Dina E. Farag

The use of opioids at the end-of-life and the survival of Egyptian palliative care patients with advanced cancer.

BACKGROUND AND AIM One of the barriers to cancer pain control and palliative care (PC) development is the misconception that the use of opioids may hasten death. This concern is exaggerated when higher doses of opioids are used at the end-of-life. The aim of this study was to investigate the relationship between survival and the dose of opioids used at the end-of-life of patients with advanced cancer in an Egyptian PC setting. METHODS Retrospective review of the medical records of 123 patients with advanced cancer managed in an Egyptian cancer center-based palliative medicine unit (PMU). Patients were classified according to the last prescribed regular opioid dose expressed in milligrams of oral morphine equivalent (OME) per day (mg OME/24 h) into three groups: no opioid or low-dose group (<120 mg OME/24 h), intermediate-dose group (120-<300 mg OME/24 h) and high-dose group (≥300 mg OME/24 h). Survival was calculated from the date of first referral to the PMU to death. RESULTS The median age of patients was 53 years, breast cancer was the most common diagnosis (18%) and the majority (68%) died at home. Opioids were prescribed for pain control in 94% of patients and were prescribed on regular basis in 89%. The mean last prescribed opioid dose for the whole group of patients was 167 (±170) mg OME/24 h and it was highest among patients with pleural mesothelioma [245 (±258) mg OME/24 h]. The last prescription included no opioids or low-dose opioids in 57 (46%) patients, intermediate-dose in 42 (34%) and high-dose in 24 (20%). The estimated median survival was 45 days for the no opioid/low-dose group, 75 days for the intermediate-dose group and 153 days for the high-dose group (P=0.031). CONCLUSIONS The results suggest that the dose of opioids has no detrimental impact on the survival of patients with advanced cancer in an Egyptian PC setting. Further research is needed to overcome barriers to cancer pain control especially in settings with inadequate cancer pain control.

High Symptom Burden Among Patients With Newly Diagnosed Incurable Cancer in a Developing Country.

To the Editor: Palliative care (PC) is ideally integrated into the care of patients with incurable cancer as early as a diagnosis is made. This is supported by the evidence that earlier PC is associated with significantly better patient-reported outcomes. Many cancer patients, especially in developing countries with limited resources, present in an advanced incurable stage and the only realistic treatment option for them is PC. Although PC is needed most in developing countries, little evidence to illustrate the need for PC and its early integration comes from these countries. A good number of studies describe the symptom burden in patients with incurable cancer. However, to the best of our knowledge, none of these studies systematically assess the prevalence of symptoms in patients with newly diagnosed incurable cancer in a developing country. The aim of this study was to describe the prevalence and severity of symptoms among patients with newly diagnosed incurable cancer in an Egyptian cancer center as an example for a developing country setting.

Cancer diagnosis disclosure preferences of family caregivers of cancer patients in Egypt

Family caregivers (FCs) of cancer patients are frequently seen as a barrier to honest communication with patients in Egypt. This study was conducted to investigate the attitude of FCs of cancer patients toward cancer diagnosis disclosure (CDD) and its determinants.

The use of the Chuang's prognostic scale to predict the survival of metastatic colorectal cancer patients receiving palliative systemic anticancer therapy

Background: With the increasing number of agents active against cancer, advanced cancer patients including metastatic colorectal cancer (mCRC) patients may continue receiving palliative systemic anticancer therapy (PSAT) near the end-of-life. Validated palliative prognostic models, such as the Chuang′s prognostic scale (CPS), may be helpful in identifying mCRC patients with limited survival who are unlikely to benefit from PSAT. Aim: To test the ability of the CPS to predict the survival of mCRC under treatment with PSAT. Methods: CPS was prospectively assessed in 36 mCRC patients who were receiving PSAT. The scale is based on eight items: ascites, edema, cognitive impairment, liver and lung metastases, performance status, tiredness, and weight loss. The total CPS score ranges from 0 to 8.5 with the higher score indicating worse prognosis. Results: Patients were divided into two groups using a CPS cutoff score of 5, Group 1 with a CPS score ≤5 and Group 2 with a CPS score >5. Using this cutoff value, 3-month mortality was predicted with a positive predictive value of 71%, a negative predictive value of 77%, a sensitivity of 67%, a specificity of 81% and an overall accuracy of 75%. Group 1 patients had a longer median survival of 149 days (95% confidence interval [CI]: 82-216) in comparison to Group 2 patients who had a median survival of 61 days (95% CI: 35-87). The difference in survival was statistically significant (P = 0.01). Conclusion: CPS may be useful in identifying mCRC patients with limited survival who are unlikely to benefit from PSAT.

A shortage of oral morphine in Egypt.

Egypt, with more than 88 million residents in 2015 and an estimated 5-year cancer prevalence of more than 215 000 cases in 2012,1,2 has effectively no oral morphine. The lack of effective and affordable analgesia is catastrophic for people with end-stage cancer. Breast, liver and bladder cancers are the most common types of cancer in Egypt, and about half of cancer patients in the eastern Mediterranean Region only visit a physician when their cancer has reached an advanced – and often incurable – stage.2,3 For these patients, the focus of care is quality of life and the only realistic treatment option is palliative care.4 Medical treatment is the main element in cancer pain management and for most patients, relatively inexpensive drugs like morphine are effective.5 For many years, morphine has been on the World Health Organization (WHO) model list of essential medicines as the strong opioid of choice because of its suitability for management of moderate to severe cancer pain.6 However, global data on licit opioid consumption shows very low levels in many countries, suggesting that pain control may be inadequate for a large number of patients worldwide.7 The International Narcotics Control Board ranked Egypt 117 out of 178 countries for its level of consumption of narcotic drugs.7 From 2011–2013, the average consumption of narcotics was 75 defined daily doses for statistical purposes (S-DDD) per million inhabitants per day in Egypt.7 For comparison, the average consumption of narcotics in the top three ranked countries was 51 374 S-DDD per million inhabitants per day in the United States of America, 29 067 in Canada and 25 273 in Germany.7 For more than two decades, the only form of oral morphine registered in Egypt has been slow-release morphine tablets (30 mg), manufactured under licence by a single supplier in the United Kingdom of Great Britain and Northern Ireland, packed by an Egyptian company, distributed by an Egyptian governmental trading company then dispensed by pharmacies. For unknown reasons, in late 2014, oral morphine became unavailable in any form in Egypt. This does not appear to have been due to cost, since fentanyl, hydromorphone and oxycodone are still available. In the absence of oral morphine, these formulations are the only locally-available alternative to oral morphine, but they are more expensive and are therefore unaffordable for many cancer patients in Egypt. Immediate action should be taken to make oral morphine available in Egypt. WHO advises governments to avoid such shortages through national policies that support cancer pain relief, educational programmes for the public, health-care personnel and regulators, and by modifying laws and regulations that limit the availability of opioid analgesics.5 We argue that morphine should be made available in Egypt in different forms and concentrations, consistent with WHO’s model list of essential medicines.6 To avoid stock-outs in the future, the country needs more than one source. Legislative changes are also required to remove the current restrictions limiting the amount of oral morphine in a single prescription to 420 mg. This is an inadequate supply for most patients with cancer-related pain.8,9 The Egyptian opioids control policy should be revised to achieve a balance between ensuring availability for medical use and preventing the misuse of these critically important drugs.10

The fear of using tramadol for pain control (tramadolophobia) among Egyptian patients with cancer

OBJECTIVES The fear of using tramadol for pain control (tramadolophobia) by Egyptian patients with cancer is a frequent problem in our practice. This study was conducted to explore the prevalence of and the reasons behind tramadolophobia among Egyptian patients with cancer. METHODS A structured interview including open-ended and closed questions. The study included 178 adult patients with cancer from two cancer centers in Cairo and Sharkia, Egypt. RESULTS The source of information about tramadol was a non-healthcare-related source in 168 (94 percent) patients, mainly the media (50 percent). The believed uses of tramadol were abuse related in 94 (53 percent) patients, stimulant (physical, sexual, and to boost alertness) in 59 (33 percent), and analgesic in 55 (31 percent). Twenty-six (15 percent) patients gave history of tramadol use, largely (69 percent) as a stimulant. In case tramadol was prescribed for pain control, 90 (51 percent) patients refused to take it, 59 (33 percent) patients agreed to take it with concern about addiction, and only 29 (16 percent) patients agreed without concerns. Among those who refused taking tramadol for pain, the mentioned reason of refusal was addiction-related fears in 57 percent. CONCLUSIONS The stigmatization and misconceptions about tramadol may have resulted in tramadolophobia among the majority of Egyptian patients with cancer. This further complicates the barriers to cancer pain control in Egypt. Being the only available World Health Organization step-II analgesic in Egypt, interventions to overcome tramadolophobia should be taken.

1511 Symptom burden among patients with newly diagnosed incurable cancer

Background: The World Health Organization (WHO) said that palliative care and cancer pain control are the only realistic treatment option for the majority of cancer patients who present in an advanced incurable stage, especially in lower-income countries. Ideally, palliative care is integrated from the point of diagnosis of incurable cancer. This would allow earlier identification and better management of symptoms in this group of patients. This study explores the symptom burden among patients with recently diagnosed incurable cancer in a lower-income setting. Materials and Methods: The study included patients with incurable cancer who presented to an Egyptian cancer center. Thirty-eight patients were interviewed within four weeks of diagnosis. Initially patients were asked to report voluntarily the symptoms they are experiencing and to name the most distressing one. This was followed by the systematic assessment of 57 symptoms. Symptoms were rated using a 4 point verbal rating scale (none, mild, moderate and severe). Results: The median age of patients was 51 years and 58% were males. The most common primary cancer site was the lung (21%) followed by the gastrointestinal system (18%). In addition to the 57 systematically assessed symptoms, patients voluntarily reported another 6 symptoms. The total number of symptom entries was 589, of which 74 (12.6%) were voluntary reported and 515 (87.4%) were found on systematic assessment. The average number of symptoms per patient was 16 and the median was 14 (range: 1−43). The average number of severe symptoms per patient was 3. The severity of symptoms was mild in 274 (46.5%) symptom entries, moderate in 200 (34%) and severe in 115 (19.5%). The total number of symptom entries related to the assessed 57 symptoms was 582. Patients voluntarily reported 2% of mild symptoms, 17% of moderate and 32% of severe. The ten most common symptoms were pain (71%), anxiety (58%), appetite loss (58%), fatigue (55%), weight loss (55%), insomnia (53%), weakness (50%), depressed mood (47%), shortness of breath (47%) and dry mouth (45%). The most distressing symptom was pain in 37% of patients, respiratory symptoms in 11% and weakness in 8%. Conclusions: In a lower-income setting, patients with recently diagnosed incurable cancer experience high symptom burden, especially pain. This supports the WHO advice to integrate palliative care and cancer pain control as early as possible in the course of disease of these patients. The majority of symptoms experienced by patients with incurable cancer are not voluntary reported, especially mild symptoms. Systematic assessment of symptoms is necessary to identify them early and to initiate management appropriately. No conflict of interest.