Anemia is an expected consequence of intensive chemotherapy regimens administered to acute leukemia patients. This study was designed to determine if epoetin alfa would decrease the number of transfusion events and units of packed red blood cells (PRBCs) transfused, and secondarily, to study its effects on quality of life (QOL) and complete remission (CR) rates.
Patients and Methods
Patients with acute lymphoblastic leukemia (ALL), lymphoblastic lymphoma (LL), or Burkitt’s lymphoma (BL) receiving frontline myelosuppressive chemotherapy were randomized to receive epoetin alfa or no epoetin during the first 6 cycles of their planned chemotherapy. QOL was assessed by Edmonton Symptom Assessment Scale (ESAS) and FACT-Anemia questionnaires.
Fifty five patients were randomized to epoetin alfa and 54 to no epoetin. Transfusion data was available in 79 of the 81 (98%) evaluable patients who completed the treatment/observation period. The trial was stopped early due to poor accrual before the target of 123 evaluable patients was met. A mean of 10.6 units of PRBCs over 5 months were administered to those receiving epoetin alfa compared to 13 units for those who did not (p=0.04). There was no significant difference in QOL as assessed by FACT-Anemia or ESAS. The CR rate and 3-year CR duration were not adversely affected by use of epoetin alfa.
Epoetin alfa decreases the number of PRBC transfusions and does not appear to negatively impact remission duration. No difference in QOL was observed.
Anemia; epoetin; leukemia
To assess rehabilitation inpatient risk of return to primary service in bone marrow transplant patients.
Inpatient rehabilitation unit within a tertiary referral based cancer center
All bone marrow transplant patients (131) who were admitted a total of 147 times to inpatient rehabilitation between January 1, 2002, and April 30, 2010.
Main Outcome Measures
We analyzed return to primary service and demographic information, cancer characteristics, medications, hospital admission characteristics, and laboratory values.
41% (61/147) of bone marrow transplant admissions were transferred from the inpatient rehabilitation unit back to the primary service. Of those transferred back, 38% (23/61) died after being transferred back to the primary service. Significant or near significant relationships were found for a platelet count < 43,000 per microliter (p<.01), a creatinine level > 0.9 milligrams/deciliter (p<.01), the presence of an antiviral agent (p=.0501), the presence of an antibacterial agent (p=.0519), the presence of an antifungal agent (p<.05) and leukemia, lymphoma or multiple myeloma diagnosis (p<.05). Using five of these factors the Return to Primary-Bone Marrow Transplant (RTP-BMT) index was formulated to determine the likelihood of return to the primary team.
Bone marrow transplant patients have a high rate of transfer from the inpatient rehabilitation unit back to the primary service. The RTP-BMT score can be a useful tool to help clinicians predict the likelihood of return to the primary acute care service.
Bone marrow transplant; Rehabilitation; Cancer
Palliative care is evolving from end-of-life care to care provided earlier in the disease trajectory. We compared clinical characteristics between patients referred late in the course of their disease (late referrals, LRs) with patients referred earlier (early referrals, ERs).
Six hundred and ninety-five patients referred to the Supportive Care Center (SCC) with follow-up within 30 days were enrolled. One hundred ERs (expected survival ≥2 years or receiving treatment for curative intent, 14.4%) were compared with a random sample of 100/595 consecutive LRs (all others).
ERs were younger (54.4 versus 59.5, p=0.009), more likely to have head and neck cancer (67% versys 6%, p<0.0001), alcoholism (15% versus 4%, p=0.014), and shorter disease duration until first palliative care consultation (3.8 months versus 16.2 months, p<0.0001). They were also more likely to be referred by radiation oncologists (49% versus 3%, p<0.0001), be referred for treatment-related side effects (70% versus 9%, p<0.0001), and receive more anticancer treatment (74% versus 48%, p=0.0002). Head and neck cancer and reason for referral were independent predictors for ERs (p<0.0001) in multivariate analysis. Baseline Edmonton Symptom Assessment System (ESAS) symptoms were similar between ERs and LRs. Both groups exhibited improved ESAS scores at follow-up; LRs experienced greater improvement in the symptom distress score (−5.5 versus −3, p=0.007). The median total number of medical visits was higher in ERs (p<0.001); however, the median number of visits per month was higher in LRs (p<0.001).
ERs had different patient characteristics than LRs, and although ERs experience distress similar to that of LRs, their needs and outcomes differ.
This study determined the frequency, indications, outcomes, and predictors of successful opioid rotation in outpatients with cancer who were receiving strong opioids.
Determine the frequency, indications, and outcomes of opioid rotation in cancer outpatients.Describe the predictors of successful opioid rotation.
Opioid rotation is used to treat uncontrolled pain and/or opioid-related adverse effects. Our aim was to determine the frequency, indications, outcomes, and predictors of successful opioid rotation in outpatients with cancer.
Medical records of consecutive outpatients with cancer who received strong opioids and returned for follow-up visit within ≤6 weeks to our supportive care center from January to December 2008 were reviewed. Data on patient characteristics, symptoms, opioid use, indications for opioid rotation, outcomes, and morphine equivalent daily dose were collected. Successful opioid rotation was defined as a two-point or 30% reduction in the symptom score or the resolution of opioid-induced neurotoxicity and continuation of the new opioid at follow-up.
Opioid rotation was performed in 120 of 385 patients (31%). The median patient age was 55 years. There were 6/120 patients with missing data. Of the 114 evaluable patients, 68 (60%) were men, 81 (71%) were white, 27 (24%) had gastrointestinal cancer, and 90 (80%) had advanced-stage disease. The median Eastern Cooperative Oncology Group score was 1 (interquartile range: 1–2) and the median time between opioid rotation and follow-up was 14 days (interquartile range: 7–21 days). The most common indications for opioid rotation were uncontrolled pain (95/114; 83%) and opioid-induced neurotoxicity (13/114; 12%). A total of 35 patients (31%) had partial opioid rotation. The median improvements in pain and symptom distress score were −2 (interquartile range: −4 to 0; p < .001) and −5 (interquartile range: −14 to 7; p = .004), respectively. The morphine equivalent daily dose did not change significantly after opioid rotation (p = .156). A total of 65% of patients (74/114) had successful opioid rotation. There were no clinically significant independent predictors for successful opioid rotation.
Opioid rotation was conducted in 31% of outpatients with cancer, with a 65% success rate. The most frequent reason for opioid rotation was uncontrolled pain. There were no independent predictors for successful opioid rotation.
Pain; Opioid rotation; Outpatient; Palliative care; Opioid-induced neurotoxicity
Delirium is a frequently under-recognized complication in patients with advanced cancer. Uncontrolled delirium eventually leads to significant distress to patients and their families. However, delirium episodes can be reversed in half of these patients by eliminating precipitating factors and using appropriate interventions. The purpose of this narrative review is to discuss the most recent updates in the literature on the management of delirium in patients with advanced cancer. This article addresses the epidemiology, cause, pathophysiology, clinical characteristics, and assessment of delirium as well as various treatment options, including nonpharmacologic intervention and palliative sedation.
Delirium; Advanced Cancer
Our aim is to describe the growth and staffing structure of a palliative care program at a comprehensive cancer center.
During fiscal years (FYs) ending in 2000 through 2010, we recorded all billed palliative care consultations and follow-ups. In order to determine the yearly clinical burden per physician, advanced practice nurse (APN) and physician assistant (PA), we calculated the mean number of patient encounters per clinical full time equivalents. Increase in absolute number of patient encounters and relative (%) growth from year to year were calculated.
Over the 10 year history of the program, the number of outpatient consultations tripled while inpatient consults increased from 73 to 1880. In all cases, with the exception of the 1st year of operation, the vast majority of clinical activity was in the inpatient hospital setting. Growth in the ratio of inpatient consultations per operational hospital beds was noted during the first 5 years of the program, followed by a more modest increase in the succeeding 5 years. In FY 2010, palliative care physicians had 6.2 patient encounters per working day, and APN/PAs, independently evaluated and treated 4.0 additional patients.
Over the 10 year history, there has been an increase in the number of patient consultations seen by our palliative care program. The clinical burden was manageable during the first 3 years but quickly became too burdensome. Active recruitment of new faculty was required to sustain the increased clinical activity.
Palliative care; program development; workforce staffing; supportive care
The reporting of funding support and conflict of interest has not been examined in the supportive/palliative oncology literature.
We examined the frequency of funding and conflict of interest reporting and various study characteristics associated with such reporting.
We systematically searched MEDLINE PubMed, PsycInfo, EMBASE, ISI Web of Science, and CINAHL for original studies related to palliative care and cancer in the first six months of 2004 and 2009. For each article, we reviewed the study design, research topic, journal type, and reporting of funding and conflict of interest.
Three hundred forty-four (41%) and 504 (59%) of 848 articles were from 2004 and 2009, respectively. Five hundred two of 848 (59%) studies reported no funding sources, whereas 216 (26%), 70 (8%), 34 (4%), and 26 (3%) reported one, two, three, and four or more sources, respectively. Key funding sources included governmental agencies (n = 182/848, 21%), philanthropic foundations (n = 163/848, 19%), university departments (n = 76/848, 9%), and industry (n = 27/848, 3%). Conflict of interest was not reported in 436 of 848 (51%) studies, and only 94 of 848 (11%) explicitly stated no conflict of interest. Other than extramural funding, conflict of interest reporting of any kind was extremely rare (mostly less than 1%). Conflict of interest reporting increased between 2004 and 2009 (39% vs. 55%, P < 0.001). Both funding and conflict of interest reporting were associated with prospective studies, larger sample sizes, nontherapeutic studies, North American authors, and publication in palliative care/oncology journals (P ≤ 0.008 for all comparisons).
A majority of supportive/palliative oncology studies did not report funding sources and conflict of interest, raising the need for standardization.
Neoplasms; palliative care; literature; funding; conflict of interest
The vast majority of patients with cancer at the end of life receive parenteral hydration in hospitals and no hydration in hospice, with limited evidence supporting either practice. In this randomized controlled trial, we determined the effect of hydration on symptoms associated with dehydration, quality of life, and survival in patients with advanced cancer.
Patients and Methods
We randomly assigned 129 patients with cancer from six hospices to receive parenteral hydration (normal saline 1 L per day) or placebo (normal saline 100 mL per day) daily over 4 hours. The primary outcome was change in the sum of four dehydration symptoms (fatigue, myoclonus, sedation and hallucinations, 0 = best and 40 = worst possible) between day 4 and baseline. Secondary outcomes included Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Nursing Delirium Screening Scale (NuDESC), Unified Myoclonus Rating Scale (UMRS), Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F), Dehydration Assessment Scale, creatinine, urea, and overall survival. Intention-to-treat analysis was conducted to examine the change by day 4 ± 2 and day 7 ± 2 between groups.
The hydration (n = 63) and placebo (n = 66) groups had similar baseline characteristics. We found no significant differences between the two groups for change in the sum of four dehydration symptoms (−3.3 v −2.8, P = .77), ESAS (all nonsignificant), MDAS (1 v 3.5, P = .084), NuDESC (0 v 0, P = .13), and UMRS (0 v 0, P = .54) by day 4. Results for day 7, including FACIT-F, were similar. Overall survival did not differ between the two groups (median, 21 v 15 days, P = .83).
Hydration at 1 L per day did not improve symptoms, quality of life, or survival compared with placebo.
Constipation is often inadequately assessed and underdiagnosed in patients with advanced cancer. Many studies use patient-reported constipation as an outcome.
The aim was to compare the accuracy of patient-reported constipation as compared with the modified Rome III (ROME) criteria and to determine the agreement between patient-reported constipation, physician assessment of constipation, and objective assessment of constipation by modified ROME criteria among outpatients with advanced cancer.
Patients with advanced cancer attending a supportive care clinic were screened. Constipation was assessed using the modified ROME criteria, patient report (yes or no and rated 0-10; 10 = worst possible symptom), and physician assessments (yes or no and rated 0-10).
One hundred patients were enrolled and 50 of 100 (50%) patients met the modified ROME criteria for constipation. Disagreement between ROME criteria and the patient report (yes/no) was found in 33 patients (33%), and between ROME criteria and the physician assessment (yes/no) in 39 (39%). The best combination of sensitivity (0.84) and specificity (0.62) was found with scores ≥ 3/10 for patient-reported constipation.
We found a high frequency of constipation. The limited agreement with modified ROME criteria suggests that a patient’s self-report as yes or no is not useful for clinical practice. Patient self-rating on a 0 to 10 scale (score of three or greater) seems to be the best tool for constipation screening among this population. More research is needed to identify the best way to assess constipation in advanced cancer patients
Constipation; assessment; Rome criteria; advanced cancer; palliative care
Pain; neoplasm; intrathecal analgesia; palliative care; psychological distress
The proportion of cancer patients who received palliative care at a comprehensive cancer center and the predictors of palliative care referral were determined. The majority of cancer patients did not access palliative care before they died.
Palliative care (PC) is a critical component of comprehensive cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually receive PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center and the predictors of PC referral.
We reviewed the charts of consecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center who died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death.
In total, 366 of 816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range, 0.5–4.2 months) and the median number of medical team encounters before PC was 20 (interquartile range, 6–45). On multivariate analysis, older age, being married, and specific cancer types (gynecologic, lung, and head and neck) were significantly associated with a PC referral. Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between an advanced cancer diagnosis and PC consultation (median, 16 months), the shortest interval between PC consultation and death (median, 0.4 months), and one of the largest numbers of medical team encounters (median, 38) before PC.
We found that a majority of cancer patients at our cancer center did not access PC before they died. PC referral occurs late in the disease process with many missed opportunities for referral.
Health services; Neoplasms; Palliative care; Quality of health care; Referral and consultation
Multiple organizations have raised concerns about the lack of standard definitions for terminology in the supportive and palliative oncology literature.
We aimed to determine: 1) the frequency of 10 commonly used terms in the supportive and palliative oncology literature; 2) the proportion of articles that provided definitions for each term; and 3) how each term was defined.
We systematically searched MEDLINE, PubMed, PsycINFO, the Cochrane Library, Embase, ISI Web of Science, and CINAHL for original studies, review articles and systematic reviews related to palliative care and cancer in the first six months of 2004 and 2009. We counted the number of occurrences for “palliative care,” “supportive care,” “best supportive care,” “hospice care,” “terminal care,” “end-of-life,” “terminally ill,” “goals of care,” “actively dying,” and “transition of care” in each article, reviewed them for the presence of definitions, and documented the journal characteristics.
Among the 1213 articles found, 678 (56%) were from 2009. “Palliative care” and “end-of-life” were the most frequently used terms. “Palliative care,” “end-of-life” and “terminally ill” appeared more frequently in palliative care journals, while “supportive care” and “best supportive care” were used more often in oncology journals (P<0.001). Among 35 of 601 (6%) articles with a definition for “palliative care,” there were 16 different variations (21 of 35 articles used the World Health Organization definition). “Hospice care” had 13 definitions among 13 of 151 (9%) articles. “Supportive care” and other terms were rarely defined (less than 5% of articles that used the term).
Our findings highlight the lack of definitional clarity for many important terms in the supportive and palliative oncology literature. Standard definitions are needed to improve administrative, clinical and research operations.
Palliative care; supportive care; neoplasms; literature; terminology; definitions
Palliative care programs are rapidly evolving in acute care facilities. Increased and earlier access has been advocated for patients with life-threatening illnesses. Existing programs would need major growth to accommodate the increased utilization. The objective of this review is to provide an update on the current structures, processes, and outcomes of the Supportive and Palliative Care Program at the University of Texas M.D. Anderson Cancer Center (UTMDACC), and to use the update as a platform to discuss the challenges and opportunities in integrating palliative and supportive services in a tertiary care cancer center. Our interprofessional program consists of a mobile consultation team, an acute palliative care unit, and an outpatient supportive care clinic. We will discuss various metrics including symptom outcomes, quality of end-of-life care, program growth, and financial issues. Despite the growing evidence to support early palliative care involvement, referral to palliative care remains heterogeneous and delayed. To address this issue, we will discuss various conceptual models and practical recommendations to optimize palliative care access.
The incidence of cancer increases with advanced age. And as the world population
ages, clinicians will be faced with a growing number of older patients with
cancer. The challenge that clinicians face involves carefully choosing the type
of therapeutic care plan that is most appropriate given a person’s level
of physical reserve, medical comorbidities, and psychosocial resources.
Inclusion of assessment tools in clinical practice such as a comprehensive
geriatric assessment can assist clinicians in identifying patients who will
benefit from aggressive cancer care or palliative measures. The role of
palliative care, especially in the frail older patient, is critical in improving
quality of life. Improvement in best care practices in older patients with
cancer requires their inclusion in clinical trials.
Advance cancer; Geriatric patient; Palliative care; Supportive care; Symptom management
Background music can be used to distract from ordinary sounds and improve wellbeing in patient care areas. Little is known about individuals' attitudes and beliefs about music versus ordinary sound in this setting.
To assess the preferences of patients, caregivers and healthcare providers regarding background music or ordinary sound in outpatient and inpatient care areas, and to explore their attitudes and perceptions towards music in general.
All participants were exposed to background music in outpatient or inpatient clinical settings. 99 consecutive patients, 101 caregivers and 65 out of 70 eligible healthcare providers (93%) completed a survey about music attitudes and preferences. The primary outcome was a preference for background music over ordinary sound in patient care areas.
Preference for background music was high and similar across groups (70 patients (71%), 71 caregivers (71%) and 46 providers (71%), p=0.58). The three groups had very low disapproval for background music in patient care areas (10%, 9% and 12%, respectively; p=0.91). Black ethnicity independently predicted lower preference for background music (OR: 0.47, 95%CI: 0.23, 0.98). Patients, caregivers and providers reported recent use of music for themselves for the purpose of enjoyment (69%, 80% and 86% respectively p=0.02). Age, gender, religion and education level significantly predicted preferences for specific music styles.
Background music in patient care areas was preferred to ordinary sound by patients, caregivers and providers. Demographics of the population are strong determinants of music style preferences.
To determine the effects of thalidomide and placebo on anorexia-cachexia and its related symptoms, body composition, resting metabolic rate, and serum cytokines and their receptors in patients with advanced cancer.
Included in the study were patients with advanced cancer with weight loss greater than 5% in 6 months and who reported anorexia, fatigue, and one of the following: anxiety, depression, or sleep disturbances. Patients on chemotherapy within 2 weeks prior or during the study were excluded from the study. Patients were randomly assigned to either 100 mg thalidomide or placebo once a day for 14 days. The Edmonton Symptom Assessment Scale (ESAS), Functional Assessment of Anorexia/Cachexia Therapy (FAACT), Functional Assessment of Cancer Illness Therapy (FACIT-F), Hospital Anxiety Depression Scale (HADS) Pittsburgh Sleep Quality Index (PSQI) were utilized, and in addition body composition, Resting Energy Expenditure (REE), and serum cytokine levels were assessed.
Of the 31 patients entered in the study, 15 were assigned to the thalidomide group and 16 to the placebo group. However only 21/31 patients were able to complete the study. Compared with their baseline values, both the thalidomide and the placebo groups showed significant reduction in cytokines. Tumor necrosis factor (TNF)-α (p=0.04) and its receptors TNFR1 (p=0.04), TNFR2 (p=0.04), and interleukin (IL)-8 (p=0.04) were statistically significant in the thalidomide group. In the placebo group, TNF-α (p=0.008), TNFR1 (p=0.005), TNFR2 (p=0.005), IL-RA (p=0.005), IL-6 (p=0.005), and IL-8 (p=0.005) were statistically significant. However, improvement in these symptoms and cytokine levels were not significantly different in the thalidomide group compared with the placebo group. None of the patients withdrew from the study because of toxicity of either thalidomide or placebo.
Based on the poor accrual rate and attrition observed in this study, it is important that future research on thalidomide as a treatment for cancer-related anorexia-cachexia symptoms (ACS) in patients with advanced cancer use less stringent entry criteria and less exhaustive outcome measures.
Breast cancer patients with a pathologic complete response (pCR) to neoadjuvant chemotherapy were compared with nonresponding controls to evaluate associations among a pCR, survival outcomes, and sarcopenia as well as the combination of sarcopenia and a high body mass index (BMI). Overweight patients had a lower pCR rate and shorter progression-free survival time. Among patients with a normal BMI, the pCR rate was better in sarcopenic patients.
Overweight women diagnosed with breast cancer have greater recurrence and mortality risks. Recent studies in advanced cancer showed that the combination of sarcopenia and an overweight or obese body mass index (BMI) is associated with poor clinical outcomes.
To compare pathological complete response (pCR) cases with controls and evaluate associations among a pCR, survival outcome, and sarcopenia as well as the combination of both sarcopenia and a BMI ≥25 kg/m2.
Sixty-seven breast cancer patients with a pCR to neoadjuvant chemotherapy (NC) were matched with controls who did not have a pCR to NC. Patients were matched by age, Black's nuclear grading system, clinical cancer stage, and estrogen receptor and progesterone receptor status. Body composition was analyzed using computed tomography images taken prior to NC.
BMI was associated with pCR. Among normal weight patients, the pCR rate was higher in sarcopenic patients and the progression-free survival (PFS) interval was significantly longer than in overweight or obese BMI patients. The death hazard was 2% higher for each unit higher skeletal muscle index and 0.6% higher for each unit higher visceral adipose tissue.
Overweight patients treated with NC had a lower pCR rate and shorter PFS time. Among patients with a normal BMI, the pCR rate was better in sarcopenic patients. More research is required to evaluate the negative impact of sarcopenic obesity on prognosis and the contributors to better response rates in operable, normal weight breast cancer patients with sarcopenia.
Breast cancer; Body composition; Clinical outcome
Cancer pain initiatives recommend using the personalized pain goal (PPG) to tailor pain management. This study was conducted to examine the feasibility and stability of PPG, and how it compares to the clinical pain response criteria.
Records of 465 consecutive cancer patients seen in consultation at the Supportive Care Clinic were reviewed. Pain relief was assessed as clinical response (≥30% or ≥2 point pain reduction), and PPG-response (pain≤PPG).
152 (34%), 95 (21%), and 163 (37%) patients presented with mild (1-4), moderate (5-6), and severe (7-10) pain, respectively. Median age (59 years), males(52%), advanced cancer status (84%) did not differ by pain category. Median PPG at initial clinic consult was 3 (interquartile range 2-3), similar across pain groups, and remained unchanged (p=0.57) at follow-up (median 14 days). Clinical response was higher among patients with severe pain (60%) as compared to moderate (40%) and mild pain (33%, p<0.001). PPG-response was higher among patients with mild pain (63%) as compared to moderate (44%) and severe pain (27%, p< 0.001). Using PPG-response as gold standard for pain relief, the sensitivity of clinical response was highest (98%) among patients with severe pain, but had low specificity (54%). In patients with mild pain, clinical response was most specific for pain relief (98%), but had low sensitivity (52%).
PPG is a simple patient reported outcome for pain goals. Majority of patients were capable of stating their desired level for pain-relief. The median PPG was 3, and it was highly stable at follow-up assessment.
Acute palliative care units (APCUs) provide intensive symptom support and transition of care for advanced cancer patients. Better understanding of the predictors of in-hospital mortality is needed to facilitate program planning and patient care. In this prospective study, we identified predictors of APCU mortality, and developed a four-item In-hospital Mortality Prediction in Advanced Cancer Patients (IMPACT) predictive model.
Between April and July 2010, we documented baseline demographics, the Edmonton Symptom Assessment Scale (ESAS), 80 clinical signs including known prognostic factors, and 26 acute complications on admission in consecutive APCU patients. Multivariate logistic regression analysis was used to identify factors for inclusion in a nomogram, which was cross-validated with bootstrap analysis.
Among 151 consecutive patients, the median age was 58, 13 (9%) had hematologic malignancies, and 52 (34%) died in the hospital. In multivariate analysis, factors associated with in-hospital mortality were advanced education (odds ration [OR]=11.8, p=0.002), hematologic malignancies (OR=8.6, p=0.02), delirium (OR=4.3, p=0.02), and high ESAS global distress score (OR=20.8, p=0.01). In a nomogram based on these four factors, total scores of 6, 10, 14, 17, and 21 corresponded to a risk of death of 10%, 25%, 50%, 75%, and 90%, respectively. The model has 92% sensitivity and 88% specificity for predicting patients at low/high risk of dying in the hospital, and a receiver-operator characteristic curve concordance index of 83%.
Higher education was associated with increased utilization of the interdisciplinary palliative care unit until at the end of life. Patients with higher symptom burden, delirium, and hematologic malignancies were also more likely to require APCU care until death.
The authors comment on the discussions of their work published in a recent issue of The Oncologist.
Opioid dose escalation may cause hyperalgesia, mediated by the N-methyl-D-aspartate (NMDA) pathway. Methadone is an atypical opioid that inhibits hyperalgesia through NMDA-blockade, especially at low doses.
To evaluate the efficacy of using very-low-dose methadone as the sole long-acting opioid agent in a hospice practice.
A retrospective, observational study of the use of methadone, ≤15 mg daily, with as-needed short-acting opiates. Adjuvant nonopioid medications included haloperidol, which may have NMDA-blocking effects.
We reviewed the records of 240 patients admitted to a community-based hospice from July 1, 2011 to April 1, 2012, with data collected until hospice discharge or until April 30, 2012.
Descriptive statistics were used to summarize patient demographics, medication regimens, and reported pain scores measured on a numeric rating scale from 0 to 10.
All patients received short-acting opiates, in a morphine-equivalent dose of 5 mg every 4 hours as needed, while 40% also received methadone at a median daily dose of 5 mg. Of those on methadone, almost half received scheduled haloperidol. The population had a median reported pain score of 0 and a peak score of 3, with similar results seen for cancer and noncancer groups. Two-thirds of patients never reported a pain score greater than 3.
The use of very-low-dose methadone in conjunction with adjuvant haloperidol resulted in excellent pain control without dose escalation or opioid-induced hyperalgesia, for both cancer and noncancer diseases. We conclude that low-dose methadone should be part of first-line treatment in palliative pain management.
This study aimed to review quantitative literature pertaining to studies of music-based interventions in palliative cancer care and to review the neurobiological literature that may bare relevance to the findings from these studies.
A narrative review was performed, with particular emphasis on RCTs, meta-analyses, and systematic reviews. The Cochrane Library, Ovid, PubMed, CINAHL Plus, PsycINFO, and ProQuest were searched for the subject headings music, music therapy, cancer, oncology, palliative care, pain, anxiety, depression, mood, quality of life, prevalence, neuroscience, functional imaging, endogenous opioids, GABA, 5HT, dopamine, and permutations of these same search terms. Data for the review were comprised of articles published between 1970 and 2012. References of all the cited articles were also reviewed.
Available evidence suggests that music-based interventions may have a positive impact on pain, anxiety, mood disturbance, and quality of life in cancer patients. Advances in neurobiology may provide insight into the potential mechanisms by which music impacts these outcomes.
More research is needed to determine what subpopulation of cancer patients is most likely to respond to music-based interventions, what interventions are most effective for individual outcomes, and what measurement parameters best gauge their effectiveness.
Music; Cancer; Oncology; Palliative; Neurobiology
Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US healthcare system in the late 1990s. The National Cancer Policy Board (NCPB), a twenty-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system, where patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. This report outlined ten recommendations, which, when implemented, would: 1) improve the quality of cancer care; 2) increase our understanding of quality cancer care; and, 3) reduce or eliminate access barriers to quality cancer care.
Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating healthcare costs, has prompted national efforts to reform the healthcare system. These efforts by healthcare providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States.
Oncology Service; Hospital; Quality of Health Care; Benchmarking; Guideline Adherence; Medically Uninsured; Palliative Care; Comparative Effectiveness Research
In the U.S., patients with advanced cancer who are dehydrated or have decreased oral intake virtually always receive parenteral hydration in acute care facilities but rarely in the hospice setting.
To describe the meaning of hydration for terminally ill cancer patients in home hospice care and for their primary caregivers.
Phenomenological interviews were conducted at two time points with 85 patients and 84 caregivers enrolled in a randomized, double-blind, controlled trial examining the efficacy of parenteral hydration in patients with advanced cancer receiving hospice care in the southern U.S. Transcripts were analyzed hermeneutically by the interdisciplinary research team until consensus on the theme labels was reached.
Patients and their family caregivers both saw hydration as meaning hope and comfort. Hope was the view that hydration might prolong a life of dignity and enhance quality of life by reducing symptoms such as fatigue and increasing patients’ alertness. Patients and caregivers also described hydration as improving patients’ comfort by reducing pain, enhancing the effectiveness of pain medication, and nourishing the body, mind and spirit.
These findings differ from traditional hospice beliefs that dehydration enhances patient comfort given that patients and their families in the study viewed fluids as enhancing comfort, dignity and quality of life. Discussion with patients and families about their preferences for hydration may help tailor care plans to meet specific patient needs.
Parenteral hydration; advanced cancer; hospice; qualitative; caregivers
Clinicians typically rely on their own or the nurses' clinical impression (NI) of symptoms rather than patient self-reports. It is unclear whether these means of assessment yield similar results.
To prospectively compare patient-reported symptoms on a modified Edmonton Symptom Assessment System (ESAS) with NI scores.
Consecutive patients with advanced cancer admitted to our acute palliative care unit between April and July 2010 were studied. We collected the results of the ESAS on the day of admission (D1) to the unit and 2 days later (D3). We also collected the NI of each patient's physical and psychological distress on D1 and D3.
One hundred eighteen patients completed the ESAS on D1 and 116 on D3. On D1 there was no significant association between NI score and ESAS assessment except for dyspnea, which was weakly correlated with NI score for physical distress (r=0.22, p=0.02). The median ESAS physical and psychosocial scores were 31 and 12 in patients with NI of low or no physical distress, versus 34 (p=0.07) and 15 (p=0.18) in patients with NI of moderate or severe distress, respectively. On D3, we found a significant association between ESAS and NI only for pain (r=0.32, p<0.001) and anxiety (r=0.30, p=0.001). Sensitivity and specificity of the NIs for ESAS scores were low on both days.
The clinical impression of highly trained palliative care nurses showed poor association with patient-reported symptom intensity. Validated symptom assessment tools are needed for bedside clinical assessment.