, the 17% frequency of CAGE+
patients found in this study was slightly lower than expected. other studies in similar populations have shown prevalences such as 27% in an inpatient palliative care unit,11
25% in an outpatient symptom control clinic,20
and 38% among inpatients in a tertiary cancer center being followed by a palliative care consultation team.21
This might be related to the lower frequency of alcohol-related cancers in our ambulatory center as compared to other settings. Head and neck cancers, for example, accounted for 68 of 665 (10%) of our outpatient population, and it was reported elsewhere to account for 21 of 61 (34%) of the cases seen by the inpatient consultation team.21
Underrepresentation of head and neck cancers in PCCs was already reported in another cancer center (8/166; 5% of patients).20
patients had a higher prevalence of head and neck malignancies, as expected.22
patients were more frequently males, as supported by the literature.5
Patients in the CAGE+
group were significantly younger, also confirmed by previous reports of alcoholism in younger patients and the trend that patients with alcoholism to die earlier than the general population.5,23
patients were referred approximately 8 months earlier to palliative care. We hypothesize that this is related to the difficult symptom management and psychological distress in this population. Further research is needed to confirm this observation.
It has been reported that somatic symptoms in cancer patients can have both physical and psychosocial contributors.24
The process by which psychological needs are expressed in physical symptoms is defined as somatization.25
it has been suggested that patients with addictive disorders are at greater risk for somatization and chemical coping.7,12,26,27
Our results showed that CAGE+
patients presented to the PCC with higher symptom expression compared to CAGE−
patients. Positive screening for alcoholism may function as a surrogate to detect a tendency to somatization. Both CAGE+
patients had symptom improvement after the palliative care consultation. Our findings suggest that the PCC was capable of providing similar symptom relief independent of the patients' CAGE status. We cannot conclude that symptom relief was equivalent in the different groups due to the small population size and the retrospective nature of the study. CAGE information is regularly used by our multidisciplinary team to assist in the management of patients and families and on the prescription of medications. However, we are not able to determine in this retrospective study if the CAGE results were instrumental in helping the palliative care team to develop strategies to effectively manage symptoms in this population.
patients were more frequently referred to palliative care already receiving opioids, probably due to their tendency to express higher symptom distress, leading to earlier opioid therapy initiation.
Patients with alcoholism can suffer stigmatization by health care professionals and this can result in the under-treatment of pain and other symptoms.2
On the other hand, the lack of appropriate diagnosis of alcoholism can result in inappropriate counseling and pharmacologic management, leading to increased patient and family suffering and drug toxicity related to escalation of opioids and other drugs.
The CAGE questionnaire can help in the screening of patients for alcoholism, but it should never be used as a diagnostic tool. Patients who screen positive using the CAGE should undergo formal diagnosis following DSM-IV criteria.