Ray Chacko

Impact of a Palliative Care Consultation Team on Cancer-Related Symptoms in Advanced Cancer Patients Referred to an Outpatient Supportive Care Clinic

CONTEXT Patients with advanced cancer may develop severe physical and psychosocial symptoms. There are limited data on the impact of an outpatient palliative consultation (PC) team on cancer-related symptoms. OBJECTIVES To study the impact of the PC on symptoms in patients with advanced cancer receiving outpatient palliative care. METHODS Four hundred six consecutive patients referred to a supportive care outpatient center (OPC) from January 2006 to June 2007 with complete Edmonton Symptom Assessment Scale (0-10 scale) at the initial and follow-up visits were reviewed. Patient characteristics, change of symptoms at follow-up visit, and response rate were analyzed. Using logistic regression models, the predictors of improvement of pain and fatigue were assessed. RESULTS Median age was 59 years; 53% were female. Median interval between visits was 15 days. Mean scores at baseline and follow-up visits were fatigue 6.8 and 5.3 (P<0.0001), pain 5.3 and 4.1 (P<0.0001), depression 3.2 and 2.5 (P<0.0001), anxiety 3.7 and 2.8 (P<0.0001), dyspnea 2.7 and 2.5 (P=0.05), sleep 5 and 4 (P<0.0001), and well-being 5.2 and 4.4 (P<0.0001). Dyspnea (odds ratio and P-value, 0.90, 0.03), nausea (0.92, 0.06), and depression (0.91, 0.04) were associated with improvement in fatigue; drowsiness (1.10, 0.04), and feeling of well-being (0.87, 0.02) were associated with improvement in pain. CONCLUSION The initial consult by PC achieved significant symptom improvement in patients receiving treatment in the OPC. Further prospective studies are needed.

Alcoholism Screening in Patients with Advanced Cancer: Impact on Symptom Burden and Opioid Use

PURPOSE Alcoholism is a devastating disease that can cause patient and family suffering and is frequently underdiagnosed. Preliminary studies suggest that it is associated with increased symptom expression and opioid dose escalation. The CAGE questionnaire is a widely used tool for alcoholism screening. The purpose of this study was to determine the frequency and characteristics of patients who screen positive for alcoholism in a palliative care outpatient clinic (PCOC). METHODS We reviewed 665 consecutive charts of patients referred to the PCOC and collected data regarding age, gender, and type of cancer. For the first 100 consecutive CAGE positive (CAGE+) and 100 consecutive CAGE negative (CAGE-) patients, time from advanced cancer diagnosis (AC) to PCOC was calculated, and symptoms (Edmonton Symptom Assessment Scale, ESAS) and Morphine Equivalent Daily Dose (MEDD) were collected. RESULTS CAGE was available for 598 of 665 (90%) patients. Of 598 patients, 100 (17%) were CAGE+. CAGE+ patients were younger (58 versus 60 years, p < 0.05), predominantly male (68% versus 47%, p < 0.0001), and with head/neck malignancies (24% versus 9%, p < 0.05). CAGE+ patients were referred earlier (5 +/- 27 months after AC, p < 0.0001). At baseline, pain, sleep, dyspnea, well-being, and total symptom distress were significantly worse among CAGE+ patients. Both groups showed similar improvement in symptoms. CAGE+ patients were more frequently on opioids upon referral (47/100 versus 29/100, p < 0.05) and follow-up (27/65 versus 16/68, p < 0.05). At follow-up, opioid doses did not show significant changes. CONCLUSION Seventeen percent of the patients were CAGE+. These patients were referred earlier to palliative care, had more symptom expression, and were more frequently on opioids. The palliative care team successfully improved symptom control in both groups without opioid dose escalation.

Achievement of personalized pain goal in cancer patients referred to a supportive care clinic at a comprehensive cancer center

Cancer pain initiatives recommend using the personalized pain goal to tailor pain management. This study was conducted to examine the feasibility and stability of personalized pain goal, and how it compares to the clinical pain response criteria.

Factors Associated with Response to Methylphenidate in Advanced Cancer Patients

BACKGROUND There has been increasing interest in the use of methylphenidate for cancer-related fatigue (CRF) in patients with advanced cancer. However, there is limited literature on the specific patient characteristics associated with response to methylphenidate. Our objective of this study was to identify the specific patient characteristics associated with response to methylphenidate and to compare day 1 response with day 8 response. METHODS We retrospectively reviewed the records of patients in two prospective controlled clinical trials that we had conducted who had received methylphenidate for cancer-related fatigue. Baseline patient characteristics, symptoms (as assessed by the Edmonton Symptom Assessment System [ESAS] and Functional Assessment of Chronic Illness Therapy-Fatigue [FACIT-F]), and response (change in fatigue) at the end of day 1 treatment were analyzed to determine their association with response to methylphenidate on day 8. RESULTS A total of 82 patients with advanced cancer who received methylphenidate for CRF were included in our review. The median age was 55 years, 66% were female, 74% were white, and the most common cancer type was breast (37%). Fifty out of 82 patients (61%) responded to methylphenidate (≥ 7 points in FACIT-F). The intensity of baseline fatigue positively correlated with the response to methylphenidate (p < .001). Change in fatigue in response to methylphenidate was not associated with intensity of baseline depression, anxiety, drowsiness, or daily opioid dose. Better improvement of fatigue after treatment on day 1 was associated with more improvement with fatigue on day 8 as assessed by FACIT-F (p = .0004) and ESAS (p = .0001). Day 1 response as a predictor of day 8 response had a sensitivity of 0.84, a positive predictive value of 0.67, and specificity of 0.6. CONCLUSIONS Response to methylphenidate is associated with higher baseline fatigue but not with higher baseline depression or sedation. Additionally, day 1 improvement is highly sensitive as a predictor of long-term improvement.

Achievement of personalized pain goal (PPG) in cancer patients referred to a supportive care clinic.

9060 Background: Cancer pain quality improvement initiatives recommend tailoring pain treatments to patients (pts) individual goals for comfort/functioning. The pts PPG for pain relief (0-10 pain-intensity that pt considers to be comfortable, in physical, functional, and psychosocial domains) is a simple measure of such goals. Pain and PPG are routinely assessed at our institution. Study was conducted to determine the proportion of cancer pts treated for pain, who achieve a pain response, as determined by their PPG, and identify factors associated with its non-achievement. METHODS Records of consecutive cancer pts seen in the Supportive-Care Clinic in consultation, who had follow-up visits within 1-5 weeks (n=348) were reviewed. All pts were treated by palliative-medicine specialists. Pain-response was defined as (1) Clinical-response (30% or ≥2 point pain reduction), and (2) PPG-response (if pain ≤ PPG). Logistic-regression model was used to estimate the effect of various factors on PPG-response. RESULTS Males 51%, median age 58 years, and survival 188 (IQR 92-412) days. At baseline, 239 pts (69%) had pain ≥4. Median pain was 7 (IQR 5-8) and PPG 3 (2-3). At follow-up (median 14-days), pain significantly decreased (7 vs 5, p < 0.001), while PPG remained stable (p=0.9). Initial PPG remained the same (51%) or changed by <2-points (31%) in 195 pts (82%). 122 pts (51%) achieved a clinical-response, but only 66 (28%) achieved their PPG (Table). Using PPG as gold-standard, sensitivity of clinical-response was 89%, and specificity 65%. Baseline factors associated with non-achievement of PPG were higher Memorial Delirium Assessment Scale scores (odds-ratio 1.43 per point, p= 0.002), positive alcoholism screening (CAGE ≥ 2) (2.79, 0.04) and insomnia (1.13, 0.04). CONCLUSIONS PPG is a simple pt reported outcome for pain goals. Our preliminary findings suggest that PPG is stable over time, and that traditional definitions of clinical-response have a large percentage of false-positives. Predictors of lack of PPG-response include delirium, alcoholism history, and insomnia. [Table: see text].

Alcoholism screening in advanced cancer patients: Impact on symptom burden and opioid use

9543 Background: Alcoholism is frequently underdiagnosed in cancer patients. Preliminary studies suggest that it is associated with increased symptom expression and opioid dose escalation. The CAGE...