Sriram Yennu

Minimal clinically important differences in the Edmonton Symptom Assessment Scale in cancer patients: A prospective, multicenter study

The Edmonton Symptom Assessment Scale (ESAS) is widely used for symptom assessment in clinical and research settings. A sensitivity‐specificity approach was used to identify the minimal clinically important difference (MCID) for improvement and deterioration for each of the 10 ESAS symptoms.

Clinical Signs of Impending Death in Cancer Patients

BACKGROUND The physical signs of impending death have not been well characterized in cancer patients. A better understanding of these signs may improve the ability of clinicians to diagnose impending death. We examined the frequency and onset of 10 bedside physical signs and their diagnostic performance for impending death. METHODS We systematically documented 10 physical signs every 12 hours from admission to death or discharge in 357 consecutive patients with advanced cancer admitted to two acute palliative care units. We examined the frequency and median onset of each sign from death backward and calculated their likelihood ratios (LRs) associated with death within 3 days. RESULTS In total, 203 of 357 patients (52 of 151 in the U.S., 151 of 206 in Brazil) died. Decreased level of consciousness, Palliative Performance Scale ≤20%, and dysphagia of liquids appeared at high frequency and >3 days before death and had low specificity (<90%) and positive LR (<5) for impending death. In contrast, apnea periods, Cheyne-Stokes breathing, death rattle, peripheral cyanosis, pulselessness of radial artery, respiration with mandibular movement, and decreased urine output occurred mostly in the last 3 days of life and at lower frequency. Five of these signs had high specificity (>95%) and positive LRs for death within 3 days, including pulselessness of radial artery (positive LR: 15.6; 95% confidence interval [CI]: 13.7-17.4), respiration with mandibular movement (positive LR: 10; 95% CI: 9.1-10.9), decreased urine output (positive LR: 15.2; 95% CI: 13.4-17.1), Cheyne-Stokes breathing (positive LR: 12.4; 95% CI: 10.8-13.9), and death rattle (positive LR: 9; 95% CI: 8.1-9.8). CONCLUSION We identified highly specific physical signs associated with death within 3 days among cancer patients.

Optimal Screening for Geriatric Assessment in Older Allogeneic Hematopoietic Cell Transplantation Candidates

OBJECTIVE Older patients who receive hematopoietic cell transplantation (HCT) may be at risk for adverse outcomes due to age-related conditions or frailty. Geriatric assessment (GA) has been used to evaluate HCT candidates but can be time-consuming. We therefore sought to determine the predictive ability of two screening tools, the Vulnerable Elders Survey (VES-13) and the G8, for abnormal GA or frailty. MATERIALS AND METHODS We enrolled 50 allogeneic HCT candidates age ≥60 years. The GA included measures of medical, physical, functional, and social health. Frailty was defined as 3 or more abnormalities on grip strength, gait speed, weight loss, exhaustion, and activity. We associated baseline characteristics and abnormal GA or frailty. We determined the sensitivity and predictive ability of the VES-13 and G8 for GA and frailty. RESULTS Overall, 33 (66%) patients (mean age 65.4 years) had an abnormal GA, and 11 patients (22%) were frail. The G8 screening tool had a higher sensitivity for an abnormal GA (69.7%), and the VES-13 had a higher specificity (100%). Both tools had similar discriminatory ability. CONCLUSIONS Older HCT candidates had a significant number of deficits on baseline GA and a high prevalence of frailty. Existing screening tools may not be able to replace a full GA.

Use of Palliative Care Services in a Tertiary Cancer Center

This study analyzed palliative/supportive care use in a single cancer center over 8 years. Billing data showed the inpatient consultations as a percentage of hospital admissions and the ratio of inpatient consultations to hospital beds almost doubled. In the outpatient setting, data revealed earlier access to outpatient referrals to palliative care service (from 4.8 months to 7.9 months; p = .001) during the study period.

Factors associated with the severity and improvement of fatigue in patients with advanced cancer presenting to an outpatient palliative care clinic

BackgroundThe aim of this study was to determine factors associated with the severity of cancer related fatigue (CRF) and predictors of improvement of CRF at the first follow-up visit in patients with advanced cancer referred to outpatient palliative care clinic (OPC).MethodsWe reviewed the records of consecutive patients with advanced cancer presenting to OPC. Edmonton Symptom Assessment System (ESAS) scores were obtained at the initial and subsequent visits between January 2003 and December 2008. All patients received interdisciplinary care led by palliative medicine specialists following an institutional protocol. Fatigue improvement was defined as a reduction of ≥2 points in ESAS score relative to the baseline. Descriptive statistics were used to summarize patient characterstics. Univariate analyses were performed and only significant variables were included in multivariate regression analysis to determine factors associated with severity and improvement in CRF.ResultsA total of 1778 evaluable patients were analyzed (median age, 59 years; 52% male). The median time between visits was 15 days. Median fatigue scores on the ESAS were 6 at baseline and 5 at follow-up. Severity of all ESAS items and low serum albumin were associated with fatigue at baseline (p < 0.0001). The improvement of fatigue was observed in 586 patients (33%). The hierarchical model showed that fatigue improved over time (b = −0.009; p = 0.0009). low appetite (odds ratio [OR] = 1.09 per point; p = 0.0113) and genitourinary cancer (OR = 1.74 per point; p = 0.0458) were significantly associated with improvement of fatigue.ConclusionsCRF is strongly associated with physical and emotional symptoms. Genitourinary cancer and low appetite at baseline were associated with successful improvement of fatigue.

Barriers to research in palliative care in France

Purpose Palliative care (PC) needs expansion of its research capacity to improve the quality of care. This is particularly true for France that contributed less than 2% of all European PC research publications. We conducted a survey to assess the barriers French healthcare professionals (HCPs) involved in PC research had to face. Methods We surveyed all 420 PC departments registered in the French National Association for Palliative Care (SFAP) database using a previously used questionnaire. We documented the ethical limitations, time constraints, financial resources, patient issues and methodological issues related to PC research. Results We obtained 382 responses. Ninety-two (24.1%) HCPs were involved in a research project during the last 5 years. In univariate results, predictors of being involved in PC research were men (p=0.004), physician (p=0.022), working at a university hospital (p<0.001). There was a trend towards working in a PC unit (p=0.052). The main barriers to participating in PC research were lack of time (80.1%) and patient issues (47.4%). Lack of methodological support (33.0%) and financial limitations (30.4%) were also reported as major barriers. Conclusions There is a consensus that PC research and publication in the English language for peer-reviewed journals must be expanded in France but at this stage, clinical teams still lack specific funding and appropriate support. More research is needed to confirm our results and to determine the best ways to develop PC research capacity in France.

Increased Symptom Expression among Patients with Delirium Admitted to an Acute Palliative Care Unit

INTRODUCTION Delirium is the most common neuropsychiatric condition in very ill patients and those at the end of life. Previous case reports found that delirium-induced disinhibition may lead to overexpression of symptoms. It negatively affects communication between patients, family members, and the medical team and can sometimes lead to inappropriate interventions. Better understanding would result in improved care. Our aim was to determine the effect of delirium on the reporting of symptom severity in patients with advanced cancer. METHODS We reviewed 329 consecutive patients admitted to the acute palliative care unit (APCU) without a diagnosis of delirium from January to December 2011. Demographics, Memorial Delirium Assessment Scale, Eastern Cooperative Oncology Group (ECOG) Performance status, and Edmonton Symptom Assessment Scale (ESAS) on two time points were collected. The first time point was on admission and the second time point for group A was day one (+two days) of delirium. For group B, the second time point was within two to four days before discharge from the APCU. Patients who developed delirium and those who did not develop delirium during the entire course of admission were compared using chi-squared test and Wilcoxon rank-sum test. Paired t-test was used to assess if the change of ESAS from baseline to follow-up was associated with delirium. RESULTS Ninety-six of 329 (29%) patients developed delirium during their admission to the APCU. The median time to delirium was two days. There was no difference in the length of stay in the APCU for both groups. Patients who did not have delirium expressed improvement in all their symptoms, while those who developed delirium during hospitalization showed no improvement in physical symptoms and worsening in depression, anxiety, appetite, and well-being. CONCLUSION Patients with delirium reported no improvement or worsening symptoms compared to patients without delirium. Screening for delirium is important in patients who continue to report worsening symptoms despite appropriate management.

The routine use of the Edmonton classification system for cancer pain in an outpatient supportive care center.

180 Background: There is no standardized and universally accepted pain classification system for the assessment and management of cancer pain in both clinical practice and in research studies. The Edmonton Classification System for Cancer Pain (ECS-CP) is an assessment tool that has demonstrated value in assessing pain characteristics and response. The purpose of the study was to determine the relationship between the negative ECS-CP features and some pain related variables like pain intensity and opioid use. Also, we explored whether the number of negative ECS-CP features was associated with higher pain intensity. METHODS Electronic charts of 100 patients at the outpatient supportive care clinic in a comprehensive cancer center were reviewed for patient characteristics, initial ECS-CP assessment, the morphine equivalent daily dose (MEDD), opioid rotation, the Edmonton Symptom Assessment Score (ESAS), Memorial Delirium Assessment Scale (MDAS), performance status, and the use of adjuvant analgesics. RESULTS Ninety one out of the 100 charts were therefore eligible for analysis. The median age was 58.4 years. The most common primary cancer site was gastrointestinal cancer (22.1%). The median pain intensity was 6 and the median MEDD was 45mg. Incident pain was the most common ECS-CP feature (60%) and cognitive dysfunction was the least frequent feature (2%). Neuropathic pain was associated with higher median pain intensity (7 vs. 5, p=0.007) and median MEDD requirement (83 vs. 30, p=0.013). Psychological distress was associated with higher median pain intensity (7 vs. 5, p=0.042). Incident pain was also associated with a trend for higher pain intensity (6 vs 5, p= 0.06). A higher number of negative ECS-CP features was associated with higher pain intensity (p=0.01). CONCLUSIONS The ECS-CP was successfully completed in the majority of patients, demonstrating its utility in routine clinical practice. Neuropathic pain and psychological distress were associated with higher pain intensity. Also, neuropathic pain was associated with higher MEDD. A higher sum of negative ECS-CP features was associated with higher pain intensity. Further studies will be needed to explore this observation.

Post-Discharge Survival Outcomes of Patients with Advanced Cancer from the University of Texas MD Anderson Cancer Center Investigational Cancer Therapeutics (Phase i Trials) Inpatient Unit

Background: Patients with advanced cancer who progress on standard therapy are potential candidates for phase I clinical trials. Due to their aggressive disease and complex comorbid conditions, these patients often need inpatient admission. This study assessed the outcomes of such patients after they were discharged to hospice care. Patients and Methods: We performed a retrospective analysis of patients with solid tumor malignancies who were discharged to hospice care from the inpatient service. Results: One hundred thirty-three patients were included in the study cohort. All patients had metastatic disease and an Eastern Cooperative Oncology Group performance status ≥3. The median survival after discharge to hospice from an inpatient setting was 16 days, with a survival rate of 5% at 3 months after discharge. The median survival after the last cancer treatment was 46 days, with survival of 17% at 3 months, and 5% at 6 months. Patients with lactate dehydrogenase (LDH) >618 IU/L had a median post-discharge survival of 11 days versus 20 days for patients with LDH ≤618 IU/L. Conclusions: Patients with metastatic cancer participating in phase I trials who have poor performance status and require inpatient admission have a very short survival after discharge to hospice. A high LDH level predicts an even shorter survival.

Effects of high-dose Asian ginseng (Panax ginseng) to improve cancer-related fatigue: Results of a double-blind, placebo-controlled randomized controlled trial.

209 Background: Cancer related fatigue (CRF) is the most common and disabling symptom in cancer.Panax ginseng extract (PG) is frequently used as a nutraceutical treatment for fatigue. There are no well-powered placebo-controlled trials that used validated CRF outcome measures to investigate of PG effects in cancer patients. The primary objective of this trial was to evaluate the effects oral PG versus Placebo (PL) for CRF. METHODS Patients with cancer fatigue ≥ 4/10 on Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomized to either 400mg of standardized PG or matching PL orally twice a day for 28 days. The primary endpoint was change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) fatigue subscale from baseline to Day 28. Secondary outcomes were Functional Assessment of Cancer Therapy-General (FACT-G), Hospital Anxiety and Depression Scale (HADS), and ESAS. RESULTS Total evaluable patients were 112 (56 for PG and PL groups). No significant differences in baseline characteristics between the two groups except cancer type (p = 0.002). There was significant improvement in FACIT fatigue and ESAS fatigue scores in PG and PL groups at Day 15 and Day 29. The mean (SD) of FACIT-F fatigue scores at baseline, Day 15, and Day 29 were 22.6 (10.4), 29.8(10.7), 30.1 (11.6) and 23.8 (9.1), 30.0 (10.1), 30.4 (11.6) for PG and PL respectively. Mean (SD) improvement in the FACIT-F subscale at Day 29 was not significantly different in PG than in the PL group [7.5 (12.7) vs 6.5 (9.9), P = 0.67]. Mean (SD) improvement in the ESAS fatigue, FACT-G, and HADS at Day 29 were also not significantly different in PG than in the PL group. In a multiple linear model analysis, the change in FACIT-F fatigue from Day 0 to Day 29 was negatively correlated with baseline FACIT-F fatigue (p = 0.0005), baseline HADS score (p = 0.032), and male gender (p = 0.023). There were a significantly higher number of any grade of toxicities in PL group than in PG group (33/62 vs. 28/64, p = 0.024). CONCLUSIONS Both PG and Placebo result in a significant improvement in CRF at Day 15 and Day 29. PG was not significantly superior to placebo after 4 weeks of treatment. Further studies are needed. CLINICAL TRIAL INFORMATION NCT01375114.