Maria Nabal

Prognostic factors in advanced cancer patients: Evidence-based clinical recommendations - A study by the Steering Committee of the European Association for Palliative Care

PURPOSE To offer evidence-based clinical recommendations concerning prognosis in advanced cancer patients. METHODS A Working Group of the Research Network of the European Association for Palliative Care identified clinically significant topics, reviewed the studies, and assigned the level of evidence. A formal meta-analysis was not feasible because of the heterogeneity of published studies and the lack of minimal standards in reporting results. A systematic electronic literature search within the main available medical literature databases was performed for each of the following four areas identified: clinical prediction of survival (CPS), biologic factors, clinical signs and symptoms and psychosocial variables, and prognostic scores. Only studies on patients with advanced cancer and survival < or = 90 days were included. RESULTS A total of 38 studies were evaluated. Level A evidence-based recommendations of prognostic correlation could be formulated for CPS (albeit with a series of limitations of which clinicians must be aware) and prognostic scores. Recommendations on the use of other prognostic factors, such as performance status, symptoms associated with cancer anorexia-cachexia syndrome (weight loss, anorexia, dysphagia, and xerostomia), dyspnea, delirium, and some biologic factors (leukocytosis, lymphocytopenia, and C-reactive protein), reached level B. CONCLUSION Prognostication of life expectancy is a significant clinical commitment for clinicians involved in oncology and palliative care. More accurate prognostication is feasible and can be achieved by combining clinical experience and evidence from the literature. Using and communicating prognostic information should be part of a multidisciplinary palliative care approach.

Breakthrough Cancer Pain: Prevalence and Characteristics in Patients in Catalonia, Spain

Breakthrough pain (BTP), a transitory exacerbation of pain superimposed on a background of persistent, usually adequately controlled pain, has been reported to occur in 50% to 75% of cancer patients. However, a 23% prevalence of BTP was recently reported in a study of Spanish patients with advanced cancers, showing probably a low detection rate of this clinical problem. The purpose of the present study was to determine the prevalence of BTP among oncology patients managed by palliative care teams in Catalonia, Spain, and to characterize the frequency, intensity, and treatment of BTP episodes. Sixty-two teams studied 397 patients on a predetermined index day. BTP was reported by 163 (41%) patients, with a total of 244 episodes (mean 1.5 episodes/patient/day). Mean (SD) intensity of BTP episodes was 7.3 (2.0), compared with 2.9 (2.7) for persistent pain (both 0-10 scales). Morphine was used to treat 52% of BTP episodes, while 25% were untreated. These findings indicate that BTP remains underrecognized and undertreated in Spain.

Original articleBreakthrough Cancer Pain: Prevalence and Characteristics in Patients in Catalonia, Spain

Breakthrough pain (BTP), a transitory exacerbation of pain superimposed on a background of persistent, usually adequately controlled pain, has been reported to occur in 50% to 75% of cancer patients. However, a 23% prevalence of BTP was recently reported in a study of Spanish patients with advanced cancers, showing probably a low detection rate of this clinical problem. The purpose of the present study was to determine the prevalence of BTP among oncology patients managed by palliative care teams in Catalonia, Spain, and to characterize the frequency, intensity, and treatment of BTP episodes. Sixty-two teams studied 397 patients on a predetermined index day. BTP was reported by 163 (41%) patients, with a total of 244 episodes (mean 1.5 episodes/patient/day). Mean (SD) intensity of BTP episodes was 7.3 (2.0), compared with 2.9 (2.7) for persistent pain (both 0-10 scales). Morphine was used to treat 52% of BTP episodes, while 25% were untreated. These findings indicate that BTP remains underrecognized and undertreated in Spain.

The role of paracetamol and nonsteroidal anti-inflammatory drugs in addition to WHO Step III opioids in the control of pain in advanced cancer. A systematic review of the literature

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol are used widely in the management of mild to moderate cancer pain and are frequently combined with opioids in the treatment of moderate to severe pain. Aim: To perform a systematic literature review of the evidence of the efficacy and toxicity of NSAIDs or paracetamol added to WHO Step III opioid treatment for cancer pain. Design and data sources: A systematic literature review of MedLine, EMBASE and Cochrane Central register of controlled trials database was carried out using both text words and MeSH/EMTREE terms. Results: Seven eligible papers were retrieved from the new search and five from the Cochrane review. Five of seven studies showed an additive effect of NSAIDs when combined with opioids either by improving analgesia (three studies) or by reducing the opioid dose (two studies). Paracetamol was only marginally effective in one of five trials. The study designs were not adequate to assess differences in side effects between the opioids alone and opioids in combination with NSAIDs or paracetamol. Conclusions: The evidence from the available clinical trials is of limited amount and quality, but it weakly supports the proposal that the addition of an NSAIDs to WHO Step III opioids can improve analgesia or reduce opioid dose requirement. There is insufficient evidence to support the use of paracetamol in combination with Step III opioids. Data on the toxicity of NSAIDs in this indication are insufficient owing to the small number of patients and the short duration of treatment reported in the studies.

Traducción, adaptación y validación de la Palliative Care Outcome Scale al español

Fundamento y Objetivo El objetivo de este estudio es traducir y validar al espanol la Palliative Care Outcome Scale (POS). Material y Metodo La traduccion y adaptacion se realizo por el metodo de traduccion y retraduccion centrada en garantizar la equivalencia conceptual de los terminos utilizados. Para el estudio de las propiedades psicometricas se selecciono una muestra de 200 enfermos en cuidados paliativos a los que, en una primera visita, se les aplico, ademas del cuestionario a evaluar, el EORTC QLQ C-30, el indice de Barthel y el de Karnofsky. Para la evaluacion de la fiabilidad intraobservador, a la semana de la primera visita se volvio a aplicar la version espanola de la POS. Resultados El proceso de traduccion y adaptacion no planteo mayores problemas. La Escala de Cuidados Paliativos (ECP) mostro una excelente aceptacion tanto por parte de los enfermos como de los profesionales sanitarios, asi como una fiabilidad inter e intraobservador con unos coeficientes de correlacion intraclase entre 0,61 y 0,93 segun el item. El analisis de la consistencia interna mostro un α de Cronbach de 0,62 en el formato para el personal sanitario y de 0,64 en el formato para el enfermo. La mayoria de los items de la ECP se correlacionaron con la escala de funcion emocional y la escala de calidad de vida global del EORTC QLQ C-30. Conclusiones La ECP es un instrumento de medida de la calidad de vida de los pacientes en cuidados paliativos valido y fiable que puede ser util tanto en trabajos de investigacion como en la practica clinica diaria.

Screening for Constipation in Palliative Care Patients

INTRODUCTION The objective of this study was to establish screening criteria for constipation in palliative care and, subsequently, to determine data for diagnostic suspicion of constipation in a palliative care population. Also we investigate the incidence of fecal impaction in the same sample of palliative care patients. MATERIALS AND METHODS A descriptive, multicenter cross-sectional study was done. All patients in active care by a group of hospital and home palliative care teams were studied. A questionnaire on signs (frequency and consistency of stools) and symptoms (pain, discomfort, or a sensation of incomplete evacuation when having a bowel movement) of constipation in last weeks, and a verbal numerical scale (VNS) (0-10) on discomfort or difficulty with constipation was completed by the patients. The patients were asked about impaction in the last 3 months. RESULTS One hundred twenty patients from 21 palliative care teams were included; the majority of patients received opiates (66%) and also laxatives (60%). Bowel movement rate less than three stools per week was found in 13% of patients, stools harder than normal were experienced in 24% patients, and 33% exhibited pain, discomfort, or sensation of incomplete evacuation. Of the patients studied 13% had some signs of habitual constipation but they did not complain of symptoms, others (17%) had some discomfort in spite of not having signs of constipation. As screening criteria for constipation in palliative care we elected to include indistinct presence of constipation symptoms or constipation signs in recent weeks. A diagnosis of suspicion of constipation was established in almost 1 of 2 patients (48%) of our palliative care population. VNS with cutoff point of 3 or more of 10, showed a sensitivity of 0.70 and a specificity of 0.74 and positive predictive value (PPV) of 73% positive and negative predictive value (NPV) of 70%. In addition to these findings a considerable number of our palliative care patients (20%) reported episodes of fecal impaction in the last 3 months. CONCLUSION The screening for constipation in palliative care should be performed exploring subjective symptoms and other objective signs. A diagnosis of suspected constipation was found in almost half of the palliative care patients studied. A VNS of constipation did not produce good predictive values for the detection of constipation in our sample.

An International Consensus Definition of the Wish to Hasten Death and Its Related Factors

Background The desire for hastened death or wish to hasten death (WTHD) that is experienced by some patients with advanced illness is a complex phenomenon for which no widely accepted definition exists. This lack of a common conceptualization hinders understanding and cooperation between clinicians and researchers. The aim of this study was to develop an internationally agreed definition of the WTHD. Methods Following an exhaustive literature review, a modified nominal group process and an international, modified Delphi process were carried out. The nominal group served to produce a preliminary definition that was then subjected to a Delphi process in which 24 experts from 19 institutions from Europe, Canada and the USA participated. Delphi responses and comments were analysed using a pre-established strategy. Findings All 24 experts completed the three rounds of the Delphi process, and all the proposed statements achieved at least 79% agreement. Key concepts in the final definition include the WTHD as a reaction to suffering, the fact that such a wish is not always expressed spontaneously, and the need to distinguish the WTHD from the acceptance of impending death or from a wish to die naturally, although preferably soon. The proposed definition also makes reference to possible factors related to the WTHD. Conclusions This international consensus definition of the WTHD should make it easier for clinicians and researchers to share their knowledge. This would foster an improved understanding of the phenomenon and help in developing strategies for early therapeutic intervention.

Vitamin D deficiency and its association with fatigue and quality of life in advanced cancer patients under palliative care: A cross-sectional study

Background: A normal vitamin D status is required for bones and muscles to maintain their function and structure, but it also contributes to the functional integrity of other multiple physiologic systems in the body. Aim: To assess the relationship of Vitamin D deficiency with health-related quality-of-life issues, fatigue, and physical functioning in advanced cancer patients. Design: This is a cross-sectional study. Patients/settings: Adults under palliative care, having a locally advanced or metastatic or inoperable solid cancer. Results: Among 30 patients in palliative care with advanced solid cancer, 90% were vitamin D deficient. Serum Vitamin D concentration was positively correlated with patient-reported absence of fatigue (s = 0.49), and physical and functional well-being (s = 0.44 and s = 0.41, respectively, p < 0.01). Fatigue was the symptom with the highest median impact on their lives and was the only one associated with serum vitamin D (p = 0.031), with lower fatigue in patients with vitamin D concentrations in the third tertile. There was no evidence of a direct association between health-related quality of life and vitamin D status. Conclusion: The 90% frequency of advanced cancer patients with vitamin D deficiency, together with the positive correlation of vitamin D status with the absence of fatigue and improved physical and functional well-being, points to vitamin D supplementation as a potential therapy to enhance the patient’s quality of life.

Multicentre, double-blind, randomised placebo-controlled clinical trial on the efficacy of methylphenidate on depressive symptoms in advanced cancer patients

Introduction Methylphenidate is a psychostimulant that has been used to relieve depressive symptoms in advanced cancer patients. No studies compare its efficacy against placebo in this group of patients. Objective To explore the efficacy of methylphenidate compared with placebo in the relief of depressive symptoms in advanced cancer patients. Material and methods A multicentre, double-blind, randomised placebo-controlled clinical trial was undertaken comparing the efficacy of methylphenidate and placebo in depressive symptoms. Advanced stage cancer patients were eligible if they scored at least two points on the Two Question Screening Survey for depression. A reduction of at least two points on the Edmonton Symptom Assessment Scale for depression (0–10) was considered as a response. Results Sixty-nine patients were included (methylphenidate: n=31, placebo: n=38); median daily dose of methylphenidate was 25 mg. Fifty-eight patients (84%) who completed the first week of treatment were considered suitable for evaluation. In the intention to treat analysis, there were 14/31 (45%) responses with methylphenidate and 10/38 (26%) responses with placebo (difference: 19%; 95% CI: 4% to 39%; p=0.10). With the Hospital Anxiety and Depression Scale, 11/19 (58%) patients with methylphenidate and 10/24 (42%) with placebo improved from a score compatible with depression in the first 7 days (difference 16%; 95% CI 13% to 42%; p=0.29). The proportion of patients indicating adverse effects was similar for both cohorts (p=0.99). Conclusion Compared with the placebo, methylphenidate demonstrated a positive trend in the incidence of response for depressive symptoms in advanced cancer patients.

Valoración general del paciente oncológico avanzado. Principios de control de síntomas

La medicina paliativa esta definida como un modelo de atencion que mejora la calidad de vida de pacientes y familias. Su objetivo es afrontar los problemas asociados a enfermedades incurables mediante la prevencion y el alivio del sufrimiento producido por el dolor y otros problemas fisicos, psicosociales y espirituales. Se trata de una disciplina fundamental en la atencion oncologica a la que se deberia acceder en funcion de las necesidades de cada paciente, independientemente del