Álvaro Sanz Rubiales

The use of psychostimulants in cancer patients.

Purpose of reviewThis article reviews the most recent studies that examine the efficacy of psychostimulants for the relief of symptoms such as asthenia and depression in cancer patients. Recent findingsAlthough most research to date has focused on the use of methylphenidate for the relief of symptoms such as asthenia and depression in cancer patients, there is growing interest in the use of modafinil, a psychostimulant with a structure and mechanism that differs from other drugs belonging to this group. Initial studies mainly investigated the treatment of depressive symptoms in patients with advanced cancer; however, more recent studies have evaluated the use of psychostimulants in cancer-related fatigue identifying subgroups of patients and clinical settings in which psychostimulants are most efficient. SummaryFor the relief of chemotherapy symptoms in cancer patients, methylphenidate and modafinil were no more effective than placebo, although findings suggest that these psychostimulants may provide some benefit in patients who are suffering more severe asthenia or who are at advanced stages of the cancer. Methylphenidate showed marginal improvement in relation to symptoms such as asthenia and depression in studies in which it was compared with placebo; data from the only phase III study suggest that modafinil is an effective drug for advanced oncology patients.

Spain: Palliative Care Programs in Spain, 2000: A National Survey

Carlos Centeno, MD, Silvia Hernansanz, MD, Luis A. Flores, RN, Alvaro S. Rubiales, MD, and Francisco Lopez-Lara, MD Facultad de Medicina (C.C., S.H., L.A.F., A.S.R., F.L.L.), Universidad de Valladolid; Centro Regional de Cuidados Paliativos y Tratamiento del Dolor (C.C.), Salamanca; Equipo Domiciliario de Cuidados Paliativos (S.H.), Hospital Universitario de Valladolid; Centro de Salud de Medina del Campo (L.A.F.), Valladolid; and Servicio de Oncologia (A.S.R., F.L.L.), Hospital Universitario de Valladolid, Spain.

Impact of a new palliative care consultation team on opioid prescription in a University Hospital

BackgroundThere are no validated measuring tools to gauge the effectiveness of a Hospital Palliative Care Consultation Team (PCCT). One way would be to consider its effect on the consumption of opioids expressed in total amounts and different formulations administered. We perform this study to evaluate the impact of a hospital PCCT on the trends of opioid prescription in a University Hospital.MethodsA seven year retrospective study on opioid prescription was carried out in the Clínica Universidad de Navarra. The period includes three years before and three years after the PCCT was implemented. Prescription was analysed calculating yearly the Defined Daily Dose (DDD) adjusted to 1000 hospital stays (DDD/1000HS). Indicators considered were the proportion of patients treated using opioids compared to the total estimated in need of treatment (rate of effectiveness) and the proportion of patients potentially requiring opioids but not treated who were incorporated into the treatment group (rate of improvement).ResultsFrom 2001 to 2007, total opioid prescription was low in non-oncology Departments (range: 69–110 DDD/1000HS) while parenteral morphine and fentanyl did not register any changes. In the same period of time, total opioid prescription increased in the Oncology Department from 240 to 558 DDD/1000HS. The rate of effectiveness in the three years prior to the implantation of the consultation team was 64% and in the three following years rose to 87%. The rate of improvement prior to the palliative care consultation team was 43% and in the three following years was 64%. A change in opioid prescription was registered after the implementation of the PCCT resulting in an increase in the prescription of parenteral morphine and methadone and a decrease in transdermal fentanyl.ConclusionImplementation of a PCCT in a University Hospital is associated with a higher and more adequate use of opioids.

Survival Analysis in a Randomized Trial of HIPEC in Ovarian Cancer

Spiliotis et al. randomized 120 patients with relapsed ovarian cancer to treatment with cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (HIPEC) before systemic chemotherapy. They showed amazingly positive results favoring the HIPEC arm, with a mean survival double that reported in the non-HIPEC arm (26.7 vs. 13.4 months; p\ 0.006) and a percentage of patients surviving 3 years more than four times higher than in the non-HIPEC arm (75% vs. 18%; p\ 0.01). However, the authors do not explain how they performed the statistical analysis, only that it was conducted using SPSS software. At first view, the Kaplan–Meier plot did not seem to support such big differences, therefore we decided to perform a new analysis (using SPSS 15.0.1; SPSS Inc., Chicago, IL, USA) comparing survival of both arms to define the hazard ratio (HR) for overall survival (log rank) for patients treated with HIPEC. We performed a manual extraction of data from the Kaplan–Meier plot published in the original paper, and were able to extract data from 63 patients (53%). As survival in both arms showed a cumulative survival above 60%, we assumed that the other 57 patients remain alive at last follow-up and that their survival data were censored. With our estimated data, we were able to reproduce the original curve presented by the authors in their article. We conducted two exploratory analyses. The first, assuming that these 57 patients were censored immediately after the last death (at 22 months in the non-HIPEC arm and 34 months in the HIPEC arm), shows an HR of 0.58 [95% confidence interval (CI) 0.28–1.17; p = 0.13). In the second analysis, we assumed that these 57 patients were censored along with the patient with longer follow-up (at 32 months in the non-HIPEC arm and 80 months in the HIPEC arm), with an HR of 0.66 (95% CI 0.33–1.30; p = 0.23). According to these estimations, no significant differences in overall survival could be seen between both arms of the study. We question how the survival analysis was performed, why the authors analyzed mean survival (that use to be biased by patients with longer follow-up, as in this case), and how they entered the data of the censored patients. In addition, we do not understand where the data on the percentage of patients alive at 3 years came from as these results do not fit with the data of the Kaplan–Meier plot that the authors show in their article.

Reacción de llamarada en el cáncer de mama avanzado

• Propósito: La reacción de llamarada se manifiesta de inicio como un aumento aparente de la actividad tumoral inducido por el propio tratamiento. No es raro que se presente como un incremento del metabolismo de las lesiones tumorales, principalmente óseas, sin embargo es infrecuente que aparezca junto con otros problemas como dolor o alteración metabólica. • Material y métodos: Presentamos dos pacientes con cáncer de mama avanzado que desarrollaron esta reacción de llamarada inducida en un caso por el tratamiento hormonal (tamoxifeno) y en el otro por quimioterapia. • Resultados: Ambas pacientes presentaron de inicio un aumento del dolor que sugería progresión de la enfermedad asociado a una elevación de los marcadores. Más tarde se evidenció una clara respuesta del tumor. Destaca el manuscrito en que la propia paciente describe cómo vive los síntomas que se le presentan. • Conclusiones: La reacción de llamarada puede manifestarse como un aparente empeoramiento transitorio de la enfermedad al que sigue la respuesta tumoral.

Carcinoma de células en anillo de sello extramamario tras cáncer de mama: ¿cuándo se trata realmente de un segundo primario?

Resumen • Proposito: Es frecuente que los canceres de mama presenten areas de diferenciacion celular en anillo desello. Ademas, este subtipo celular puede estar presente en las metastasis y no aparecer en el tumor primario. • Material y metodos: Presentamos dos pacientes tratadas por cancer de mama que desarrollaron tumo-res con celulas en anillo de sello, gastrico y endocervical respectivamente, que fueron considerados inicialmen-te como segundos tumores primarios. • Resultados: En ambos casos, el estudio inmunohistoquimico encontro receptores hormonales en las ce-lulas en anillo de sello, lo que oriento al diagnostico de metastasis de cancer de mama. • Conclusiones: El cancer de mama puede desarrollar metastasis con celulas en anillo de sello. La pre-sencia de receptores hormonales en estas celulas tiene una especificad cercana al 100% en el diagnostico dife-rencial entre metastasis de cancer de mama y tumor de origen digestivo.Palabras clave:Carcinoma de mama. Celulas en anillo de sello. Receptores hormonales.Oncologia, 2005; 28 (9):448-452