Madeline Lemke

Symptom clusters in patients with metastatic cancer: a literature review

This article reviews the literature reporting empirically determined symptom clusters in patients with metastatic cancer. A literature search was conducted on symptom clusters within heterogeneous metastatic cancer patient populations using MEDLINE, EMBASE, and CINAHL. Studies examining predetermined symptom clusters were excluded. A total of eight relevant studies published between 2005 and 2011 were identified. The number of symptom clusters extracted varied from two to eight clusters per study, comprising of two to eight symptoms per cluster. There were no clusters consistently identified within all eight studies. Notable differences in symptoms assessed, assessment tools, statistical analysis, patient demographics were observed between the studies. The lack of consensus among the inter-study symptom clusters are likely due to the differences in patient population as well as study methodology. Further exploration in metastatic symptom cluster research will ideally improve patient outcomes by facilitating improved symptom management in future clinical practice.

Pasireotide for the Prevention of Pancreatic Fistula Following Pancreaticoduodenectomy: A Cost-effectiveness Analysis

Objective: To determine the cost-effectiveness of perioperative administration of pasireotide for reduction of pancreatic fistula (PF). Summary: PF is a major complication following pancreaticoduodenectomy (PD), associated with significant morbidity and healthcare-related costs. Pasireotide is a novel multireceptor ligand somatostatin analogue, which has been demonstrated to reduce the incidence of PF following pancreas resection; however, the drug cost is significant. This study sought to estimate the cost-effectiveness of routine administration of pasireotide to patients undergoing PD, compared with no intervention from the perspective of the hospital system. Methods: A decision-analytic model was developed to compare costs for perioperative administration of pasireotide versus no pasireotide. The model was populated using an institutional database containing all PDs performed 2002 to 2012 at a single institution, including data regarding clinically significant PF (International Study Group on Pancreatic Fistula Grade B or C) and hospital-related inpatient costs for 90 days following PD, converted to 2014

Doctor, what are my options? A prospective cohort study of an individualized care plan for patients with gastrointestinal cancer

USD. Relative risk of PF associated with pasireotide was estimated from the published literature. Deterministic and probabilistic sensitivity analyses were performed to test robustness of the model. Results: Mean institutional cost of index admissions was

Comparing prognostic factors in patients with spinal metastases: a literature review.

67,417 and

Response to: Post-hepatectomy Lactate: Should We Add More? And Assessing Predictive Value of Post-operative Elevated Lactate for Adverse Outcomes Following Hepatectomy

31,950 for patients with and without PF, respectively. Pasireotide was the dominant strategy, associated with savings of

Doctor, what are my options? A prospective cohort study of an individualized care plan for patients with gastrointestinal cancer.

1685, and a mean reduction of 1.5 days length of stay. Univariate sensitivity analyses demonstrated cost-savings down to a PF rate of 5.6%, up to a relative risk of PF of 0.775, and up to a drug cost of

Symptom clusters using the Spitzer quality of life index in patients with brain metastases—a reanalysis comparing different statistical methods

2817. Probabilistic sensitivity analysis showed 79% of simulations were cost saving. Conclusions: Pasireotide appears to be a cost-saving treatment following PD across a wide variation of clinical and cost scenarios.

The Effect of Early Postoperative Non-Steroidal Anti-Inflammatory Drugs on Pancreatic Fistula Following Pancreaticoduodenectomy.

BACKGROUND For cancer patients, information about their disease and its treatment is often delivered within a short time period, potentially leading to patient misunderstanding, which can impede optimal patient care. In this 3-part clinical study, we investigated the utility of an individualized care plan for patients with gastrointestinal (gi) cancer starting a new treatment. METHODS In part 1, a comprehensive literature search identified items for potential inclusion in the care plan. Those items were formatted into a questionnaire. The questionnaire was then administered to patients as a structured interview. In part 2, health care professionals involved in the care of patients with gi cancer evaluated the resulting care plan for content and relevancy. In part 3, a 20-week prospective cohort study (10 weeks using standard of care, 10 weeks using individualized care plans) was conducted. Outcomes were assessed at baseline and at 2-4 weeks after administration of the care plan. RESULTS In part 1, a 73-item questionnaire was developed and completed by 20 patients in semi-structured interviews. In part 2, long and short versions of the care plan were created. Most health care professionals preferred the long version. Based on their comments, a final version of the care plan was created. The part 3 study enrolled 104 patients. Overall satisfaction scores were significantly higher in the intervention group at baseline (p = 0.010) and follow-up (p = 0.005). Compared with control patients, the intervention cohort also reported significantly higher overall quality of life (p = 0.044) and fewer symptoms of anxiety (p = 0.048) at follow-up. CONCLUSIONS Provision of an individualized care plan resulted in improvements in outcome measures at both baseline and follow-up. Future studies are needed to confirm these findings.

Validation of clinical risk score for colorectal liver metastases resected in a contemporary multicenter cohort

For cancer patients with spinal metastases, palliative treatments are directed toward improving the patients symptoms and quality of life. The expected prognosis of patients plays a large role in guiding treatment decisions, particularly when deciding between surgical management and conservative treatments, such as radiotherapy. This study aims to review the factors that can accurately predict the survival of patients with spinal metastases. The authors conducted a literature search on studies identifying prognostic factors using PubMed (1966–2011), Ovid MEDLINE (1948 to July 2011) and EMBASE (1947–2011) databases. Articles in English were included if they conducted retrospective or prospective analyses on predictors of survival for patients with spinal metastases; articles validating or examining the accuracy of existing scoring systems using prognostic factors were also included. A total of 29 studies were identified. A general consensus of the literature was found with respect to three prognostic factors: the patients primary cancer site, the extent of the metastases and the general condition or performance score. Further research is recommended to assess the prognostic value of other factors identified by several studies, including age, neurological deficit and previous treatments. For future studies, the authors encourage the development of models capable of inclusion of all patients with spinal metastases.

New Considerations in the Design of Clinical Trials for Bone Metastases

To the Editors, Thank you for the opportunity to reply to the letters by Ariffin as well as Wen et al. regarding the recently published article entitled ‘‘Elevated Lactate is Independently Associated with Adverse Outcomes Following Hepatectomy’’ [1]. We read the letters with interest. The aim of this study was to assess the association between early post-hepatectomy lactate (PHL) and shortterm post-operative outcomes. While interesting, many of the additional analyses suggested by the Ariffin and Wen fall beyond the scope of this study. Firstly, this study focused on early PHL (on the night of surgery). This timing can reliably be related to pre and intra-operative factors, rather than post-operative complications. Moreover, functional liver remnant issues are not relevant here as they would impact PHL later in the postoperative course. Secondly, this study sought to examine the ability of lactate to support identification of patients at risk poor postoperative outcomes early in the post-operative course, as part of a multi-factorial assessment encompassing. It was not meant to be examined as an isolated diagnostic test. Therefore, measures of sensitivity, specificity, positive and negative predictive values were not used. While it would be interesting to correlate the trends of PHL over the first post-operative night with outcomes, multiple lactate levels over that period were available for a minority of patients. Therefore, such an analysis would have been underpowered and not have yielded valid conclusions; it was not undertaken. This would be an interesting question to address, possibly with a prospective design. Finally, we acknowledge the selection bias inherent to the retrospective design of this study. This was accounted for as much as possible by (1) providing characteristics of the excluded patients for the reader to appreciate differences and enhance assessment applicability to one’s practice and (2) performing a detailed multivariable analysis. The multivariable analysis included variables associated with the outcomes on univariable analysis and determined to be potential confounders. We kept a final parsimonious set of covariates to ensure adequate fit and performance of the model. Comorbidities were adjusted for using the Charlson Comorbidity Index (CCI) which is a comprehensive and accurate measure known to provide a better assessment of comorbidity burden than a single comorbidity in isolation (such as diabetes) [2]. In addition, diabetes is included in the CCI and therefore was not added to the model to avoid collinearity issues. As a sensitivity analysis, we did replace the CCI with diabetes alone which did not alter the findings. Inflow occlusion was adjusted for in the model, with a practice of intermittent 15 min of clamp time followed up 5–10 unclamped. The extent of liver resection was included using consensus definition that is standard in research addressing hepatectomy [3]. Finally, post-operative complications being on the causal pathway to mortality, this variable was not included in the regression model as dictated by standard good statistical analysis methods, to avoid overadjustment [4]. This study provides an accurate assessment of the relationship between early PHL and short-term post-operative outcomes. It is based on a large contemporary cohort of & Julie Hallet julie.hallet@sunnybrook.ca