Declan Walsh

2016 Updated MASCC/ESMO consensus recommendations: Management of nausea and vomiting in advanced cancer

PurposeThe aim of this paper is to review the existing literature related to the management of nausea and vomiting (N & V) in advanced cancer and derive clinical evidence-based recommendations for its management.MethodsAvailable systematic reviews on antiemetic drug effectiveness were used. One generic systematic review of antiemetics in advanced cancer (to 2009) was updated to February 2016. Agreement on recommendations was reached between panel members, and these were voted in favor unanimously by the larger antiemetic committee membership (nu2009=u200937).ResultsThe evidence base in this field is minimal with largely poor quality trials or uncontrolled trials and case studies. The level of evidence in most studies is low. The drug of choice for managing N & V in advanced cancer is metoclopramide titrated to effect. Alternative options include haloperidol, levomepromazine, or olanzapine. For bowel obstruction, the recommendation is to use octreotide given alongside an antiemetic (haloperidol) and where octreotide is not an option to use an anticholinergic antisecretory agent. For opioid-induced N & V, no recommendation could be made.ConclusionThese new guidelines, based on the existing (but poor) evidence, could help clinicians manage more effectively the complex and challenging symptoms of N & V in advanced cancer.

Subjective taste and smell changes in treatment-naive people with solid tumours

PurposeTaste and smell changes (TSCs) are common in head and neck (H&N) cancer and during and after chemotherapy (CT) and radiotherapy (RT). It is an area that has been under-investigated, particularly in the treatment-naive, but can negatively impact nutritional status. This study examined the prevalence, severity and characteristics of TSCs in people with non-H&N solid tumours, before CT and RT, and their relationship with co-occurring symptoms.MethodsA prospective, observational study was conducted. Forty consecutive pre-treatment cancer patients, referred to radiation oncology outpatients over 6xa0weeks, were recruited. Data on TSCs, symptoms and nutritional status were obtained using the ‘Taste and Smell Survey’ and the ‘abridged Patient-Generated Subjective Global Assessment’ (abPG-SGA). BMI was measured. SPSS® was used for statistical analysis. Two-sided P values <0.05 were considered statistically significant.ResultsMost patients were newly diagnosed (nxa0=xa028; 70xa0%). Nineteen (48xa0%) reported TSCs; nine noted a stronger sweet and seven a stronger salt taste. Of these, four reported a stronger and four a weaker smell sensation. Those at nutritional risk reported more TSCs (nxa0=xa013/20). TSCs were significantly associated with dry mouth (Pxa0<xa00.01), early satiety (Pxa0<xa00.05) and fatigue (Pxa0<xa00.05).ConclusionsTSCs preceded CT or RT in almost half of treatment-naive patients with solid tumours, notably stronger sweet and salt tastes. Half of the study group were at nutritional risk; the majority of these reported TSCs. TSCs were significantly associated with other symptoms. Future research and clinical guidelines, with a common terminology for assessment, diagnosis and management of cancer TSCs, are needed.

Cancer symptom scale preferences: does one size fit all?

Objectives Patients with advanced cancer do not report all symptoms, so assessment is best done systematically. However, for such patients, completion rates of some symptom instruments are <50%. Symptoms can be quantified by various scales including the Categorical Response Scale (CRS), Numerical Rating Scale (NRS) and Visual Analogue Scale (VAS). Patient preferences for CRS, NRS and VAS in symptom assessment and their clinical utility in 3 cancer symptoms: pain, tiredness and appetite loss were determined. Methods A prospective survey was conducted involving cancer admissions to a 36-bed palliative care unit. Results 100 inpatients were recruited, aged 38–93u2005years (x̅ =71u2005years; SD=11.6), with median Eastern Cooperative Oncology Group (ECOG) scores of 2 (range 0–4). VAS was the least preferred measure. 52% of patients choose the same scale for all 3 symptoms and 44% for 2, with 4% choosing a different individual scale per symptom. There was moderate agreement between participant scale preference and observer determined ease of scale completion (loss of appetite: κ=0.36; pain: κ=0.49; tiredness: κ=0.45). Participants preferred CRS for appetite loss (48%) and tiredness (40%) and NRS for pain (44%). Conclusions VAS was the least favoured scale and should be used cautiously in this population. Most participants had a scale preference with high intrapatient consistency between scales. CRS was preferred for appetite loss and tiredness and NRS for pain. Consideration should be given to individualised cancer symptom assessment according to patient scale preference.

Complete oral nutritional supplements: dietitian preferences and clinical practice

ABSTRACT Oral nutritional supplements (ONS) are frequently prescribed for those at risk of malnutrition. Palatability is an important factor in long-term compliance. ONS selection is typically dietitian led, but the degree to which individual perceptions of palatability influence dietitian clinical decision making is unclear. This study aimed to explore factors that influence dietitians ONS clinical practice, evaluate dietitian hedonic preferences and overall impression of specific ONS products, and study phenylthiocarbamide (PTC) sensitivity in relation to ONS hedonic ratings. Dietitians were recruited from six urban teaching hospitals. They completed a 10-item Clinical Practices Questionnaire prior to taste testing five samples of three ONS products. A 7-point hedonic Likert scale recorded ONS palatability ratings. A PTC test was conducted. Thirty-one dietitians were recruited. Nutritional value, patient palatability, patient acceptability, tolerance and hospital contracts were the factors identified as most likely to influence ONS prescription. All ONS were consistently highly rated for overall impression. The high-protein ONS was most highly rated for all hedonic characteristics. Taste was the highest rated hedonic characteristic across all products. No statistically significant relationship was found between PTC sensitivity and ONS overall impression. The key drivers of ONS dietitian clinical practice were identified. ONS hedonic characteristics and overall impression were highly rated, which suggested this range of products had wide appeal for dietetic professionals. The taste and consistency of the ONS were rated better than other hedonic characteristics (appearance, smell, aftertaste).

Oropharyngeal Dysphagia Evaluation Tools in Adults with Solid Malignancies Outside the Head and Neck and Upper GI Tract: A Systematic Review

Dysphagia is often associated with head and neck and upper gastrointestinal (GI) tract cancers. Evidence suggests that those with solid malignancies in other primary sites may also have swallowing difficulties. Timely and accurate identification of dysphagia is important given the impact it has on hydration, medical treatment, nutrition, prognosis, and quality of life. A systematic review was conducted to identify swallow screening, evaluation, and quality of life tools for those with solid malignancies outside the head and neck and upper GI tract. Ten electronic databases, one journal and two published conference proceedings were searched. Following deduplication, 7435 studies were examined for relevance. No tools were validated solely in this cancer population, though some included this group in larger cohorts. Comments are provided on the diagnostic properties and applicability of these tools. In the absence of appropriate diagnostic instruments, the exact prevalence of dysphagia and its impact on clinical and psychosocial well-being remain unknown. Accurate and adequate measurement of therapeutic intervention is also compromised. This review establishes the need for validated dysphagia evaluation tools for this clinical population.

P-24 A clinical audit of xerostomia assessment and treatment practices amongst advanced cancer patients in a palliative care setting

Background Xerostomia is the subjective sensation of dry mouth. It is the fourth most common symptom in advanced cancer patients and impacts negatively on physical and psychosocial wellbeing. Older age and polypharmacy are risk factors for dry mouth and are common in advanced disease. This study aims to evaluate prevalence of xerostomia, as well as compliance with assessment and treatment practices. Methods A retrospective chart audit was conducted on 173 admissions from an in-patient palliative care unit. Data were collected pertaining to patient demographics, cancer diagnosis, medications, oral health assessment and xerostomia treatment. Audit standards were based on local policy as follows: Oral Health Assessment Tool (OHAT) completed on all patients; OHAT completed within one day of admission; oral care plan completed if problem diagnosed; xerostomia treatment prescribed where necessary. Descriptive statistics were used to report compliance with standards. Cohen’s Kappa and Intraclass Correlation Coefficient were used for inter- and intra-rater reliability based on a 10% sample of the dataset. Results Palliative in-patients were significantly more likely than the general population to experience dry mouth (p<0.001). 86% of admissions had OHAT completed and 91% of these were on day of admission. Care plans were completed for 76% of patients with oral care needs. Appropriate medications were prescribed for 34% of patients with dry mouth. Inter- and intra-rater reliabilities were high or perfect for all primary outcomes. Conclusions Results indicate that oral health is evaluated in the majority of patients, however treatment appears low. This may be partly due to poor instrument design, where non-prescription treatments or ‘treatment unnecessary’ cannot be documented. Existing tools could be amended to reflect patient care needs more accurately. A change project is currently underway within the care setting to improve practice as a result of the study.

O-2 Cancer related insomnia: wireless monitoring of sleep metrics

Background Insomnia involves difficulty with sleep onset, maintenance, early morning wakening or non-restorative sleep. Prevalence is 30%–75% in cancer. Consequences include fatigue and impaired memory or concentration. It is under-reported, overlooked and severely impairs quality of life. ?Subjective sleep diaries underestimate insomnia. Objective measurements previously required dedicated sleep laboratories. Wireless medical technology enables objective sleep measurement in the natural environment. Aims Conduct a feasibility study to examine if a wireless monitor can measure sleep in cancer. Evaluate acceptability in: Patient Nurse Family Correlate objective device results with subjective reports. Methods A prospective observational study recruited 10 consecutive hospice inpatients (IP) and 20 consecutive community participants (CP) with cancer. Insomnia Severity Index recorded subjective sleep pattern. Participants used a wireless non-contact bedside sleep monitor for 3 nights. Three insomnia features were examined (sleep onset, maintenance, early awakening). A daily sleep diary was completed. Acceptability questionnaires were completed by patient, nurse and family. Statistical analysis was undertaken with SPSS version 22. Results The device successfully recorded sleep patterns in all 30 participants. Inpatients: Mean age was 63 years (range 47–61). 7/10 were positive for one or more insomnia features. Delayed sleep onset was most common (7/10). Community Participants: Mean age was 64 years (range 47–84). 15/20 were positive for one or more insomnia features. Fragmented sleep was most common. 14/20 recorded over 30u2009min awake overnight with more than 2 awakenings. Early morning wakening was not present in either cohort. Poor sleep hygiene was noted in community participants compared to inpatients. Correlation between subjective and objective measures was not significant (IP: p=0.07; CP: p=0.106). Patients, nurses and family members reported 100% device acceptability. Conclusions A wireless bedside monitor effectively measures sleep in cancer. High patient acceptability supports clinical use. Cancer-related insomnia features were common in both cohorts. Objective measurements correlated poorly with subjective.

P-46 Orthostatic hypotension and heart rate variability in the diagnosis of autonomic dysfunction in advanced cancer

Background Autonomic dysfunction (AD) is common in advanced cancer. Cardiovascular signs include loss of heart rate variability (HRV) and later, orthostatic hypotension (OH). OH increases risk of falls and mortality. HRV is the time difference between successive heartbeats, measured as a standard deviation (SDNN). The mean SDNN found in normative population is 41.51ms (σ:26.28ms). OH is a decrease of ≥ 20mHg in systolic and/or 10mHg in diastolic blood pressure (BP) upon orthostatic stress. Persistence of OH (POH) is OH beyond three minutes Methods This prospective, observational study aimed to identify prevalence of OH and POH, examine the relationship between autonomic symptoms (AS) and OH, and to ascertain whether OH and HRV are equivocally reliable for AD diagnosis. Consecutive ambulant adults attending day or in-patient hospice services were recruited. Interviews established demographics and AS. Objective tests for HRV and BP measurement were conducted. Postural symptoms were recorded during testing. Results 22 (12 male, 10 female) participants were recruited. Median age was 70 (33–89). Eight had OH, three of these had POH. None with OH reported postural symptoms. Mean number of AS reported in non-POH group (n=5) and POH group (n=3) was 8 (σ:2.55) and 12 (σ:1.73) respectively. Mean SDNN (n=20) was 25.53 ms (σ:17.55ms). Association between OH and HRV (p=0.048, unpaired t test). Conclusions OH was prevalent in this advanced cancer cohort and was associated with increased HRV. No association was found between AS and OH. Therefore, AS profile was not a useful tool for assessing AD. Active stand test was tolerated by all participants and could be considered for routine screening in advanced cancer. HRV screening may be an alternative for frailer patients