Tw Leung

Use of methylphenidate for the management of fatigue in Chinese patients with cancer.

Reason for the Study: Studies on methylphenidate for cancer-related fatigue showed conflicting results. This prospective study aims to determine whether methylphenidate is useful for relieving fatigue in Chinese patients with cancer. Chinese Version of Brief Fatigue Inventory (BFI-C) was administered on days 1, 8, and 29. Methylphenidate dose on day 1 was 5 mg daily then adjusted after day 8 according to response and side effects tolerance. Main Findings: Only 48% of the 25 recruited patients were on methylphenidate by day 29. Overall, no significant improvement in fatigue level was observed after methylphenidate, though benefits were shown in subgroups with age ≤ 65 and higher baseline BFI-C values. Principal Conclusions: Methylphenidate may be useful for management of cancer-related fatigue in selected Chinese patients.

Patients’ Views on Failure to Gain Expected Clinical Beneficial Outcomes From Participation in Palliative Medicine Clinical Trials

Reason for the Study: This study aims to understand patients’ views on failing to gain expected beneficial outcomes from palliative medicine clinical trials. This is a qualitative study involving semistructured interviews. Main Findings: Seven patients were interviewed. Despite loss of initial hope in benefiting themselves in terms of better disease or symptom control, patients interviewed still found joining clinical trials meaningful experience in terms of benefiting future patients and being valuable life experience. Experience in interacting with research staff partly formulated final impressions on clinical trial participation experience. Principal Conclusions: Joining well-designed clinical trials unlikely causes harm to patients. Caring attitudes of researchers and maintaining good researcher–patient relationships can help patients in meaning-finding process, especially if they have failed to gain anticipated clinical benefits.

End-of-life-care for Chinese patients in acute care ward setting: Experience in an oncology ward and report on a pilot project on the use of an integrated care pathway

Dear Sir Our institute provides services to cancer patients in various stages of their illness. The ward providing in-patient care is an acute care ward setting, and hospice beds are booked for patients who require prolonged in-patient stays for symptom control and palliative care. However, some patients die in our ward instead of being transferred to hospices as hospice beds may not be available before their deaths, or their conditions are not fit for transfer by the time hospice beds become available. Most of them do not die from acute complications. An integrated pathway modified from the Liverpool Care Pathway for the Dying Patient and end-of-lifecare pathway used in a Palliative Care Unit in Hong Kong Special Administrative Region (HKSAR), China has been designed for use in our department’s ward to improve the organization of end-of-life care. It is kept as simple as possible with seven sections in only six pages to allow for better acceptance. Most of the items are simple checklists. Doctor assessment is performed daily, and nursing assessment is performed three times daily (once every shift) to fit into existing clinical routines. In our hospital, visiting hours are limited due to infection control policy, but patients recruited into the pathway are allowed flexible visiting hours as special cases. Fluid supplement is allowed as it is not yet generally acceptable to withhold artificial hydration for dying patients in our locality. A pilot project on the use of this pathway was conducted during July–September 2009. The pathway was used in addition to but not replacing existing ward Kardex as it was not yet in formal use. Twenty-four patients died in our ward during that period, but only 10 (41.7%) were recruited into the project. This may be because our staff less readily identify patients moving towards end-of-life phases so that only those who deteriorated more slowly were recruited. Recruited patients had a longer end-of-life period and were older than those on average when retrospectively reviewing in-patient medical records of patients died in our ward during March 2009 to February 2010. Compliance with six selected items (those involving doctors making management orders, as these are more easily counter-checked with in-patient records) in the pathway range from 80.0% to 100.0% (Table 1). A questionnaire survey was performed with nursing staff and most agreed that use of pathway helped them to provide efficient care of dying patients. Extra time is needed, however, to use the pathway and all felt extra resources were needed to use the pathway as clinical routine in the long run. Opinions from bereaved relatives were collected during bereavement by phone contact. They appreciated the flexible visiting hours and ward setting so that they could accompany patients in their last days of life at the bedside. They also appreciated doctors for relieving patient suffering and for clear explanations about patients’ conditions. The attitudes of staff were considered good, and showing of concern facilitated peaceful death with minimal suffering. Relatives felt comfortable and easier to accept patients’ deaths. The use of the end-of-life care pathway was considered to have improved care in the acute hospital setting as the ward environment was more humanized, warm and relatives felt being respected. Even though the pathway was not put into routine clinical practice immediately after completion of the

Impact of CAPOX or FOLFOX4 on Spleen size, Platelet Count and Liver Function when Partnered Cetuximab as First-line Treatment for KRAS Wild-type Metastatic Colorectal Cancer

Objectives: Oxaliplatin can cause hepatic sinusoidal injury and splenomegaly. It remains unknown if the magnitude of injury would differ when oxaliplatin is combined with capecitabine or 5-FU with/without cetuximab. We investigated the impact of 1 st line CAPOX or FOLFOX4 and the additional cetuximab on spleen size, platelet count and liver function in patients with KRAS wild-type metastatic colorectal cancer (mCRC). Methods: 101 Patients planned to receive either CAPOX or FOLFOX4 with/without cetuximab as first-line treatment were prospectively recruited. Changes in spleen size by volumetric measurement after treatment were determined. Correlation studies were performed for factors associated with changes in spleen size, thrombocytopenia and impaired liver function. Results: The spleen enlarged (median +17.9%, P < 0.001) after treatment. Multivariable analysis revealed that capecitabine, its dose intensity and cumulative dose (per 10000mg increase) correlated with splenomegaly (P = 0.01, P = 0.02 and P = 0.006, respectively). Increase in spleen size (P = 0.004) and splenomegaly (P = 0.002) correlated with thrombocytopenia. Dose intensity and cumulative dose of capecitabine (per 10000mg increase) and increase in spleen size correlated with grade 1 impaired liver function (P = 0.01, P = 0.003 and P = 0.04, respectively). Use of cetuximab correlated with less splenic enlargement (+13.7% vs. +22.7%; P = 0.04), especially when coupled with FOLFOX4 rather than CAPOX (+1.1% vs. + 23.0%; P = 0.003). Conclusions: Capecitabine was associated with more splenomegaly which in turn correlated with thrombocytopenia and impaired liver function. Cetuximab offered some protection from further splenic enlargement especially when combined with FOLFOX4.

Addition of cetuximab to oxaliplatin-based chemotherapy on liver and spleen size and thrombocytopenia in patients with metastatic colorectal cancer

Introduction Colorectal cancer (CRC) is the third most prevalent human cancer worldwide, with 1 million estimated new cases annually. The National Program of Prevention and Early Detection of Colorectal Cancer started in November 2007. The screening method for early detection of colorectal cancer is the Faecal Occult Blood Test (FOBT). The target population is an asymptomatic population at average risk, aged 50-74. The expected time of one screening cycle was extended from 2 to 4 years because of the technical difficulties in implementing the Program. Invitation letters have been sent by mail. There are three FOBT with instructions for their use, a questionnaire about risk factors and an educational brochure in each envelope. Invited people have been asked to mail applied testing-cards back, together with a filled out questionnaire. People testing positive are invited for colonoscopy in the Clinical Hospital Centre Osijek. Methods The individuals who tested positive for FOBT accepted a colonoscopy examination. During the colonoscopy examination premalignant lesions are removed and the samples are sent for histopathological analysis. Patients are called in to the Clinical Hospital Centre Osijek for a check-up when the gastroenterologist decides on further treatment depending on the results of the analysis. The colonoscopy results are collected and analysed in the Institute of Public health. Results Until February 2012 we sent FOBT to 75.021 individuals (71% of target population). The responding rates are 20.3%. The percent of FOBT positive tests were 9.6%. From 1.412 individuals who were invited 968 underwent a colonoscopy. 87.5% had a pathological finding. There are 68 newly discovered carcinomas (7.0% of those who underwent colonoscopy), 474 polyps (49.0%), 173 haemorrhoids (17.9%), 85 diverticula (8.8%) and 47 other diagnoses (4.9%). 121 individuals were without a pathological finding (12.5%). Conclusion It is necessary to increase public awareness about colorectal cancer. With higher response rates more cancers and premalignant lesions in the population will be detected. The detection of cancer in early stages increases the survival rate and quality of life.

Bevacizumab after cetuximab failure in Kras wild-type metastatic colorectal carcinoma

Introduction Colorectal cancer (CRC) is the third most prevalent human cancer worldwide, with 1 million estimated new cases annually. The National Program of Prevention and Early Detection of Colorectal Cancer started in November 2007. The screening method for early detection of colorectal cancer is the Faecal Occult Blood Test (FOBT). The target population is an asymptomatic population at average risk, aged 50-74. The expected time of one screening cycle was extended from 2 to 4 years because of the technical difficulties in implementing the Program. Invitation letters have been sent by mail. There are three FOBT with instructions for their use, a questionnaire about risk factors and an educational brochure in each envelope. Invited people have been asked to mail applied testing-cards back, together with a filled out questionnaire. People testing positive are invited for colonoscopy in the Clinical Hospital Centre Osijek. Methods The individuals who tested positive for FOBT accepted a colonoscopy examination. During the colonoscopy examination premalignant lesions are removed and the samples are sent for histopathological analysis. Patients are called in to the Clinical Hospital Centre Osijek for a check-up when the gastroenterologist decides on further treatment depending on the results of the analysis. The colonoscopy results are collected and analysed in the Institute of Public health. Results Until February 2012 we sent FOBT to 75.021 individuals (71% of target population). The responding rates are 20.3%. The percent of FOBT positive tests were 9.6%. From 1.412 individuals who were invited 968 underwent a colonoscopy. 87.5% had a pathological finding. There are 68 newly discovered carcinomas (7.0% of those who underwent colonoscopy), 474 polyps (49.0%), 173 haemorrhoids (17.9%), 85 diverticula (8.8%) and 47 other diagnoses (4.9%). 121 individuals were without a pathological finding (12.5%). Conclusion It is necessary to increase public awareness about colorectal cancer. With higher response rates more cancers and premalignant lesions in the population will be detected. The detection of cancer in early stages increases the survival rate and quality of life.