Catherine M. Neumann

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 patients 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.

Attitudes and beliefs of palliative care physicians regarding communication with terminally ill cancer patients

The subject of communication between palliative care physicians and their patients regarding their diagnosis and prognosis has not been extensively researched. The purpose of this survey was to compare the attitudes and beliefs of palliative care specialists regarding communication with the terminally ill in Europe, South America, and Canada. A sample of palliative care physicians from South America (Argentina and Brazil), French-speaking Europe, and Canada were identified, and posted a questionnaire. Physicians who stated that they practised palliative care at least 30% of their time were considered evaluable as palliative care specialists. Of a total of 272 questionnaires, 228 were returned (84%); and 182/228 (81%) respondents were considered to be palliative care specialists. Palliative care physicians in all three regions believed that cancer patients should be informed of their diagnosis and the terminal nature of their illness. Physicians reported that at least 60% of their patients knew their diagnosis and the terminal stage of their illness in 52% and 24% of cases in South America, and 69% and 38% of cases in Europe, respectively. All physicians agreed that ‘do not resuscitate’ orders should be present, and should be discussed with the patient in all cases. While 93% of Canadian physicians stated that at least 60% of their patients wanted to know about the terminal stage of their illness, only 18% of South American, and 26% of European physicians said this (P < 0.001). Similar results were found when the physicians were asked the percentage of families who want patients to know the terminal stage of their illness. However, almost all of the physicians agreed that if they had terminal cancer they would like to know. There was a significant association between patient based decision-making and female sex (P = 0.007), older age (P = 0.04), and physicians from Canada and South America (P < 0.001). Finally, in their daily decision making, South American physicians were significantly more likely to support beneficence and justice as compared with autonomy. Canadian physicians were more likely to support autonomy as compared with beneficence. In summary, our findings suggest that there are major regional differences in the attitudes and beliefs of physicians regarding communication at the end of life. More research is badly needed on the attitudes and beliefs of patients, families, and health care professionals in different regions of the world.

Thalidomide in patients with cachexia due to terminal cancer: preliminary report.

Anorexia/cachexia occurs in approximately 80% of patients with advanced cancer [1]. These patients experience progressive weight loss, and complain of complex symptoms such as anorexia, chronic nausea, fatigue, sleep disorders and decreased sensation of well being. Recently, it has been recognized that cachexia and many of its symptoms are at least partially due to the production of cytokines as a response of the host to neoplastic disease [1, 2]. Tumor necrosis factor-a (TNF-a), a cytokine, is one of the likely mediators of cancer cachexia [2]. Thalidomide, a mild anxiolytic and antiemetic, is capable of reducing the production of TNF-a both in vitro and in vivo [3, 4], and also has anti-angiogenic effects. Because of its ability to reduce the production of TNF-a, thalidomide has been used in AIDS associated cachexia, which is similar to cancer induced cachexia. Thalidomide is very effective in halting and reversing weight loss in AIDS associated cachexia [5, 6]. The usefulness of thalidomide in cancer cachexia has not yet been examined. Therefore, we present our experience with thalidomide in an open study with advanced cancer patients suffering from cachexia.

The Impact of a Regional Palliative Care Program on the Cost of Palliative Care Delivery

In July 1995 the Edmonton Regional Palliative Care Program (ERPCP) was established in the City of Edmonton to increase the access of patients with terminal cancer to palliative care services, decrease the number of cancer deaths in acute-care facilities, and increase the participation of family physicians in the care of terminally ill patients. The objective of this retrospective study was to determine the cost of implementation of the ERPCP and savings in acute-care facility costs after its implementation. We did this by comparing the cost of care for patients during 1992-93 (prior to the ERPCP) and 1996-97 (with the ERPCP). The main outcome measures were the cost of care and the total hospital stay in days for all patients during their last acute-care hospital admission. The increased funding for the ERPCP was offset by a significant decrease in the overall cost of palliative care in the acute-care facilities. There was a substantial decrease in the palliative care costs in acute facilities from 11,963,846 dollars in 1992/93 to 3,449,055 dollars in 1996/97. This can be explained by the significant decrease in the number of palliative care patient days in acute-care facilities from 22,608 during 1992/93 to 6085 during 1996/97. Physician billings were slightly higher for 1996 as compared to 1992. In 1992, 90% (195,117/427,780) of the billings were made by the specialists (internists, surgeons, and other specialists), while in 1996/97 67% (359,869/537,342) of the payments were made to primary care practitioners (p < 0.0001). Overall, there were estimated saving of 1,650,689 dollars for palliative care costs in 1996/97 as compared to 1992/93. Our results suggest that the establishment of an integrated palliative care program reduced the cost of care. Prospective cost measurement studies are required.

The uses of psychotropics in symptom management in advanced cancer

Approximately 50% of patients diagnosed with cancer die because of progressive disease. Psychotropic drugs are frequently used for the management of physical and psychosocial symptoms in these patients. Thalidomide, cannabinoids and melatonin are emerging agents for the management of cachexia. Psychostimulants have a defined role in the management of opioid‐induced sedation. Haloperidol, tricyclic anti‐depressants and newer anti‐depressants also have an established role in the management of neuropsychiatric symptoms such as delirium or depression. Cancer patients present unique challenges for successful psychotropic therapy including older age, malnutrition, autonomic failure, borderline cognition, opioid and psychotropic therapy. A practical clinical approach which defines a specific target symptom, an outcome latency period, expected side effects, and reviews possible drug interactions, and frequent monitoring is outlined. Continued research is needed to further define the role of psychotropics in the management of the different physical and psychosocial symptoms in advanced cancer patients.

A randomized controlled trial of local injections of hyaluronidase versus placebo in cancer patients receiving subcutaneous hydration

BACKGROUND Most cancer patients develop reduced oral intake or dehydration before death. Subcutaneous hydration (SCH) can be safe and effective. SCH is frequently administered using hyaluronidase to improve fluid absorption. The objective of this study was to determine the effects of hyaluronidase on patient comfort during bolus SCH. PATIENTS AND METHODS Twenty-one cancer patients requiring parenteral hydration were administered a 500 cc bolus of two-thirds dextrose (5%) and one-third normal saline solution subcutaneously at 08:00 and 16:00 hours during day 1 and day 2. On day 1 patients were randomized on a double-blind basis to receive 150 units of hyaluronidase versus placebo as a bolus into the site of infusion immediately before starting each one-hour infusion. During day 2 patients were crossed over to receive the alternate treatment at a new infusion site. Visual analogue scales (0 = best, 100 = worst) for pain and swelling at the infusion site were completed by each patient. In addition, investigators blindly assessed the site of infusion for the presence of edema, rash, and leakage. RESULTS No significant differences were observed for pain, swelling, edema, rash or leakage between the placebo and the hyaluronidase scores. After completion of the two days of the study, patients blindly chose hyaluronidase in 1 (5%) case, placebo in 5 (24%) cases, and no preference in 15 (71%) cases (P < 0.01). There was no treatment or interaction effect for pain, except for a period effect (P = 0.045) for the morning bolus administration. There were no treatment, period, or interaction effects for any of the other variables. CONCLUSIONS Our results suggest that hyaluronidase is not necessary for routine bolus SCH. It may still be useful for a minority of patients who are not able to tolerate infusion well due to swelling or pain.

Respective limits of palliative care and oncology in the supportive care of cancer patients.

Abstract Advanced cancer patients develop a number of devastating physical and psychosocial symptoms before death. In recent years, there have been great advances in our knowledge on the appropriate assessment and management of many of the physical and psychosocial symptoms. There is also increasing understanding on the need for patients and families to receive appropriate follow-up and to have access to multiple settings for optimal care. Unfortunately, both models developed on the basis of palliative care/hospice and those developed on the basis of supportive care/oncology have failed to achieve these goals. Future models for the delivery of supportive cancer care will have to consider the need to ensure that patients receive a consistent level of assessment and management up to the time of death, that there is appropriate flexibility, to allow patients to access multiple levels of care in the trajectory of their illness, and that there is a significant contribution to the body of knowledge and future education of health care professionals. These programs will need to develop individually for each country with due consideration for the structure of the health care system, the structure of the academic system, and the financing of health care in different regions of the world.

Bus rounds for medical congresses on palliative care

Abstract Three 4-hour bus rounds were organized as part of an international palliative care congress, to promote patient-based education both at home and in acute care hospitals. Patient cases were presented and discussed en route to and from each visit. A total of 23 medical specialists visited 16 patients (10 in three different hospitals and 6 at home). A mean of 5.3 cases were presented during each round. A total of nine journal club articles were presented, a mean of three (2–4) articles per round. A questionnaire was filled out anonymously by all 23 participants. On a scale of 1 (worst) to 5 (best) they gave the rounds an overall rating of 5 (range 4–5). These findings suggest bus rounds provide an opportunity for intensive exposure to patient-based learning, both in acute care hospitals and at home.