Cathann Manderson

Does aromatherapy massage benefit patients with cancer attending a specialist palliative care day centre

A randomised controlled pilot study was carried out to examine the effects of adjunctive aromatherapy massage on mood, quality of life and physical symptoms in patients with cancer attending a specialist unit. Participants were randomised to conventional day care alone or day care plus weekly aromatherapy massage using a standardised blend of oils for four weeks. At baseline and at weekly intervals, patients rated their mood, quality of life and the intensity and bother of two symptoms most important to them. Forty-six patients were recruited to the study. Due to a large number of withdrawals, only 11 of 23 (48%) patients in the aromatherapy group and 18 of 23 (78%) in the control group completed all four weeks. Mood, physical symptoms and quality of life improved in both groups. There was no statistically significant difference between groups in any of the outcome measures. Despite a lack of measurable benefit, all patients were satisfied with the aromatherapy and wished to continue. Whilst this pilot study has shown that a randomised controlled trial of complementary therapy is feasible, it has also identified several areas that would require further consideration when designing future studies, e.g., the recruitment and retention of appropriate numbers of patients and the outcome measures used.

Pilot study of nasal morphine-chitosan for the relief of breakthrough pain in patients with cancer.

Breakthrough pain in patients with cancer is common, often unpredictable, and can rapidly become severe. Treatment using the oral administration of opioids is not optimal due to the slow onset of pain relief. Nasal administration of analgesics potentially offers more rapid pain relief. This study investigates the tolerability and efficacy of a novel morphine-chitosan formulation. Twenty episodes of breakthrough pain were observed in 14 patients with cancer who received 5-80 mg of nasal morphine-chitosan. Nasal symptoms, sedation, giddiness, nausea, and other volunteered symptoms, along with pain scores (pain intensity and pain relief), were recorded at baseline and at regular intervals up to 4 hours after administration, together with an overall satisfaction rating. The formulation was acceptable to patients, generally well tolerated, and had an onset of pain relief 5 minutes after dosing. This formulation warrants further study.

Randomised, placebo controlled trial of nebulised furosemide for breathlessness in patients with cancer

Background: Breathlessness is a common and difficult symptom to treat in patients with cancer. Case reports suggest that nebulised furosemide can relieve breathlessness in such patients but few data are available. Method: Patients with primary or secondary lung cancer and a Dyspnoea Exertion Scale score of ⩾3 were recruited. Following familiarisation, patients received either nebulised furosemide 40 mg or nebulised 0.9% saline under double blind conditions or no treatment, in random order on 3 consecutive days. Patients undertook number reading and arm exercise tests to assess breathlessness and its impact, and were asked to report subjective benefit and any preference between nebulised treatments. Results: 15 patients took part. There were no differences between furosemide, saline and no treatment in the outcomes of the number reading test (eg, mean number read per breath was 6.7, 6.4 and 6.7, respectively) or arm exercise test (eg, mean Borg score at maximum equivalent workload was 2.3, 2.5 and 2.7, respectively). No adverse effects were reported, although there was a small fall in forced expiratory volume in 1 s and forced vital capacity following saline. Six patients considered that their breathlessness improved with nebulised treatment, three preferring saline, one furosemide and two reporting they were of equal benefit. Conclusions: Our findings do not support a beneficial effect from nebulised furosemide in patients with cancer related breathlessness. Listed on the National Research Register (N0170118249) and the UK Clinical Research Network Portfolio Database (1428).

Factors influencing exercise performance in thoracic cancer

BACKGROUND Patients with incurable thoracic cancer often complain of a reduced ability to exercise, but the cause of this has been little studied. Thus, we have explored how various physiological and psychological factors relate to exercise performance in this group. METHODS Inspiratory muscle strength, peripheral muscle power, lung function and mastery over breathlessness were assessed using sniff nasal inspiratory pressure, leg extensor power, simple spirometry and the mastery domain of the Chronic Respiratory Disease Questionnaire respectively. Exercise performance was assessed using the Incremental Shuttle Walking Test (ISWT) during which patients wore a K4 b(2) system permitting measurement of resting and breakpoint heart rate, minute ventilation (VE) and oxygen uptake (VO(2)). Relationships between ISWT distance and the four factors were determined using correlation and β regression coefficients. RESULTS Forty-one patients (21 male, mean (SD) age 64 (8) years) walked a median [IQR] of 320 [250-430] metres and reached a mean (SD) of 76 (10), 77 (25), and 48 (14) of their percent predicted maximum heart rate, VO(2), and VE respectively. Exercise performance was significantly associated only with inspiratory muscle strength (r = 0.42, P < 0.01) and peripheral muscle power (r = 0.39, P = 0.01). These factors were also significant determinants of exercise performance (β coefficients [95%CI] 1.77 [0.53, 3.01] and 1.22 [0.31, 2.14] respectively). CONCLUSION Of the factors examined, only inspiratory and peripheral muscle performance were significantly related to and predictive of exercise performance. Rehabilitation interventions which include inspiratory and peripheral muscle training are worth exploring further in this group of patients with thoracic cancer.

When will I get my breath back? Recovery time of exercise-induced breathlessness in patients with thoracic cancer.

Breathlessness is a common symptom in thoracic cancer. It mpacts adversely on physical activity levels and the resultant econditioning may exacerbate the decline in physical capacity 1,2]. Therapeutic exercise can help counter this downward spiral nd a rehabilitation approach is recommended [3–5]. A prerequiite to encourage exercise is the provision of appropriate assurance hat breathlessness per se is not dangerous, and that it will settle ith rest [4,5]. To our knowledge, the time taken for breathlessess to recover following exertion has not been formally studied n patients with thoracic cancer. To better inform patient and carer xpectations and the advice given by professionals, we have colated recovery data from two studies in which the Incremental huttle Walk Test (ISWT) was used to assess exercise performance n this group. The methods employed have been published in full [6,7]. atients underwent an ISWT [8] and at breakpoint, i.e. the point t which they were unable to continue or maintain the required alking speed, they reported the main symptom(s) limiting their xercise together with the severity of their breathlessness on modified Borg scale; this was repeated every minute until educed to their baseline value. Recovery time was described by Kaplan–Meier curve. Fifty-seven patients (30 male; mean (SD) age 63 (8) years; % redicted FEV1 60 (19); FEV1:FVC 0.72 (0.19)) with non-small cell 42), mesothelioma (11) and small cell (4) cancer took part; 31 had tage IV disease, the remainder stage III. To date 46 patients have ied with a median [IQR] survival of 39 [24–61] weeks. At baseline ll but four patients (each scoring 0.5 ‘very, very slight’) rated their reathlessness as 0 ‘none at all’. Patients walked a median [IQR] istance of 360 [270–510] m over a mean (SD) test duration of 373 116) s. Main reasons given for stopping were shortness of breath lone (37), shortness of breath and leg fatigue equally (13) and leg atigue alone (6). At breakpoint, median [IQR] values for breathlessess were 3 ‘moderate’ [2 ‘slight’–4 ‘somewhat severe’] and ranged etween 0.5 ‘very, very slight’ to 8 ‘very very severe’). Overall, the edian [IQR] time for breathlessness to return to baseline value as 4 [2–5] minutes with a range of 1–7 min (Fig. 1). These data indicate that even when undertaking a progressive xercise test to a symptom-limited maximum, breathlessness levls recover rapidly, and can be used to support the assurances

Symptoms limiting activity in cancer patients with breathlessness on exertion: ask about muscle fatigue

Rehabilitation is an integral part of cancer care and aims to maximise the functional ability and independence of patients, whatever the stage of their disease.1 To help achieve this, there is a need to identify which (if any) symptoms limit the patient’s ability to undertake activities of daily living. Patients with cancer commonly report breathlessness on exertion, and practitioners may assume that the breathlessness is the limiting symptom and may not enquire about peripheral muscle fatigue, even though this is known to contribute to exercise limitation in patients with cardiopulmonary disease and …

How practical are transmucosal fentanyl products for breakthrough cancer pain? novel use of placebo formulations to survey user opinion

Background Three transmucosal fentanyl products have recently been licensed for cancer-related breakthrough pain: a sublingual tablet, a buccal/sublingual tablet and a nasal spray. Limited comparative data hinder identifying the most appropriate to use and adopt onto a service formulary. However, the availability of placebo formulations provides a unique opportunity to compare the practical aspects of their use. Methods 30 patients with cancer accessed and administered a placebo of each product and were asked to rate them using 1–7 Likert agree–disagree scales and free-text responses, with regard to ease of access and administration, palatability and overall impression. Participants rated their usual rescue analgesic similarly, based on recall. They also indicated whether they would be prepared to use the fentanyl product, and their most preferred. Results For accessibility, the usual rescue analgesic was rated best (median score 3), significantly better than the buccal/sublingual tablet (p=0.01) and nasal spray (p<0.01), but not the sublingual tablet. Conversely, the nasal spray was rated significantly worse (median score 7) than the others (p<0.01). For ease of administration, the usual rescue analgesic and sublingual tablet were rated equally best (median score 1), with only the latter being significantly different to the buccal/sublingual tablet (p=0.04) and nasal spray (p=0.05). For palatability, the sublingual tablet was rated the best (median score 2), but was significantly different only to the buccal/sublingual tablet (p<0.01). For overall impression, the sublingual tablet was rated significantly better (median score 3) than the others, with more patients prepared to use it and selecting it as their most preferred (27 and 18, respectively). Conclusion This survey provides valuable insight into the practical aspects of these three transmucosal fentanyl products for practitioners considering their use.

Prolongation of the QT interval in palliative care patients

Prolonged QT interval on the electrocardiogram (ECG) is associated with an increased risk of cardiac arrhythmia and sudden death. Many drugs used in palliative medicine increase the QT interval and several have had their licenses withdrawn or severely restricted. The relative importance of prolonged QT interval will increase for palliative medicine physicians when dealing with patients with longer prognoses and especially cardiac disease. Given these safety concerns, the aim of this study was to determine the prevalence of a prolonged QT interval in palliative care patients who were not in the terminal stage and were referred to a specialist service. Of 300 patients, 47 (16%) had prolonged QTc but only two had QT >500ms. The presence of coexistent cardiac disease or high levels of serum alkaline phosphatase appear to be the clinical features most robustly associated with a prolonged QTc. Although prolonged QTc is relatively common in patients referred to a specialist palliative care service, severely prolonged QT is rare.

Exploring autonomic nervous system dysfunction in patients with cancer cachexia: A pilot study

INTRODUCTION Abnormalities of the autonomic nervous system (ANS) have been associated with cachexia. METHODS In nine cancer patients who had lost weight and nine age-matched healthy volunteers heart rate variability (HRV) components were determined, together with serum cortisol and urinary catecholamines/metanephrines. RESULTS Compared to volunteers, patients exhibited a global reduction in HRV parameters, significantly so for high frequency, low frequency and total power (median values ms(2) 103 vs. 313, 62 vs. 148 and 316 vs. 736 respectively, P<0.05). Biochemical values did not differ. CONCLUSION Our results suggest the presence of ANS dysfunction in patients with cancer cachexia, with reduction in both sympathetic and parasympathetic components.

Development and testing of a cancer appetite and symptom questionnaire

BACKGROUND Poor appetite and weight loss are common in patients with cancer, contributing to an increase in morbidity and mortality. Early identification of those at greatest risk is problematic. The Council on Nutrition Appetite Questionnaire (CNAQ) is short and easy to use, although it is not specific to cancer populations. The present study aimed to build on the CNAQ to develop a cancer appetite and symptom questionnaire (CASQ) for predicting weight loss in patients with cancer. METHODS The content validity of the CNAQ was assessed by an expert panel (n = 41) using the content validity index (CVI). The resulting CASQ was tested for reliability among patients receiving radiotherapy (n = 34). Predictive validity of the CASQ was determined in patients with lung or upper gastrointestinal cancer (n = 185), comparing CASQ scores (possible range 0-48) recorded at baseline with percentage weight change after 12 weeks. RESULTS  In all but one CNAQ item, the CVI was above the minimum level of agreement (>0.70). Comments from expert panel members led to minor modifications and the introduction of new items resulting in the 12-item CASQ. The intraclass correlation coefficient of the CASQ was 0.80 [95% confidence interval (CI) = 0.68-0.92] and the difference between total scores at two time points was -0.20 (95% CI = -1.21 to 0.80). The optimum cut-off point of the instrument to predict >10% weight loss was 29/30 (area under curve = 0.75; sensitivity 71%, specificity 66%, positive predictive value 19%, negative predictive value 95%) [Correction added on 30 April 2012, after first online publication: in the preceding sentence, <10% was corrected to >10%]. CONCLUSIONS The CASQ can predict weight loss among patients with lung and upper gastrointestinal cancer. Acknowledgment of the low positive predictive value is needed if the instrument is to be used within clinical practice.