Report of the Fourteenth International Symposium of the Foundation for Promotion of Cancer Research: Pain Control, Palliative Medicine and Psycho-oncology.
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Anxiety↗
Biomedical subjects
E Bruera
Publications and source records attributed to E Bruera.
Clinical research in palliative care: patient populations, symptoms, interventions and endpoints.
Clinical trials in palliative care involve multiple issues relating to patient populations, interventions and endpoints. Careful data collection and analysis of variables are vital for good clinical research in this complex area.
Data Collection↗
Clinical research in palliative care: choice of trial design.
Prospective controlled clinical trials provide the highest level of evidence in palliative care. Both parallel and crossover studies have unique advantages and disadvantages. Excellent knowledge of the patient population, interventions and endpoints are useful in choosing the most appropriate trial. Open pilot studies can assist the investigator in understanding the intervention and measurement tools better before embarking in costly and lengthy controlled trials. More controlled clinical trails are need to generate the evidence that will advance patient management in palliative care.
Cross-Over Studies↗
Palliative care on the net: an online survey of health care professionals.
A survey was conducted to explore Internet use by palliative care health professionals (HCP). The survey was placed on the World Wide Web with an underlying database, and palliative care HCP were invited to participate via a palliative-care-related website, listserv, and newsletter. A total of 417 evaluable responses were received over a four-month period. Of these, 36% indicated they were from physicians and 30% from nurses, a third of respondents were practicing palliative care full time. Although 63% of respondents were from North America, regions from all over the world were represented. Eighty-eight percent of respondents were searching the Internet for clinical information, 80% were using email, 69% were accessing online medical journals, and 59% were subscribers to a palliative-care-related listserv or newsgroup. This survey illustrates the global outreach of the Internet and draws attention to the growing interest in the use of the Internet for education, research, and clinical use. Further development of online resources should address the needs of users. Evaluation of these resources is called for.
Adult↗
Pharmacologic management of nonpain symptoms in surgical patients.
Palliative care patients present with multiple symptoms other than pain and cachexia. Asthenia, delirium, dyspnea, and chronic nausea and constipation cause significant distress to patients and families and frequently coexist in the same patient. A careful assessment frequently identifies reversible causes. When none are identified or there is no improvement, symptomatic pharmacologic interventions are available. The success rate is variable, and it is very high for symptoms such as chronic nausea or constipation and less effective for symptoms such as asthenia and delirium. More research on the mechanism and treatment of these symptoms is needed.
Algorithms↗
Research opportunities in palliative medicine.
Patients who require palliative care have many physical and psychosocial needs. Their families also require care and advice. Despite recent advances in assessment and management, major issues relating to palliative care for patients and their families remain unanswered. Several challenges face researchers in this area. We discuss administrative issues, including historical development, funding, academic recognition, integration of services, and cooperation among different centers. Methodological challenges in patient issues and trial design are outlined, and areas for future research are proposed.
Humans↗
Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide.
BACKGROUND: The practices of euthanasia and physician-assisted suicide remain controversial. OBJECTIVE: To achieve better understanding of attitudes and practices regarding euthanasia and physician-assisted suicide in the context of end-of-life care. DESIGN: Cohort study. SETTING: United States. PARTICIPANTS: 3299 oncologists who are members of the American Society of Clinical Oncology. MEASUREMENTS: Responses to survey questions on attitudes toward euthanasia and physician-assisted suicide for a terminally ill patient with prostate cancer who has unremitting pain, requests for and performance of euthanasia and physician-assisted suicide, and sociodemographic characteristics. RESULTS: Of U.S. oncologists surveyed, 22.5% supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain and 6.5% supported euthanasia. Oncologists who were reluctant to increase the dose of intravenous morphine for terminally ill patients in excruciating pain (odds ratio [OR], 0.61 [95% CI, 0.48 to 0.77]) and had sufficient time to talk to dying patients about end-of-life care issues (OR, 0.79 [CI, 0.71 to 0.87]) were less likely to support euthanasia or physician-assisted suicide. During their career, 3.7% of surveyed oncologists had performed euthanasia and 10.8% had performed physician-assisted suicide. Oncologists who were reluctant to increase the morphine dose for patients in excruciating pain (OR, 0.58 [CI, 0.43 to 0.79]) and those who believed that they had received adequate training in end-of-life care (OR, 0.86 [CI, 0.79 to 0.95]) were less likely to have performed euthanasia or physician-assisted suicide. Oncologists who reported not being able to obtain all the care that a dying patient needed were more likely to have performed euthanasia (P = 0.001). CONCLUSIONS: Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.
Adult↗
Use of trade names of drugs in abstracts from pain congresses.
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Abstracting and Indexing↗
Clinical survival predictors in patients with advanced cancer.
BACKGROUND: The clinical and epidemiological relevance of different prognostic factors for survival in patients with advanced or terminal cancer remains controversial. PURPOSES: To establish the survival of patients with cancer after diagnosis of terminal disease and to determine the predictors of survival. METHODS: An inception cohort of 227 consecutive patients aged 18 years or older with terminal cancer of the lung, breast, and gastrointestinal tract were observed from July 1, 1996, through December 31, 1998. Tumor- and treatment-specific, clinical, laboratory, demographic, and socioeconomic variables were recorded at baseline. The relationships between these characteristics and survival time were examined using univariate Kaplan-Meier and multivariate Cox regression analyses. RESULTS: At the time of data analysis, 208 patients (91.6%) had died; the overall median survival for the sample was 15.3 weeks. Shorter survival was independently associated (P< or =.05) with a primary tumor of the lung (vs breast and gastrointestinal tract combined), liver metastases, moderate to-severe comorbidity levels (vs absent-to-mild levels), weight loss of greater than 8.1 kg in the previous 6 months, serum albumin levels of less than 35 g/L, lymphocyte counts of less than 1 X 10(9)/L, serum lactate dehydrogenase levels of greater than 618 U/L, and clinical estimation of survival by the treating physician of less than 2 months (vs 2-6 and >6 months). Performance status, symptoms other than nausea and vomiting, tumor burden, and socioeconomic characteristics such as social support and education and income levels did not appear to be independently associated with survival after adjusting for the effect of prognostic factors. CONCLUSIONS: Simple clinical and laboratory assessments are useful aids in the prediction of survival in patients with solid malignant neoplasms at the onset of terminal stages. Methodological improvements in the design and implementation of survival studies may reduce prognostic uncertainty and ultimately provide better care for the terminally ill patients and their families.
Adult↗
A survey of mouth pain and dryness in patients with advanced cancer.
An 11-item face-to-face survey was conducted in 99 consecutive patients with advanced cancer to determine the prevalence, intensity, reporting and treatment, presumed cause(s), and importance of mouth pain and dryness. Sixteen of the 99 patients (16%) reported experiencing mouth pain at a mean intensity corresponding to 5.5 +/- SD 2.21 on a 0 (no pain) to 10 (worst possible pain) numerical scale, and 88 (88%) patients reported dry mouth at a mean intensity corresponding to 6.2 +/- SD 2.21. Nine (56%) of the 16 patients with mouth pain and 39 (44%) of the 88 patients with mouth dryness reported these symptoms to their attending physician(s). Sixty-nine percent (27/39) of patients who reported having a dry mouth were advised by their physician(s) to pursue one or more treatments. The most common treatments recommended (and frequencies) were drinking water/taking sips of fluid (13), gargling with bicarbonate mouthwash (4), using an artificial saliva spray (4), and using an oral fungal suspension for thrush (4). The most common findings on oral examination included: possible thrush (53 patients), upper and lower dentures (33 patients), and multiple dental restorations (23 patients). The causes most frequently assumed to be responsible were ill-fitting dentures for mouth pain, and medications and possible oral fungal infections for mouth dryness. The mean values given for the importance of the symptoms of mouth pain and dryness relative to other symptoms or problems experienced by the patients were 4.4 +/- SD 1.84 and 3.6 +/- SD 1.67, respectively, on a Likert scale ranging from 1 (not important) to 7 (great importance). Mouth dryness was more frequently reported than mouth pain. The mean rating for the intensity of mouth pain was higher than that for mouth dryness, although both were of moderate importance to patients relative to other symptoms or problems experienced at the time. Patients tended to underreport mouth pain and dryness, and physicians tended to address such complaints inadequately.
Adult↗
Regional pain syndromes in cancer patients.
Pain is one of the cardinal presenting symptoms in cancer patients and often seems to progress in the natural history of the disease. In light of the past neglect of this problem, it is becoming crucial for clinicians and researchers in the fields of oncology, pain management, and others dealing with this patient population to have a thorough understanding of the often complex pain syndromes that are relevant to managing cancer. In this article we briefly review the important topics related to cancer pain syndromes with some emphasis on those that typically generate localized pain.
Humans↗
Difficulties in diagnosing neuropsychiatric complications of corticosteroids in advanced cancer patients: two case reports.
Because of their variety of uses, corticosteroids are frequently prescribed in advanced cancer patients. Two patients who developed neuropsychiatric complications on corticosteroids and their subsequent management are described. The first patient, who had a known history of steroid-induced psychotic depression, required corticosteroids to treat recurrent brain edema from a malignant meningioma. The patient was managed by using low-dose corticosteroids and concomitant haloperidol. The second patient was prescribed corticosteroids for a constellation of symptoms, including pain and nausea from a possible bowel obstruction, and developed a severe delirium that required discontinuation of the corticosteroids. The difficulties of diagnosing steroid-related cognitive and mood changes in advanced cancer patients who often have multisystem disease are discussed, as well as strategies for minimizing the effects of corticosteroids' neuropsychological complications.
Adrenal Cortex Hormones↗
The frequency and correlates of dyspnea in patients with advanced cancer.
Dyspnea is a devastating symptom in patients with advanced cancer. Unfortunately, very limited research has been done on the frequency and correlates of dyspnea in this particular patient population. The purpose of this prospective study was to assess the frequency of moderate to severe dyspnea and the correlates of dyspnea in a population of ambulatory terminally ill cancer patients. One hundred thirty-five consecutive patients attending a multidisciplinary pain clinic were tested for respiratory function (vital capacity, peak flow, maximal inspiratory pressure, and oxygen saturation). All patients gave their rating of dyspnea, anxiety, and fatigue/tiredness using visual analogue scales (VAS). Lung involvement by the tumor (primary or metastatic) was determined from the patient's chart. Moderate dyspnea occurred in 74/135 (55%) patients with terminal cancer. Lung involvement (r = 0.285, P = 0. 0009), anxiety (r = 0.306, P = 0.0003), fatigue/tiredness (r = 0.211, P = 0.0146), and vital capacity (r = -0.189, P = 0.0444) were significantly correlated with the intensity of dyspnea. Multivariate analysis demonstrated that lung involvement (P = 0.0016) and anxiety (P = 0.0027) were independently correlated with the intensity of dyspnea. In the subgroup of patients with moderate to severe dyspnea, multivariate analysis found anxiety (P = 0.0318) and maximal inspiratory pressure (P = 0.0187) to be independent correlates of the intensity of dyspnea. Dyspnea is a frequent symptom in patients with advanced cancer. The presence of cancer in the lungs, anxiety, and maximal inspiratory pressure are correlates of the intensity of dyspnea in this patient population. Possible treatments addressing low maximal inspiratory pressure and anxiety are needed, as well as further research in finding new correlates of dyspnea in advanced cancer patients.
Aged↗
A double-blind, crossover study of controlled-release metoclopramide and placebo for the chronic nausea and dyspepsia of advanced cancer.
To compare a novel controlled-release formulation of metoclopramide with placebo in patients with cancer-associated dyspepsia syndrome, 26 adult patients with a >/=1 month history of cancer-associated dyspepsia syndrome were randomized to receive either controlled-release metoclopramide 40 mg every 12 hours or matching placebo for a period of 4 days. On day 5, patients crossed over to the alternate treatment for a further period of 4 days. Dose adjustments and rescue antiemetics were permitted during both phases. Nausea, anorexia, bloating, vomiting/retching, and drowsiness were assessed on a 100-mm VAS scale in a daily diary. On the last day of treatment of each phase, nausea was significantly lower in the controlled-release metoclopramide group compared to placebo (17 +/- 12 mm versus 12 +/- 10 mm). Nausea scores tended to increase across days during the placebo phase and to decrease during the controlled-release metoclopramide phase. There was a trend for improvement in the intensity of all symptoms on controlled-release metoclopramide with the exception of appetite, but this trend only reached statistical significance for nausea. The frequency and severity of elicited adverse events did not differ significantly between treatments, although drowsiness, dizziness, and poor sleep were somewhat higher in the placebo group. In no case was it necessary to discontinue controlled-release metoclopramide because of toxicity. These results indicate that controlled-release metoclopramide reduces gastrointestinal symptoms in this population of advanced cancer patients.
Aged↗
Recent onset of abdominal pain in a patient with advanced breast cancer.
Abdominal pain is a frequent complaint heard in medical practice. For palliative care patients, there are numerous causes of abdominal pain. Because of the non-invasive nature of palliative care practice, emphasis is made on minimal investigations. We present a case of a 49-year old patient who developed progressive abdominal pain and was found to have gangrenous appendicitis. The patient underwent surgery and was able to be discharged home. Our findings suggest that any new pain in a cancer patient must be carefully evaluated. Because of the presence of opioid analgesics and corticosteroids, symptoms can be less severe and related to diagnosis in palliative care patients.
Breast Neoplasms↗
High-dose ketamine in the management of cancer-related neuropathic pain.
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Analgesics↗
An international survey of undergraduate medical education in palliative medicine.
A 9-item mail survey dealing with availability and characteristics of undergraduate medical education programs in palliative medicine was sent to all medical schools in Canada (16) and the United Kingdom (UK) (30), and 129 randomly selected medical schools in the United States (US) and Western Europe. The overall response rate was 117/175 (67%). The highest percentage of mandatory (required by the university) rotations in palliative medicine was in the UK medical schools (14/22, 64%). Considerably lower numbers were obtained from the other countries: US; 4/37, 11%, Canada; 2/14, 14%, and Western Europe; 8/43, 19% (P = 0.001). Elective rotations in palliative medicine were more readily available in the UK; 18/22, 82% and Canada; 10/14, 71%, compared with the US; 23/37, 62%, and Western Europe; 13/43, 30% (P=0.001). Seventy-two percent (13/18) of UK, 70% (7/10) of Canadian, 59% (16/27) of US, and 9/30 (30%) of Western European medical schools provide educational reading material in palliative medicine (P = 0.014). Case-based learning in small groups and small group discussion were favored by the UK, 14/22 (63%) and 17/22 (77%), respectively, and Canadian medical schools, 8/14 (57%) and 8/14 (57%), respectively (P = 0.176). The number of universities with academic faculty positions for palliative medicine and the median number of positions for the countries were as follows-Canada 8/13 (62%) and 2; UK 12/22 (55%) and 1; US 5/36 (14%) and 1; and Western Europe 9/24 (21%) and 1, respectively (P = 0.001). Besides the UK, mandatory (required) rotations in undergraduate palliative medicine education are lacking in Canadian, US, and Western European medical schools. The median number of 1 academic faculty member per responding medical school is discouraging. In order for undergraduate and postgraduate medical education in palliative medicine to improve, the number of both educational programs and faculty members will need to be increased.
Canada↗