Oscar Corli

Effectiveness of levosulpiride versus metoclopramide for nausea and vomiting in advanced cancer patients: A double-blind, randomized, crossover study

The antiemetic efficacy of levosulpiride (L) was compared to metoclopramide (M) in a double-blind, randomized, crossover study. Thirty patients with advanced cancer, who were no longer receiving antineoplastic therapy, were randomly assigned to receive either L 75 mg/day or M 30 mg/day. After 7 days, patients were crossed over to the alternate treatment, which was also given for 7 days. The hours with nausea were 1.08 (mean value/day/patient) during treatment with L and 2.01 with M (P = 0.002), independent of the order of administration. The nausea intensity was 0.76 (mean value/day/patient) with L and 1.42 with M (P = 0.0004). Complete control of nausea was obtained in 84.6% of patients receiving L and 42.3% of those treated with M (P = 0.0034). The number of vomiting episodes was 0.38 (mean value/day/patient) during treatment with L and 0.70 with M (P = 0.002), independent of the order of administration. Vomiting disappeared in 81.5% of patients receiving L and 51.8% of those treated with M (P = 0.041). There was a carry-over effect in favor of L. These data indicate that both L and M reduce nausea and vomiting, but L is more effective.

Managing severe cancer pain: The role of transdermal buprenorphine: A systematic review

Pain is a frequent and important symptom in cancer patients. Among the available strong opioids, transdermal buprenorphine has been licensed in Europe since 2002, and results from a few clinical studies suggest that it may be a good alternative to the other oral or transdermal opioids. To assess the best available evidence on its efficacy and safety, we carried out a systematic literature review with the aim of pooling relevant studies. We identified 19 eligible papers describing 12 clinical studies (6 randomized controlled trials and 6 observational prospective studies), including a total of about 5000 cancer patients. Given the poor quality of reports and the heterogeneity of methods and outcomes, pooling was not feasible as the type of data was not appropriate for combining the results statistically. A meta-analysis based on individual data is ongoing in the context of the Cochrane Collaboration. In conclusion, although the narrative appraisal of each study suggests a positive risk benefit profile, well designed and statistically powered controlled clinical trials are needed to confirm this preliminary evidence.

Pain management and outcomes in cancer patients: comparison between oncological and palliative sets of care

Background: medical oncologists and palliative care physicians have different tasks even if they play a similar role when coping with pain of their patients. In spite of this converging goal, oncologists and palliative care therapists can not have the same approach and impact in managing pain. This study analyzes how pain is treated and which outcomes derive from in 1 461 cancer patients separately cared by oncologists or palliative care physicians. Methods: data derive from an observational, multicentre, prospective, longitudinal study carried out in 110 Italian hospitals. After inclusion, the data were recorded weekly for a 28 days period of follow-up. Results: 876 patients (60%) were cared by oncologists and 585 (40%) by palliative care physicians. The two professional categories tended to similarly manage the drugs of WHO analgesic ladder, while rescue and adjuvant therapies were more frequently used by palliative care physicians. Opioids daily dose increased from 68.3 to 92.5 mg/day (Effect size=0.282) among oncologists and from 70.8 to 107.8 mg/day (Effect size=0.402) among palliative care physicians. The switch of opioids was applied in 12.3% and in 19.1% (p=0.1634), respectively. Pain intensity decreased in both groups but more strongly in the palliative context. The full responders patients were 50% in oncology wards and 58.9% in palliative care (p=0.0588). Conclusions: this study indicates how much oncologists and palliative care physicians differ in managing cancer pain. The observational nature of this study reflects the natural and unaffected choice of the professionals. As intrinsic limit the study only describes their behaviors without a stringent comparative evaluation.

Nonresponsiveness and Susceptibility of Opioid Side Effects Related to Cancer Patients’ Clinical Characteristics: A Post-Hoc Analysis

The response to opioids is not always positive in cancer patients. A considerable proportion of patients do not respond (nonresponders [NRs]) or experience severe toxicity. The aim of this analysis was to assess the role of demographic characteristics, pain features, comorbidities, and ongoing therapy on the lack of efficacy and on the occurrence of severe adverse drug reactions (ADRs).

Systematic review and meta-analysis on neuropsychological effects of long-term use of opioids in chronic non-cancer pain patients

Opioid treatments are often prolonged because of the pathology causing pain. We focused on the cognitive functions in patients with chronic pain treated with opioids. This topic is currently controversial, but in practice, the consequences are important in patients’ daily lives, social interactions, working ability, and driving.

A New Focus on Breakthrough Cancer Pain: Commentary on Davies et al.

A recent review article reports thatmore than one of two patients with cancer-related pain also suffers from breakthrough cancer pain (BTcP); however, this finding is based on several investigations with inconsistencies in the definition and assessment of the phenomenon. In the study by Davies et al., with a sample of 1000 European BTcP patients, BTcP was defined by a unique and standardized diagnostic algorithm. A first interesting result of this study is that epidemiological and clinical aspects of BTcP (prevalence, daily number of episodes, time to peak, duration, and interference with daily activities) are referred to separately for the main subtypes of BTcP, that is, incident (44% of the sample) and spontaneous (42%). This is an original approach that highlights some dissimilar featuresdmost notably, peak and durationdwhich could imply the use of different therapeutic strategies. For instance, these observeddifferences couldbeused todetermine which available rescuedrugs are likely to bemost effective on the basis of their different pharmacokinetic properties. Moreover, as to patient treatment preference, pharmacological intervention was the preferred option in 29% of cases, whereas a nonpharmacological option was selected by 23% of patients. This is quite surprising because a higher rate of

Quality for home palliative care: an Italian metropolitan multicentre JCI-certified model

Background Assessing the quality of care and service delivery through the analysis of ad hoc indicators is a relevant process for quality monitoring and improvement with a view to providing patients, the community and administrators alike with appropriate elements of evaluation. This paper describes the key results of a certification process based on the Joint Commission International (JCI) criteria for the home hospitalisation model implemented by the palliative care units of seven Milan hospitals for terminally ill patients with cancer. Methods In 2006, the interhospital working team implemented a certification project based on the JCI Disease or Condition-Specific Care (DSCS) programme. Thirty standards subdivided into five functional areas with 150 measurable elements were the starting-point for periodic improvement plans within and across participating hospitals. Programme compliance was analysed in terms of annual performance improvement and consistency across the seven PCUs involved in achieving set goals. The JCI standards were applied on 3316 terminally ill patients with cancer treated at home from 2005 to 2009. Results As a result of the work carried out, the JCI survey conducted 3 years after project implementation demonstrated full compliance with the established standards, leading to the JCI certification award (for the first time in this clinical setting internationally). Conclusion The work carried out with a view to certification has confirmed the possibility that facilities spread across different hospitals can actually share common processes and standardise the activities for the care of end-of-life patients with cancer at home as if they were one single service provider.