John Bryson

Phase II Study of an Outpatient Palliative Care Intervention in Patients With Metastatic Cancer

PURPOSE Although there is increasing advocacy for timely symptom control in patients with cancer, few studies have assessed outpatient palliative care clinics. This study assessed prospectively the efficacy of an Oncology Palliative Care Clinic (OPCC) in improving patient symptom distress and satisfaction. PATIENTS AND METHODS Eligible patients were new referrals to an OPCC, had metastatic cancer, were at least 18 years old, and were well enough and able to speak and read English sufficiently to provide informed consent and complete questionnaires. Patients received a consultation by a palliative care team. The primary end points of symptom control and patient satisfaction were assessed using the Edmonton Symptom Assessment Scale (ESAS) and patient-adapted Family Satisfaction with Advanced Cancer Care (FAMCARE) scale at baseline, 1 week, and 1 month. Initial and follow-up scores were compared using paired t tests. RESULTS Of 150 patients enrolled, 123 completed 1-week assessments, and 88 completed 4-week assessments. At baseline, the mean ESAS Distress Score (EDS) was 39.5. The mean improvement in EDS was 8.8 points (P < .0001) at 1 week and 7.0 points (P < .0001) at 1 month. Statistically significant improvements were observed for pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, dyspnea, insomnia, and constipation at 1 week (all P < or = .005) and 1 month (all P < or = .05). The mean improvement in FAMCARE score was 6.1 points (P < .0001) at 1 week and 5.0 points (P < .0001) at 1 month. CONCLUSION This phase II study demonstrates efficacy of an OPCC for improvement of symptom control and patient satisfaction with care. Randomized controlled trials are indicated to further evaluate the effectiveness of specialized outpatient palliative care.

Simple Prognostic Model for Patients With Advanced Cancer Based on Performance Status

PURPOSE Providing survival estimates is important for decision making in oncology care. The purpose of this study was to provide survival estimates for outpatients with advanced cancer, using the Eastern Cooperative Oncology Group (ECOG), Palliative Performance Scale (PPS), and Karnofsky Performance Status (KPS) scales, and to compare their ability to predict survival. METHODS ECOG, PPS, and KPS were completed by physicians for each new patient attending the Princess Margaret Cancer Centre outpatient Oncology Palliative Care Clinic (OPCC) from April 2007 to February 2010. Survival analysis was performed using the Kaplan-Meier method. The log-rank test for trend was employed to test for differences in survival curves for each level of performance status (PS), and the concordance index (C-statistic) was used to test the predictive discriminatory ability of each PS measure. RESULTS Measures were completed for 1,655 patients. PS delineated survival well for all three scales according to the log-rank test for trend (P < .001). Survival was approximately halved for each worsening performance level. Median survival times, in days, for each ECOG level were: EGOG 0, 293; ECOG 1, 197; ECOG 2, 104; ECOG 3, 55; and ECOG 4, 25.5. Median survival times, in days, for PPS (and KPS) were: PPS/KPS 80-100, 221 (215); PPS/KPS 60 to 70, 115 (119); PPS/KPS 40 to 50, 51 (49); PPS/KPS 10 to 30, 22 (29). The C-statistic was similar for all three scales and ranged from 0.63 to 0.64. CONCLUSION We present a simple tool that uses PS alone to prognosticate in advanced cancer, and has similar discriminatory ability to more complex models.

Nurse and physician inter-rater agreement of three performance status measures in palliative care outpatients

IntroductionPerformance status (PS) scales are used widely in oncology practice and research. We compared inter-rater agreement, between nurses and physicians, for three commonly used PS scales.Materials and methodsPatients attending an oncology palliative care clinic were assessed by a physician and nurse who blindly completed Eastern Cooperative Oncology Group (ECOG), Karnofsky PS (KPS), and palliative PS (PPS) scales. Patients completed the Edmonton symptom assessment system (ESAS).ResultsInter-rater agreement (weighted kappa) for the 457 patients was 0.67 for the ECOG, 0.74 for the KPS, and 0.72 for the PPS. There was no difference between proportions of physicians’ vs. nurses’ ratings of KPS, >60 vs. ≤60 (McNemar’s test, p = 0.33); however, physicians were more likely to rate patients as having better PS for the ECOG (77% in the 0–2 range vs. 70% for nurses, p = 0.0003) and PPS (63% in the 70–100 range vs. 54% for nurses, p = 0.0001). Physician and nurse scores of ECOG, KPS, and PPS were all correlated with ESAS distress score (Pearson correlation, r = 0.4–0.5).ConclusionsAlthough inter-rater agreement was good for all three scales, physicians tended to rate patients as healthier for the PPS and ECOG. The KPS may provide greater consistency of PS ratings by different oncology professionals in clinical and research settings.

Predictors of Symptom Severity and Response in Patients With Metastatic Cancer

We examined determinants of symptom severity and response to treatment among 150 patients with cancer participating in a phase II trial of a palliative care team intervention. Patients completed a modified Edmonton Symptom Assessment Scale (ESAS) at baseline and 1 week. Women had a worse baseline ESAS Distress Score (EDS; P = .003) and Total Distress Score (TDS; P = .005); differences were particularly marked for anxiety and appetite. Performance status was inversely associated with EDS, TDS, well-being, appetite, and fatigue (Kruskal-Wallis, all P < .005). Multivariate analysis of covariance (ANCOVA) showed that symptom improvement was independently predicted by worse baseline EDS score and female gender. Performance status, gender, and baseline symptom severity should be accounted for in trials of palliative care interventions; inclusion criteria based on symptom severity should also be considered.

The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advanced cancer

Several recently published randomized controlled trials have demonstrated the benefits of early palliative care involvement for patients with advanced cancer. In the oncology outpatient setting, palliative care clinics are an ideal site for the provision of early, collaborative support, which can be maintained throughout the cancer trajectory. Despite this, access to ambulatory palliative care clinics is limited, even at tertiary cancer centres. Existing programs for outpatient palliative care are variable in scope and are not well described in the literature. We describe the development and expansion of an outpatient palliative care clinic at the Princess Margaret Cancer Centre, Toronto, Canada, demonstrating how the clinic functions at a local and regional level. This clinic served as the intervention for a recent large cluster-randomized trial of early palliative care. The model for this service can be adapted by other palliative care programs that aim to provide early, integrated oncology care.

Administrative Outcomes Five Years after Opening an Acute Palliative Care Unit at a Comprehensive Cancer Center

PURPOSE We examined administrative outcomes after opening an oncology acute palliative care unit (APCU), to determine attainment of administrative targets related to the units function of acute palliation. METHODS We retrospectively reviewed the administrative database for our APCU for the 5 years following its opening in 2003. Data were abstracted on demographic information, as well as source of admission, primary reason for admission, discharge destination, inpatient death rate, and length of stay. Linear regression and the Cochran-Armitage trend test were used for analysis. In keeping with targets set at the units opening, our primary hypotheses were that outpatient admissions, admissions for symptom control, and discharges home would increase over the study period; secondary hypotheses were that length of stay and inpatient death rate would decrease. RESULTS There were 1748 admissions during the study period: the median age was 64, 54% were women, and the most common cancer sites were gastrointestinal (24%), lung (20%), and gynecologic (13%). There were significant changes for all primary endpoints: outpatient admissions increased from 47% to 70% (p < 0.0001), admissions for symptom control increased from 42% to 75% (p < 0.0001), and discharges home increased from 18% to 39% (p < 0.0001). The secondary end points of death rate and length of stay decreased from 65% to 40% (p < 0.0001) and 12 to 11 days (p = 0.54), respectively. CONCLUSION Setting and adhering to administrative targets for an APCU is possible with appropriate admission criteria, adequate community resources, and education of patients, families and health professionals regarding the model of care.

Addition of Methadone to Another Opioid in the Management of Moderate to Severe Cancer Pain: A Case Series

BACKGROUND Previous research has reported improved pain after adding methadone to another opioid, but did not quantify this benefit using a validated outcome measure. OBJECTIVE To assess quantitatively the effectiveness of adding methadone to another opioid for moderate to severe cancer-related pain. DESIGN All outpatients attending the Oncology Palliative Care Clinic from September 2010-September 2011, who had received methadone, were identified from pharmacy records. Inclusion criteria included: histological diagnosis of malignancy, age >18 years, taking regular opioids and Edmonton Symptom Assessment System (ESAS) pain score ≥ 4. MEASUREMENT The primary outcome measure was a decrease in pain score of ≥ 2 points from methadone initiation to one-month follow-up (or closest available ESAS). RESULTS Twenty patients were available for analysis, 16 of whom had neuropathic pain (80%). Eight patients (40%) had a decrease in pain score of ≥ 2 points at 1 month and a further 7 (35%) had a decrease of ≥ 2 points at the closest available time point. The mean pain score decreased from 7.7 +/- 1.8 to 5.2 +/- 2.4 from time of initiation to time of evaluation. The mean daily routine morphine equivalent, (excluding methadone), was 338 +/- 217.8 mg/day at initiation and 332 +/- 191 mg/day at evaluation; for methadone, mean doses at initiation and evaluation were 4.4 +/- 1.4 mg/day and 15.5 +/- 5.9 mg/day, respectively. Methadone was well tolerated in 17 patients (85%). CONCLUSIONS The addition of methadone was associated with improved pain control for patients with moderate to severe pain on another opioid and appears to offer a safe, well-tolerated and practical alternative in this situation.

The Role of Fentanyl in Refractory Opioid-Related Acute Colonic Pseudo-Obstruction

To the Editor: Ogilvie syndrome, or acute colonic pseudoobstruction (ACPO), refers to symptoms and signs of intestinal obstruction in the absence of a mechanically obstructing lesion. Several medical, surgical, and procedural risk factors have been identified, in particular its association with opioid use. We present a case of ACPO in a patient taking opioids for an osteoporotic fracture, whose symptoms resolved dramatically after opioid rotation from hydromorphone to fentanyl.

Impact of an Oncology Palliative Care Clinic on Access to Home Care Services

Home care (HC) is important for patients with cancer as performance status declines. Our study of 1224 patients at a Canadian cancer center examined the impact of an oncology palliative care clinic (OPCC) on HC referral. The HC referral frequency was calculated before and after the first OPCC consultation, in total and according to performance status (Palliative Performance Scale, PPS). Characteristics associated with HC referral were investigated. After the first OPCC consultation, there was an increase in HC referral from 39% (477 of 1224; 49% of those with PPS ≤60) to 69% (841 of 1224; 88% of those with PPS ≤60). Factors independently associated with HC referral were poor PPS (P < .001) and older age (P = .003). Thus OPCC involvement resulted in markedly increased HC referrals, particularly for older patients with poor performance status.