Carmen P. Escalante

Outpatient Treatment of Febrile Episodes in Low-Risk Neutropenic Patients with Cancer

Background. Hospitalization and intravenous (IV) broad‐spectrum antibiotics are the standard of care for all febrile neutropenic patients with cancer. Recent work suggests that a low‐risk population exists who might benefit from an alternate approach.

Evaluation of antineoplastic drug exposure of health care workers at three university-based US cancer centers

Objective: This study evaluated health care worker exposure to antineoplastic drugs. Methods: A cross-sectional study examined environmental samples from pharmacy and nursing areas. A 6-week diary documented tasks involving those drugs. Urine was analyzed for two specific drugs, and blood samples were analyzed by the comet assay. Results: Sixty-eight exposed and 53 nonexposed workers were studied. Exposed workers recorded 10,000 drug-handling events during the 6-week period. Sixty percent of wipe samples were positive for at least one of the five drugs measured. Cyclophosphamide was most commonly detected, followed by 5-fluorouracil. Three of the 68 urine samples were positive for one drug. No genetic damage was detected in exposed workers using the comet assay. Conclusions: Despite following recommended safe-handling practices, workplace contamination with antineoplastic drugs in pharmacy and nursing areas continues at these locations.

Dyspnea in cancer patients: Etiology, resource utilization, and survival-Implications in a managed care world

Dyspnea is the fourth most common symptom of patients who present to the emergency department (ED) at The University of Texas M. D. Anderson Cancer Center and may, in some patients with advanced cancer, represent a clinical marker for the terminal phase of their disease. This retrospective study describes the clinical characteristics of these patients, the resource utilization associated with the management of dyspnea, and the survival of patients with this symptom.

Chromosome 5 and 7 abnormalities in oncology personnel handling anticancer drugs.

Objective: To determine the frequency of “signature” chromosomal abnormalities in oncology workers handling anticancer drugs. Methods: Peripheral blood from health care personnel (N = 109) was examined with probes for targets on chromosomes 5, 7, and 11. The effect of drug-handling frequency on chromosome abnormalities was assessed. Results: An excess of structural (0.18 vs 0.02; P = 0.04) and total abnormalities (0.29 vs 0.04; P = 0.01) of chromosome 5 was observed in the high-exposure group compared with the unexposed. Increased incidence rate ratios (IRRs) for abnormalities of chromosome 5 (IRR = 1.24; P = 0.01) and for either chromosome 5 or 7 (IRR = 1.20; P = 0.01) were obtained at 100 handling events. Effect sizes were augmented 2- to 4-fold when alkylating agent handling alone was considered. Conclusions: Biologically important exposure to genotoxic drugs is apparently occurring in oncology work settings despite reported use of safety practices.

Treatment of febrile neutropenic patients with cancer who require hospitalization: A prospective randomized study comparing imipenem and cefepime

The objective of the current study was to compare the efficacy and safety of imipenem and cefepime in the treatment of adult patients with cancer who had fever and neutropenia requiring hospitalization according to Infectious Disease Society of America criteria.

Comorbid disease and cancer : The need for more relevant conceptual models in health services research

Theadverseconsequencesofcomorbidityposeamajor clinical challenge in the care of older cancer patients. While the burden of comorbidity is clearly a major prognostic factor for long-term survival, the underlying mechanisms are not well understood. Health services research that focuses on specific comorbidities and their effects in a cancer patient’s clinical trajectory can produce new insights into the optimal diagnosis, treatment, and long-term surveillance of cancer patients with comorbid disease. This information can then be used to design interventions that improve prognosis. We propose a conceptual model of comorbidity and cancer that can guide this research. The model illustrates the potential impact of a specific comorbidity at multiple points of a patient’s clinical trajectory, from cancer detection through diagnosis and treatment. Comorbid illness is a significant concern in patients with cancer. 1,2 For example, patients with severe underlying chronic obstructive pulmonary disease are not good candidates for resection of a lung malignancy, and therefore their chance of cure is decreased. 3,4 Similarly, a diagnosis of congestive heart failure precludes some cancer treatments. 5,6 Comorbid disease is also a competing cause of death. This is particularly true for older patients with cancer, who comprise the majority of new cancers diagnosed.

Cancer-Related Fatigue: The Approach and Treatment

As the volume of cancer survivors continues to increase, clinicians are being faced with a growing number of patients with cancer-related fatigue (CRF). Survivors with a variety of malignancies may experience fatigue. Many potential barriers to the identification of this symptom in a cancer survivor may exist, due in part to both the patient and the clinician. Assessment of patients for fatigue is important because it can profoundly effect their daily lives. Many factors contribute to CRF. Hence, the clinician may face a daunting challenge in attempting to alleviate CRF. Treatment modalities for CRF include nonpharmacologic interventions, such as psychosocial interventions, exercise, sleep therapy, and acupuncture. Pharmacologic interventions include stimulants, namely modafinil and methylphenidate. In some patients antidepressants may be beneficial. Clinicians should assess cancer survivors for the presence of fatigue and focus on its treatment in an attempt to ensure that these patients have the best possible symptom control.As the volume of cancer survivors continues to increase, clinicians are being faced with a growing number of patients with cancer-related fatigue (CRF). Survivors with a variety of malignancies may experience fatigue. Many potential barriers to the identification of this symptom in a cancer survivor may exist, due in part to both the patient and the clinician. Assessment of patients for fatigue is important because it can profoundly effect their daily lives. Many factors contribute to CRF. Hence, the clinician may face a daunting challenge in attempting to alleviate CRF. Treatment modalities for CRF include nonpharmacologic interventions, such as psychosocial interventions, exercise, sleep therapy, and acupuncture. Pharmacologic interventions include stimulants, namely modafinil and methylphenidate. In some patients antidepressants may be beneficial. Clinicians should assess cancer survivors for the presence of fatigue and focus on its treatment in an attempt to ensure that these patients have the best possible symptom control.

Treatment of cancer-related fatigue: an update

Abstract. Fatigue, a common complaint of cancer patients, requires a multidisciplinary evaluation and treatment approach because of the multiple etiologies and contributing factors. Current treatments for fatigue include educating patients and caregivers about fatigue, applying etiology-specific treatments, utilizing nonpharmacologic interventions, and prescribing pharmacologic therapies. Often, an individualized treatment plan that includes several modalities may be developed. Presently, there is a lack of well-designed clinical trials to evaluate pharmacologic agents for the treatment of cancer-related fatigue.

Identifying risk factors for imminent death in cancer patients with acute dyspnea.

A substantial proportion of cancer patients presenting to an emergency center (EC) or clinic with acute dyspnea survives fewer than 2 weeks. If these patients could be identified at the time of admission, physicians and patients would have additional information on which to base decisions to continue therapy to extend life or to refocus treatment efforts on palliation and/or hospice care alone. The purpose of this study was to identify risk factors for imminent death (survival </= 2 weeks) and short-term survival (1, 3, or 6 months) in cancer patients presenting to an EC with acute dyspnea and to combine these factors into a model to help clinicians identify patients with short life expectancies. A random sample of 122 patients presenting to an EC with acute dyspnea was selected for a retrospective analysis. Data that were available to physicians during the initial EC visit included patient histories, triage and discharge vital signs, chest radiographs, and laboratory results. These variables were used in univariate and logistic regression models to develop predictive models for imminent death and short-term survival. Variables and interactions meeting a univariate criterion of P < 0.10 were included in stepwise regression by using forward and backward stepping. Models were compared with the use of Hosmer-Lemeshow statistics and receiver operating characteristics curves. Underlying cancers were 30% breast, 37% lung, and 34% other cancers. Triage respiration greater than 28/min., triage pulse greater than or equal to 110 bpm, uncontrolled progressive disease, and history of metastasis were found to be statistically significant predictors (alpha </= 0.05) of imminent death. Patients with uncontrolled progressive disease had a relative risk of imminent death of 21.93. Relative risks for triage respiration, pulse, and metastases were 12.72, 4.92, and 3.85, respectively. Cancer diagnosis was not predictive of imminent death but was predictive when longer time periods were modeled. It may be possible to identify patients whose death is imminent from a group of cancer patients with acute dyspnea. Some factors that predict imminent death (triage pulse and respiration) differ from those (cancer diagnosis) that predict short-term survival. Extent of disease/response to treatment is common to all models. These factors need further examination and validation. If these findings are confirmed, this quantified information can help physicians in making difficult end-of-life decisions.

A Randomized, Double-blind, 2-Period, Placebo-Controlled Crossover Trial of a Sustained-Release Methylphenidate in the Treatment of Fatigue in Cancer Patients

PurposeThis study assessed the efficacy of methylphenidate versus placebo for cancer-related fatigue reduction. Other objectives were to analyze cytokine levels and to determine the effects of methylphenidate on other symptoms, cognitive function, work yield, and patients’ perceptions and preferences. MethodsPatients were randomly assigned (1:1) to receive methylphenidate-placebo or placebo-methylphenidate for 4 weeks. Patients crossed over after 2 weeks. Wilcoxon signed rank tests and McNemar tests were used to assess continuous and categorical variables. The primary efficacy endpoint was change in the level of worst fatigue on the Brief Fatigue Inventory (BFI) at the end of each 2-week period. ResultsThe mean baseline BFI score was moderate (5.7). Methylphenidate treatment did not affect patients’ worst level of fatigue or other symptoms. Results from the Wechsler Adult Intelligence Scale Digit Symbol Test and the Hopkins Verbal Learning Test with BFI interference questions and BFI activity questions showed significant improvement in the methylphenidate-treated patients’ verbal learning, memory, visual perception, analysis, and scanning speed. Patients treated with methylphenidate missed significantly fewer work hours owing to health reasons and worked significantly more hours. After 4 weeks, 64% of patients reported that methylphenidate improved their cancer-related fatigue, and 58% wanted to continue treatment. Significant difference in interleukin 6R (positive), interleukin 10 (negative), and tumor necrosis factor &agr; (positive) was noted between the methylphenidate and the placebo group. ConclusionsLow-dose methylphenidate did not improve cancer-related fatigue. Patients taking methylphenidate had better cognition and were able to work more hours. Patients tolerated methylphenidate well, and the majority felt better and wanted to continue treatment.