Nicholas Chiu

Cut points for mild, moderate, and severe pain among cancer and non-cancer patients: a literature review

Defining cut points (CPs) for varying levels of pain intensity is important for assessing changes in patients functional status, and guiding the development and evaluation of treatment options. We aimed to summarize CPs identified in the literature for mild, moderate, and severe pain on the numeric rating scale (NRS), and recommend optimal CPs for cancer and non-cancer patients. We searched MEDLINE and EMBASE (inception to May 2015) for studies that used CPs to classify pain intensity on the NRS among patients with cancer or non-cancer conditions leading to acute or chronic pain. A CP was defined as the upper bound of a mild or moderate pain category. Of 1,556 identified articles, 27 were included for review. Among patients with cancer pain, mild-moderate pain CPs ranged from 1 to 4 (mean, 3.5±1.08), with CP4 being the most recommended CP (80%). For moderate-severe pain, CPs ranged from 4 to 7 (mean, 6.2±0.92), and CP6 (50%) was the optimal CPs. Among patients with non-cancer pain, mild-moderate pain CPs ranged from 2 to 5 (mean, 3.62±0.78), and CP4 was the most frequently used CP (52.9%). For moderate-severe non-cancer pain, CPs ranged from 4 to 8 (mean, 6.5±0.99), and CP6 (41.2%) was the most frequently recommended CP. A wide range of CPs for mild, moderate, and severe pain categories were identified in the literature among both cancer and non-cancer patient populations. Further studies are needed to delineate more accurate and precise CPs for pain intensity.

Enteral and parenteral nutrition in cancer patients: a systematic review and meta-analysis

BACKGROUND In cancer patients, weight loss is an ominous sign suggesting disease progression and shortened survival time. As a result, providing nutrition support for cancer patients has been proposed as a logical approach for improving clinical outcomes. Nutrition support can be given to patients through enteral nutrition (EN) or parenteral nutrition (PN). The purpose of the review was to compare the outcomes of PN and EN in cancer patients. METHODS A literature search was conducted in Ovid MEDLINE and OLDMEDLINE, Embase Classic and Embase, and Cochrane Central Register of Controlled Trials. Studies were included if over half of the patient population had cancer and reported on any of the following endpoints: the percentage of patients that experienced no infection, nutrition support complications, major complications or mortality. Risk ratios (RR) and 95% confidence intervals (CIs) using Review Manager Version 5.3 were calculated. Primary endpoints were stratified according to type of EN for subgroup analysis, grouping studies into either tube feeding (TF) or standard care (SC). Additionally, another subgroup analysis was conducted comparing studies with protein-energy malnutrition (PEM) patients and studies without PEM patients. RESULTS The literature search yielded 674 articles of which 36 were included for the meta-analysis. There were no difference in the endpoints between the two study interventions except that PN resulted in more infection when compared with EN (RR =1.09, 95% CI: 1.01-1.18; P=0.03). CONCLUSIONS Other than increased incidence of infection, PN has not resulted in prolonging the survival, increasing nutrition support complications, or major complications when compared with EN in cancer patients.

Comparison of three shortened questionnaires for assessment of quality of life in advanced cancer

OBJECTIVE Quality of life (QoL) assessment questionnaires can be burdensome to advanced cancer patients, thus necessitating the need for shorter assessment instruments than traditionally available. We compare three shortened QoL questionnaires in regards to their characteristics, validity, and reliability. METHODS A literature search was conducted to identify studies that employed or discussed three abridged QoL questionnaires: the European Organization for Research and Treatment of Cancer Quality of Life Core 15-Palliative Care (EORTC QLQ-C15-PAL), the Functional Assessment of Cancer Therapy-General-7 (FACT-G7), and the Functional Assessment of Chronic Illness Therapy-Palliative Care-14 (FACIT-PAL-14). Articles that discussed questionnaire length, intended use, scoring procedure, and validation were included. RESULTS The 7-item FACT-G7 is the shortest instrument, whereas the EORTC QLQ-C15-PAL and the FACIT-PAL-14 contain 14 and 15 items, respectively. All three questionnaires have similar recall period, item organization, and subscale components. Designed as core questionnaires, all three maintain content and concurrent validity of their unabridged original questionnaires. Both the EORTC QLQ-C15-PAL and the FACT-G7 demonstrate good internal consistency and reliability, with Cronbachs α ≥0.7 deemed acceptable. The developmental study for the FACIT-PAL-14 was published in 2013 and subsequent validation studies are not yet available. CONCLUSION The EORTC QLQ-C15-PAL and the FACT-G7 were found to be reliable and appropriate for assessing health-related QoL issues-the former for palliative cancer patients and the latter for advanced cancer patients receiving chemotherapy. Conceptually, the FACIT-PAL-14 holds promise to cover social and emotional support issues that are not completely addressed by the other two questionnaires; however, further validation is needed.

Inadequacy of Palliative Training in the Medical School Curriculum

This report examines the literature on palliative training in the current medical school curriculum. A literature search was conducted to identify relevant articles. Physicians and medical students both report feeling that their training in end-of-life care and in palliative issues is lacking. The literature expresses concerns about the varied and non-uniform approach to palliative care training across medical schools. The authors recommend the development of more palliative training assessment tools in order to aid in the standardization of curriculum involving end-of-life care. In addition, increased exposure to dying patients will aid students in building comfort with palliative care issues. Such a goal may be accomplished through required clerkships or other similar programs.

Taxane-induced arthralgia and myalgia: A literature review

Purpose Arthralgia and myalgia following taxane chemotherapy has been documented in the literature. However, these two toxicities associated with taxane treatment have not been closely examined in the literature, and data remain inconsistent in terms of the reported incidences of these toxicities. The purpose of this literature review was to provide a more comprehensive understanding of the incidence of taxane-induced arthralgia and myalgia, as well as to document the risk factors and preventative and therapeutic treatments that have been investigated. Methods A literature search was conducted in Ovid Medline, OldMedline, Embase, Embase Classic, and Cochrane Central Register of Controlled Trials using relevant subject headings and keywords such as: “arthralgia,” “myalgia,” “muscle pain,” “joint pain,” “taxane,” “chemotherapy,” “docetaxel,” “paclitaxel.” Results The reported incidences of arthralgia and myalgia were variable. Taxane chemotherapy was found to be associated with greater incidences of arthralgia and myalgia than non-taxane forms of chemotherapy. Moreover, docetaxel and nab-paclitaxel seem to be associated with lower incidences of arthralgia and myalgia than paclitaxel. Finally, the literature on prevention and therapeutic treatment of taxane-induced arthralgia and myalgia is scarce. Conclusion More studies should be done in order to more conclusively identify optimal therapeutic and preventative treatments as well as different risk factors. We recommend that a prospective study be done in order to better understand the true incidence of arthralgia and myalgia in patients being treated with the paclitaxel, docetaxel, and nab-paclitaxel.

Which pain intensity scale from the Brief Pain Inventory correlates most highly with functional interference scores in patients experiencing taxane-induced arthralgia and myalgia?

PurposeThe purpose of this study was to assess which pain intensity dimension scale (worst, least, average, or current pain) from the Brief Pain Inventory (BPI) correlates most highly with functional interference scores in patients experiencing taxane-induced arthralgia and myalgia.MethodsBreast cancer patients scheduled to receive docetaxel, paclitaxel, or albumin-bound paclitaxel (nab-paclitaxel) were enrolled in the study. Patients completed an initial baseline questionnaire and subsequently filled out a diary based on the BPI on days 1–7, 14, and 21 for three consecutive treatment cycles. Pain scores for worst, least, average, and current pain intensity dimensions as well as pain interference scores were recorded in the diaries and questionnaires using the BPI. Worst, least, average, and current pain scores were correlated with functional pain interference scores using Spearman’s rank correlation coefficients. A general linear mixed model of each functional interference measure was performed over time for cycles 1–3 with each pain intensity dimension scale.ResultsAmong worst, average, least, and current joint pain dimensions, average joint pain scores correlated best with all BPI interference responses while average muscle pain scores correlated best with all BPI interference responses except for sleeping probability and normal work.ConclusionWe recommend the BPI scale measuring average pain for future studies evaluating pain scores in patients experiencing taxane-induced arthralgia and myalgia.

Radiological changes on CT after stereotactic body radiation therapy to non-spine bone metastases: a descriptive series

BACKGROUND In recent years, stereotactic body radiation therapy (SBRT) has become increasingly used for the management of non-spine bone metastases. Few studies have examined the radiological changes in bone metastases after treatment with SBRT and there is no consensus about what constitutes radiologic response to therapy. This article describes various changes on CT after SBRT to non-spine bone metastases in eight selected cases. METHODS A retrospective review was conducted for patients treated with SBRT to non-spine bone metastases between November 2011 and April 2014 at Sunnybrook Health Sciences Centre. A musculoskeletal radiologist identified eight illustrative cases of interest and provided a description of the findings. RESULTS Different radiological changes following SBRT were described, including: remineralization of lytic bone metastases, demineralization of sclerotic bone metastases, pathologic fracture, size progression and response in different lesions, as well as lung fibrosis after SBRT to a rib metastasis. CONCLUSIONS We reviewed the radiological images of eight selected cases after SBRT to nonspine bone metastases and a number of characteristic findings were highlighted. We recommend future studies to correlate radiologic changes with clinical outcomes including pain relief, toxicity and long-term local control.

The impact of clinical and sociodemographic features on quality of life in patients with early stage cancers using the Functional Assessment of Cancer Therapy-General assessment tool

PurposeThis study aims to compare the Functional Assessment of Cancer Therapy-General (FACT-G) quality of life (QOL) scores of patient groups with varying clinical and sociodemographic features in the early stage cancer population.MethodsA literature search was conducted on both the Embase and OvidSP platforms. Weighted analysis of variance (ANOVA) was performed for binary predictors and weighted linear regression analysis was conducted for continuous predictors.ResultsSix binary features predicted at least one domain of QOL: primary cancer site (homogeneous versus heterogeneous), total per capita healthcare expenditures, mean age, previous chemotherapy, radiotherapy, and previous hormonal therapy. Two continuous factors had predictive value with respect to QOL: completion of postsecondary education and marital status.ConclusionAlthough there are limitations of the current study, similar correlations to our own have been previously described between QOL and healthcare expenditures, mean age and education. Currently, the literature conflicts in its analysis of previous radiotherapy and chemotherapy as predictors of QOL. No published evidence exists describing the presently found relationships in primary cancer site, marital status and hormonal therapy. Future work may focus on determining cause and effect relationships between these predictors and QOL.

Olanzapine for the prophylaxis and rescue of chemotherapy-induced nausea and vomiting (CINV): a retrospective study

BACKGROUND While the efficacy of olanzapine in the prophylaxis of chemotherapy-induced nausea and vomiting (CINV) has been documented, the literature on the use of olanzapine as a rescue medication for breakthrough CINV has been scarce. The following study retrospectively evaluated the safety and efficacy of olanzapine for the treatment of breakthrough CINV. The efficacy and safety of olanzapine in the prophylactic setting was also examined in a smaller cohort. METHODS Electronic medical records of adult patients aged >17 years receiving a prescription for olanzapine from the Odette Cancer Centre Pharmacy at Sunnybrook Hospital between January 2013 and June 2015 were reviewed retrospectively. Inclusion criteria required receiving one or more doses of olanzapine for the rescue or prophylaxis of CINV and documentation of the outcome. RESULTS A total of 154 patients and 193 treatment cycles were included in the breakthrough setting, while a total of 16 patients and 20 treatment cycles were included in the prophylaxis setting. In the breakthrough setting, 88% of cases experienced improved nausea, while 21% of cases reported improved vomiting. In the prophylactic setting, 100% of cases experienced improved nausea, while 65% achieved improved vomiting. A total of 43% of cases in the breakthrough setting and 65% of cases in the prophylactic setting experienced sedation. CONCLUSIONS Olanzapine is effective in improving CINV in both the prophylactic and breakthrough settings. The safety, efficacy, and appropriate dosage of olanzapine for the rescue of breakthrough CINV should be prospectively evaluated in a randomized controlled trial (RCT).

Symptom clusters using the Brief Pain Inventory in patients with breast cancer

BACKGROUND The purpose of this study was to assess symptom clusters in functional interference using the brief pain inventory (BPI) in patients with non-metastatic breast cancer (BC) during and after chemotherapy. METHODS A principal component analysis with varimax rotation was conducted on data from 228 patients to identify two clusters at baseline and two intervals following treatment. RESULTS Physical (general activity, normal work, walking ability) and psychosocial (mood, relationships, sleep, enjoyment of life) interference clusters were present at baseline. Clusters were observed at 1-month (cluster 1: general activity, normal work, enjoyment of life; cluster 2: relationships, sleep) and 3-month (cluster 1: general activity, normal work, relationships; cluster 2: sleep, enjoyment of life) post-treatment. CONCLUSIONS Results from our study suggest dynamic symptom clusters in this patient population, and encourage continued symptom management following completion of treatment.