Carmelita P Escalante

Outcomes of a Cancer-Related Fatigue Clinic in a Comprehensive Cancer Center

Cancer-related fatigue (CRF) is a significant issue for cancer patients and frequently precipitates increased stress and anxiety for patients and caregivers alike. CRF may present well after the initial phase of cancer diagnosis and treatment, regardless of whether the cancer is in remission, widely metastatic, or somewhere in between. Determining whether the etiology of fatigue is potentially reversible and whether it is an effect of treatment or another unrelated cause is often perplexing. Because of the significant impact of CRF on patients at our institution, we organized a CRF clinic and began evaluating patients for fatigue in 1998. Our goal has been to initiate a more focused and, at the same time, more comprehensive effort in educating, evaluating, and treating CRF. The purpose of this report was to present a retrospective review of patients treated in our CRF clinic between 1998 and 2005, to examine the outcomes of our patients, and to briefly describe some of the challenges encountered in treating these patients. This information may help reassess and improve approaches in addressing CRF and subsequently improve fatigue in these patients.

A randomized controlled trial of an intensive insulin regimen in patients with hyperglycemic acute lymphoblastic leukemia

UNLABELLED Hyperglycemia during hyper-CVAD (fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with methotrexate and high-dose cytarabine, with methylprednisolone premedication) chemotherapy is associated with poor outcomes of acute lymphoblastic leukemia (ALL). To examine whether intensive insulin therapy could improve outcomes, a randomized trial was conducted that compared glargine plus aspart vs. conventional therapy. Intensive insulin did not improve ALL clinical outcomes despite improved glycemic control. Secondary analysis suggests that the choice of antidiabetic pharmacotherapy may influence ALL outcomes. INTRODUCTION Hyperglycemia during hyper-CVAD (fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with methotrexate and high-dose cytarabine, with methylprednisolone premedication) chemotherapy is associated with poor outcomes of acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS To examine whether an intensive insulin regimen could improve outcomes compared with conventional antidiabetic pharmacotherapy, a randomized trial was conducted that compared glargine plus aspart vs. conventional therapy (control). Between April 2004 and July 2008, 52 patients newly diagnosed with ALL, Burkitt lymphoma, or lymphoblastic lymphoma who were on hyper-CVAD in the inpatient setting and had a random serum glucose level >180 mg/dL on ≥2 occasions during chemotherapy were enrolled. RESULTS The trial was terminated early due to futility regarding ALL clinical outcomes despite improved glycemic control. Secondary analysis revealed that molar insulin-to-C-peptide ratio (I/C) > 0.175 (a surrogate measure of exogenous insulin usage) was associated with decreased overall survival, complete remission duration and progression-free survival (PFS), whereas metformin and/or thiazolidinedione usage were associated with increased PFS. In multivariate analyses, factors that significantly predicted short overall survival included age ≥ 60 years (P = .0002), I/C ≥ 0.175 (P = .0016), and average glucose level ≥ 180 mg/dL (P = .0236). Factors that significantly predicted short PFS included age ≥ 60 years (P = .0008), I/C ≥ 0.175 (P = .0002), high systemic risk (P = .0173) and average glucose level ≥ 180 mg/dL (P = .0249). I/C ≥ 0.175 was the only significant (P = .0042) factor that predicted short complete remission duration. CONCLUSIONS A glargine-plus-aspart intensive insulin regimen did not improve ALL outcomes in patients with hyperglycemia. Exogenous insulin may be associated with poor outcomes, whereas metformin and thiazolidinediones may be associated with improved outcomes. Analysis of these results suggests that the choice of antidiabetic pharmacotherapy may influence ALL outcomes.

Chronic conditions and health status in older cancer survivors.

BACKGROUND With the aging population and improved cancer care, the number of cancer survivors is steadily increasing. Planning for their care requires an understanding of the impact of cancer and chronic conditions on quality of life. We sought to determine chronic conditions and health status in older cancer survivors compared to controls. METHODS In this retrospective cross-sectional study, we used survey data from 18,133 cancer survivors and 94,407 controls age 65 and older who participated in the Behavioral Risk Factor Surveillance System 2009 telephonic survey. Our main measures were chronic conditions (cardiovascular disease, hypertension, diabetes mellitus, high cholesterol, and arthritis) and poor health status (poor or fair self-rated health). RESULTS Cancer survivors were older, more likely white, had higher education, and slightly more likely to have a healthcare provider and higher levels of emotional support. More survivors reported having 2 or more chronic conditions compared to controls (67.5% vs. 64.5%, respectively). Health status was lower for survivors, and was significantly different by racial/ethnic group. In a multivariable model for health status, having 2 or more chronic conditions was more strongly associated with poorer health status than cancer survivorship. CONCLUSIONS Cancer survivors had slightly higher numbers of chronic conditions and poorer health status than controls. However, chronic conditions were more strongly associated with poor health status than cancer. Monitoring for recurrence and second cancers is important in cancer survivors, but chronic conditions also need to be given priority due to their substantial impact on health status.

Cost-minimization analysis of low-molecular-weight heparin (dalteparin) compared to unfractionated heparin for inpatient treatment of cancer patients with deep venous thrombosis.

GoalsLow-molecular-weight heparin (LMWH) has shown to be as effective as unfractionated heparin (UFH) in the treatment of deep venous thrombosis (DVT). Although the acquisition cost of LMWH is significantly greater than that of UFH, we hypothesized that once-daily dalteparin, a LMWH, could reduce treatment costs of cancer patients with DVT by eliminating anticoagulation monitoring and shortening hospitalization.Patients and methodsWe developed a cost-minimization model by using outcomes and resource utilization data from two retrospective matched cohorts of cancer patients who, between 1994 and 1999, were hospitalized at our comprehensive cancer center for treatment of DVT with either LMWH (n=21) or UFH (n=168). We assumed all LMWHs and UFH to be equally effective. The total costs for the dalteparin strategy and the UFH strategy were calculated in year 2003 U.S. dollars, from the provider’s perspective, by multiplying the number of resources used for inpatient treatment of DVT by their unit costs.ResultsThe mean total cost for inpatient care was

Fatigue and its risk factors in cancer patients who seek emergency care.

3,383 (95% CI=

Research into fatigue

2,683–

Results of General Internal Medicine Consultations for Diabetes Mellitus in 283 Cancer Patients

4,083) for dalteparin and

Diagnostic Evaluation of Patients with a High Suspicion of Malignancy: Comorbidities and Clinical Predictors of Cancer

4,952 (95% CI=

Outcomes and Cost of Deep Venous Thrombosis Among Patients With Cancer

4,718–

Survival in cancer patients after out-of-hospital cardiac arrest

5,185) for UFH. Substantial savings resulted from shorter hospitalization among the dalteparin-treated patients (mean 3.19 versus 5.22 days). Sensitivity analysis did not change the conclusion that dalteparin is less expensive than UFH.ConclusionsSavings realized from less anticoagulant monitoring and shorter hospitalization offset the higher acquisition cost of dalteparin. The dalteparin strategy is less expensive than the UFH strategy for the inpatient treatment of DVT among cancer patients.