Gabriel Lopez

A Month in an Acute Palliative Care Unit Clinical Interventions and Financial Outcomes

Background: Few cancer centers have developed acute palliative care units (APCUs). The purpose of this study is to highlight clinical interventions and financial outcomes during a typical 1-month period on an APCU. Methods: We evaluated consecutive patients admitted to our APCU from February 1 to 28, 2009, regarding demographic information, sources of and reasons for admissions, resuscitation status, clinical interventions, disposition, and reimbursement data. Results: Forty-two patients were admitted during a 1-month period. Of these, 30 (71%) were referred from the inpatient palliative care consultation team. In all, 10 (24%) patients had a full code status on admission, and 8 had their status changed to do not resuscitate (DNR) prior to discharge. A total of 11 (26%) patients were discharged home with hospice care, 12 (29%) died on the APCU, and 10 (24%) were discharged home with outpatient follow-up visits. All patients received intravenous medications and the majority received intravenous antibiotics. All patients met acute care criteria for hospitalization, and financial reimbursement was satisfactory and comparable to that of other oncology patients. Conclusion: The APCU model is designed for the care of very complex advanced cancer patients. Palliative interventions are given simultaneously with other medical interventions. The APCU is labor intensive and well reimbursed.

Vivekananda Yoga Program for Patients with Advanced Lung Cancer and Their Family Caregivers

Background. The primary purpose of this study was to establish the feasibility of a couple-based Vivekananda Yoga (VKC) intervention in lung cancer patients and caregivers. Secondly, we examined preliminary efficacy regarding quality of life (QOL) outcomes. Method. In this single-arm feasibility trial, patients with lung cancer undergoing radiotherapy and their caregivers participated in a 15-session VKC program that focused on the interconnectedness of the dyad. We assessed pre-and post-intervention levels of fatigue, sleep disturbances, psychological distress, overall QOL, spirituality, and relational closeness. We tracked feasibility data, and participants completed program evaluations. Results. We approached 28 eligible dyads of which 15 (53%) consented and 9 (60%) completed the intervention. Patients (mean age = 73 years, 63% female, all stage III) and caregivers (mean age = 62 years, 38% female, 63% spouses) completed a mean of 10 sessions and 95.5% of them rated the program as very useful. Paired t tests revealed a significant increase in patients’ mental health (d = 0.84; P = .04) and a significant decrease in caregivers’ sleep disturbances (d = 1.44; P = .02). Although not statistically significant, for patients, effect sizes for change scores were medium for benefit finding and small for distress (d = 0.65 and 0.37, respectively). For caregivers, medium effects were found for improvement in physical functioning (d = 0.50). Conclusion. This novel supportive care program appears to be safe, feasible, acceptable, and subjectively useful for lung cancer patients and their caregivers and lends support for further study.

High-Dose Asian Ginseng (Panax Ginseng) for Cancer-Related Fatigue A Preliminary Report

Introduction and Objective. Cancer-related fatigue (CRF) is the most common and severe symptom in patients with cancer. The number and efficacy of available treatments for CRF are limited. The objective of this preliminary study was to assess the safety of high-dose Panax ginseng (PG) for CRF. Methods. In this prospective, open-label study, 30 patients with CRF (≥4/10) received high-dose PG at 800 mg orally daily for 29 days. Frequency and type of side effects were determined by the National Cancer Institute’s Common Terminology Criteria for Adverse Events, version 4.0. Scores on the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F) scale, Edmonton Symptom Assessment System (ESAS), and Hospital Anxiety and Depression Scale (HADS) were assessed at baseline, day 15, and day 29. Global Symptom Evaluation (GSE) was assessed at day 29. Results. Of the 30 patients enrolled, 24 (80%) were evaluable. The median age was 58 years; 50% were females, and 84% were white. No severe (≥grade 3) adverse events related to the study drug were reported. Of the 24 evaluable patients, 21 (87%) had an improved (by ≥3 points) FACIT-F score by day 15. The mean ESAS score (standard deviation) for well-being improved from 4.67 (2.04) to 3.50 (2.34) (P = .01374), and mean score for appetite improved from 4.29 (2.79) to 2.96 (2.46) (P = .0097). GSE score of PG for fatigue was ≥3 in 15/24 patients (63%) with median improvement of 5. Conclusion. PG is safe and improves CRF fatigue as well as overall quality of life, appetite, and sleep at night. Randomized controlled trials of PG for CRF are justified.

Integrative oncology physician consultations at a comprehensive cancer center: Analysis of demographic, clinical and patient reported outcomes

Background: Integrative oncology (IO) is a relatively new field that seeks to bring evidence-based, non-conventional approaches into conventional oncology care in a coordinated and safe manner. Though complementary and alternative medicine (CAM) are highly utilized by cancer patients, little is known about the characteristics of patients seeking IO consultation. Methods: Patients presenting for an outpatient IO consultation completed a CAM use questionnaire, Measure Yourself Concerns and Wellbeing (MYCaW), Edmonton Symptom Assessment Scale (ESAS), Quality of Life Short Form 12 (SF-12), and post-consultation satisfaction item. Results: 2,474 new patient IO consultations were conducted from 9/2009 to 12/2013 and 2367 (96%) completed at least one measure. Most were female (69%); the most frequent cancer type was breast (29%); 38% had distant/advanced disease; 75% had used a CAM approach in prior 12 months. The most common concerns were seeking an integrative/holistic approach (34%), herbs/supplements (34%), and diet/nutrition (21%). Overall symptom burden was low, with baseline symptom scores (ESAS) highest (worst) for sleep (4.2; SD 2.8), fatigue (4.0; SD 2.8), and well-being (3.8; SD 2.6). On the SF-12, the physical health scores (35.3; SD 7.5) were significantly lower than that of a healthy population (50), but mental health scores were not (46.8; SD 10.2). Satisfaction was high (9.4; SD 1.3) with the consultation. Conclusions: Patients presenting for IO consultation tended to have early stage disease, had previously used a CAM approach, had a relatively low symptom burden, and were most interested in developing an integrative approach to their care or discussing herbs/supplement use.

Randomized controlled trial of neurofeedback on chemotherapy-induced peripheral neuropathy: A pilot study

Chemotherapy‐induced peripheral neuropathy (CIPN) is a significant problem for cancer patients, and there are limited treatment options for this often debilitating condition. Neuromodulatory interventions could be a novel modality for patients trying to manage CIPN symptoms; however, they are not yet the standard of care. This study examined whether electroencephalogram (EEG) neurofeedback (NFB) could alleviate CIPN symptoms in survivors.

An Exploration of the Effects of Tibetan Yoga on Patients’ Psychological Well-Being and Experience of Lymphoma An Experimental Embedded Mixed Methods Study

As an emergent care model combining conventional with complementary therapies, integrative interventions challenge evaluation, necessitating approaches capable of capturing complex, multilevel interactions. This article evaluates the effects of a Tibetan yoga intervention on lymphoma patients’ quality of life and cancer experience. Our methodological aims were to explore differences in therapeutic effect between treatment and control group using qualitative data, and explain equivocal findings between data sets. Use of both data transformation techniques—qualitizing and quantitizing—within an experimental embedded design comparing and integrating data between data sets and treatment groups allowed us to develop this innovative evaluative approach. Findings clarify convergence and divergence between data sets, explore participants’ complex cancer experience, and capture dimensions and intervention effects inaccessible through either method alone.

Inpatient Acupuncture at a Major Cancer Center

Background: Use of complementary and integrative therapies is increasing among cancer patients, but data regarding the impact treatments such as acupuncture have in an inpatient oncology setting are limited. Methods: Patients who received acupuncture in an inpatient hospital environment between December 2014 and December 2015 were asked to complete a modified Edmonton Symptom Assessment Scale (ESAS; 0-10 scale) before and after each visit. Pre- and post-treatment scores were examined for each symptom using paired t tests. Results: A total of 172 inpatients were treated with acupuncture in their hospital beds (257 visits). Thirty percent (n = 51) received at least one additional follow-up treatment (mean visits/patient = 1.5). Completion rate of the modified ESAS after acupuncture was 42%. The most common reasons for not completing the post-treatment ESAS were “patient too drowsy” or “patient fell asleep” (72%). For patients who reported a baseline symptom score ≥1, the greatest improvements (mean change ± SD) after acupuncture on the initial visit were found for pain (−1.8 ± 2.2; n = 69; P < .0001), nausea (−1.2 ± 1.9; n = 30; P < .001), anxiety (−0.8 ± 1.8; n = 36; P = .01), drowsiness (−0.6 ± 1.8; n = 57; P = .02), and fatigue (−0.4 ± 1.1; n = 67; P = .008). For patients who received at least one follow-up visit, significant improvement from baseline was found for sleep disturbance (−2.5 ± 4.4; n = 17; P = .03), anxiety (−2.4 ± 1.7; n = 9; P = .002), pain (−2.3 ± 2.7; n = 20; P = .001), and drowsiness (−2.0 ± 2.6; n = 16; P = .008). Conclusions: Patients who received inpatient acupuncture at a major cancer center experienced significant improvement after treatment for pain, sleep disturbance, anxiety, drowsiness, nausea, and fatigue.

Examination of moderators of expressive writing in patients with renal cell carcinoma: the role of depression and social support

To identify groups most likely to benefit from an Expressive Writing (EW) intervention, we examined psychosocial variables as intervention moderators. We hypothesized that EW would be particularly effective for participants with high levels of depressive symptoms and social support at study entry.

A double-blind, randomized, placebo-controlled trial of panax ginseng for cancer-related fatigue in patients with advanced cancer

Background: Despite the high frequency, severity, and effects of cancer-related fatigue (CRF) on the quality of life (QoL) of patients with cancer, limited treatment options are available. The primary objective of this study was to compare the effects of oral Panax ginseng extract (PG) and placebo on CRF. Secondary objectives were to determine the effects of PG on QoL, mood, and function. Methods: In this randomized, double-blind, placebo-controlled study, patients with CRF ≥4/10 on the Edmonton Symptom Assessment System (ESAS) were eligible. Based on a pilot study, we randomized patients to receive either 400 mg of standardized PG twice daily or a matching placebo for 28 days. The primary end point was change in the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) subscale from baseline to day 29. Results: Of 127 patients, 112 (88.2%) were evaluable. The mean (SD) FACIT-F subscale scores at baseline, day 15, and day 29 were 22.4 (10.1), 29.9 (10.6), and 30.1 (11.6) for PG (P<.001), and 24.0 (9.4), 30.0 (10.1), and 30.4 (11.5) for placebo (P<.001). Mean (SD) improvement in the FACIT-F subscale at day 29 was not significantly different in the PG than in the placebo group (7.5 [12.7] vs 6.5 [9.9]; P=.67). QoL, anxiety, depression, symptoms, and functional scores were not significantly different between the PG and placebo groups. Improvement in the FACIT-F subscale correlated with baseline scores (P=.0005), Hospital Anxiety and Depression Scale results (P=.032), and sex (P=.023). There were fewer any-grade toxicities in the PG versus placebo group (28/63 vs 33/64; P=.024). Conclusions: Both PG and placebo result in significant improvement in CRF. PG was not significantly superior to placebo after 4 weeks of treatment. There is no justification to recommend the use of PG for CRF. Further studies are needed. Trial Registration: ClinicalTrials.gov identifier: NCT01375114.

Couples’ symptom burden in oncology care: perception of self and the other

BackgroundThe literature suggests that psychological distress and quality of life are interdependent in couples coping with cancer. The current study seeks to extend these findings to physical symptom burden, examining differences in symptom self-rating and perception of partner symptoms.MethodsCouples were approached while waiting for an integrative oncology service. Fifty patients and their partners completed the Edmonton Symptom Assessment Scale (ESAS-FS; twelve symptoms, scores 0–10, 10 worst possible) and a Global Health measure (PROMIS10). Patient and partner each also completed the ESAS-FS as it related to their perception of the other’s symptoms. ESAS distress subscales analyzed included Global (GDS), Psychosocial (PSS), and Physical (PHS). Analyses included paired t tests to examine all measures.ResultsFifty-eight percent of patients were female with most common cancer diagnoses of breast (22%), gastrointestinal (16%), and thoracic/H&N (16%). For ESAS-FS self-ratings, patients had significantly higher physical distress than partners, with a no significant difference in psychosocial distress. For PROMIS10 self-ratings, patients reported significantly lower global health and physical health, (p’s < 0.001); no differences were found for mental health between patients and caregivers. Patient rating of partner physical distress (PHS, p = 0.01) was significantly higher than partner self-rating, with no significant difference observed in ratings for psychosocial distress. Partner rating of patient psychosocial distress (PSS, p < 0.001) and physical distress (PHS, p = 0.001) was significantly higher than that of patient self-rating.ConclusionsOur findings suggest that both patients and partners perceive physical distress of the other higher than self; however, patients may be more sensitive to psychosocial distress in their partners.