V. Poulter

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.

Donepezil for Cancer Fatigue: A Double-Blind, Randomized, Placebo-Controlled Trial

PURPOSE To evaluate the effectiveness of donepezil compared with placebo in cancer patients with fatigue as measured by the Functional Assessment for Chronic Illness Therapy-Fatigue (FACIT-F). PATIENTS AND METHODS Patients with fatigue score >or= 4 on a scale of 0 to 10 (0 = no fatigue, 10 = worst possible fatigue) for more than 1 week were included. Patients were randomly assigned to receive donepezil 5 mg or placebo orally every morning for 7 days. A research nurse contacted the patients by telephone daily to assess toxicity and fatigue level. All patients were offered open-label donepezil during the second week. FACIT-F and/or the Edmonton Symptom Assessment System (ESAS) were assessed at baseline, and days 8, 11, and 15. The FACIT-F fatigue subscale score on day 8 was considered the primary end point. RESULTS Of 142 patients randomly assigned to treatment, 47 patients in the donepezil group and 56 in the placebo group were assessable for final analysis. Fatigue intensity improved significantly on day 8 in both donepezil and placebo groups. However, there was no significant difference in fatigue improvement by FACIT-F (P = .57) or ESAS (P = .18) between groups. In the open-label phase, fatigue intensity continued to be low as compared with baseline. No significant toxicities were observed. CONCLUSION Donepezil was not significantly superior to placebo in the treatment of cancer-related fatigue.

Comparison of symptom burden among patients referred to palliative care with hematologic malignancies versus those with solid tumors.

BACKGROUND Patients with hematologic malignancies have reduced and later access to palliative care services (APCS) than do those with solid tumors. It is unclear whether these patients develop a high symptom burden at the end of life that requires special palliative care interventions. The purposes of this retrospective study were to determine whether symptoms are less severe in patients with hematologic than in those with solid malignancies on APCS and whether symptom severity is associated with early APCS. METHODS We studied the records of consecutive patients with hematologic and solid malignancies at their first palliative care consultation (PC1). We collected information about demographics, cancer type, date of PC1, and the interval from PC1 to death (PC1-D). We reviewed the charts for the Edmonton Symptoms Assessment System (ESAS) and presence of delirium. RESULTS We included 250 patients (125 with each type of malignancy). Median pain and drowsiness were 4 (3-5) and 7 (5-10) among hematologic compared to 5 (4-6, p=0.043) and 5 (3-6, p=0.0008) among patients with solid malignancies, respectively. Delirium was detected in 51 of 125 (41%) hematologic versus 20 of 125 (16%) solid (p=0.0001). Median PC1-D was 13 days for hematologic versus 46 days for solid (p=0.0001). There was no correlation between PC1-D and pain (r= -0.117, p=0.4 for hematologic and r=0.09, p=0.37 for solid), dyspnea (r= -0.02, p=0.85 for hematologic and r=0.09, p=0.42 for solid) or the Symptom Distress Score (r= -0.047, p=0.72 for hematologic and r= -0.093, p=0.32 for solid). CONCLUSIONS Hematologic patients had increased delirium and drowsiness and later APCS The overall symptom severity was similar in both groups of patients and did not correlate with early APCS. Future prospective studies are needed to better define APCS patterns in this group.

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.

Association between fatigue and other cancer-related symptoms in patients with advanced cancer

Goals of workAlthough fatigue is the chronic symptom most commonly experienced by patients with advanced cancer, little research has been done on the associations and correlates of fatigue in this population. The aim of this study was, therefore, to determine whether fatigue scores, as measured by the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), are associated with age, gender, type of cancer diagnosed, pain, and other cancer-related symptoms measured using the Edmonton Symptom Assessment Scale (ESAS).Materials and methodsWe retrospectively reviewed the FACIT-F (when a higher score denotes lower fatigue) and ESAS (when a lower fatigue score denotes lower fatigue intensity) scores of 268 patients with advanced cancer who had been previously enrolled in clinical trials of therapies for fatigue. To determine associations between variables, we performed univariate and multivariate analyses on the data.ResultsWe found no univariate association between fatigue score and gender, ethnicity (p = 0.31), or type of cancer diagnosed. Performance status was associated with fatigue (p < 0.0001). On multivariate analysis, we found, however, significant association between fatigue and pain (r = −0.20, p = 0.0012), nausea (r = −0.13, p = 0.04), anxiety (r = −0.27, p < 0.0001), fatigue and depression (r = −0.19, p = 0.0019), drowsiness (r = −0.24, p = 0.0002), dyspnea (r = −0.17, p = 0.007), anorexia (r = −0.29, p < 0.0001), insomnia (r = −0.25, p < 0.0001), and feelings of well-being (r = −0.37, p < 0.0001). Using backward stepwise logistic regression analysis, independent correlative factors associated with fatigue include well-being (p = .0003), drowsiness (0.006), anorexia (0.01), and anxiety (0.03). However, this model only explained 21% of the variation in the intensity of fatigue.ConclusionsAlthough we found that fatigue is significantly associated with the severity of psychological symptoms (anxiety and depression) and physical symptoms (pain, dyspnea, insomnia, anorexia, and drowsiness), additional research is required to confirm that these are indeed the main associations of fatigue and, by doing so, enable physicians to better characterize fatigue in patients receiving palliative care.

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...