Victor Tsu-Shih Chang

Opioid pharmacotherapy in the management of cancer pain. A survey of strategies used by pain physicians for the selection of analgesic drugs and routes of administration

Background. This survey documents the strategies used by pain control physicians in the selection of opioid drugs and routes of administration in the management of inpatients referred to a cancer pain service.

Multidimensional independent predictors of cancer-related fatigue☆

The purpose of this study was to identify independent predictors of clinically significant fatigue based upon a multidimensional model. A total of 180 cancer patients completed the Brief Fatigue Inventory (BFI), Functional Assessment of Cancer Therapy-Fatigue (FACT-F), Memorial Symptom Assessment Scale Short Form (MSAS-SF), and the Zung Self-Rating Depression Scale (SDS). Additional data included Karnofsky Performance Status (KPS) score, laboratory tests, and demographic information. The BFI usual fatigue severity > or =3/10 was defined as clinically significant fatigue. Possible independent variables were identified from a biopsychosocial model of fatigue. Fishers exact test was used to univariately assess the association of each variable with clinically significant fatigue. Multiple logistic regression analyses were used to identify independent predictors of fatigue within each dimension, and then across dimensions. Fatigue was present in 113 (62%) patients, and 80 (44.4%) patients had usual fatigue > or =3/10. The unidimensional independent predictors were use of analgesics (situation dimension); hemoglobin and serum sodium (biomedical dimension); feeling drowsy, dyspnea, pain and lack of appetite (physical symptom dimension); and feeling sad and feeling irritable (psychological symptom dimension). In a multidimensional model, dyspnea, pain, lack of appetite, feeling drowsy, feeling sad, and feeling irritable predicted fatigue independently with good calibration (Hosmer Lemeshow Chi Square=5.73, P=0.68) and discrimination (area under the receiver operating characteristic curve=0.88). Physical and psychological symptoms predict fatigue independently in the multidimensional model, and superseded laboratory data. These findings support a symptom-oriented approach to assessment of cancer-related fatigue.

Shorter Symptom Assessment Instruments: The Condensed Memorial Symptom Assessment Scale (CMSAS)

Background. Rapid and efficient symptom assessment is an important aspect of palliative care. The objective was to determine whether a smaller number of symptoms from the 32-item Memorial Symptom Assessment Scale Short-Form (MSAS-SF) could convey equivalent quality of life (QOL) information. Methods. Responses from 479 medical oncology patients who completed the MSAS-SF and the Functional Assessment Cancer Therapy (FACT-G) were analyzed. Canonical correlations were performed to assess the relationships of 32 MSAS-SF symptoms to quality of life (FACT-G domains) and clinical variables [age, Karnofsky performance status (KPS), stage of disease, and inpatient status]. The relation of the subscales of the Condensed MSAS (CMSAS) and FACT-G to survival was assessed in a multivariate model. Results. The median age was 67 years (range, 20–89) and median KPS was 80% (range, 20–100). Primary sites were prostate in 141 (29%) patients, lung in 121 (26%) patients, colorectal in 53 (11%) patients, hematologic in 50 (10%) patients, head and neck in 30 (6%) patients and other in 84 (18%) patients. Median survival was 245 days (range, 1–2,215 days). Canonical correlation analyses identified a five-dimensional QOL factor structure. Symptoms important for QOL also correlated significantly with survival and provided the basis for the CMSAS with 14 symptoms and 3 subscales (CMSAS SUM, CMSAS PHYS, and CMSAS PSYCH). In multivariate analyses, the CMSAS PSYCH predicted survival independently of stage, performance status, and QOL. The CMSAS takes 2–4 minutes to complete. Conclusion. The CMSAS contains both QOL and survival information approximately equivalent to the original 32 items.

Asymptomatic mantle cell lymphoma in the trachea.

A 66-year-old black male was diagnosed with mantle cell lymphoma (MCL) of the gastrointestinal tract after he had presented with dyspepsia, poor oral intake and 17 kg weight loss. His bone marrow was involved diffusely. He was staged as IVB with a FLIPI score of 3. He underwent treatment with four cycles of standard dose R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). Follow-up examination and imaging 17 months after diagnosis showed continued remission. However, a surveillance colonoscopy after 3 months revealed biopsy-confirmed ileal recurrence. Staging PET/CT was also remarkable for diffuse metabolic uptake in the cervical lymph nodes and the mesentery. He was treated with bortezomib 1.3 mg/m. A 6-month follow-up CT showed a 15 mm6 12.5 mm elliptical shaped mass in the proximal trachea with significant airway narrowing, in addition to diffuse thickening of the mesentery. An MRI confirmed the tracheal mass (Figure 1). Biopsy of this lesion showed recurrent MCL (Figure 2). The patient denied any respiratory symptoms. He underwent prophylactic tracheostomy followed by local irradiation. Maintenance rituximab was initiated. However, because of extreme fatigue the patient refused more than 2 weekly infusions. He wished to be managed with comfort care alone. He expired 29 months after initial diagnosis. MCL comprises about 7% of all adult nonHodgkin lymphomas in the western world, [1] and is characterised by translocation of chromosomes 4 and 11 [t(4;11)], bcl-1 rearrangement and cyclin D1 staining on immunohistochemistry. Approximately 25% of patients have extranodal manifestations. We were able to find three reports of MCL with tracheal involvement, two in English and one in Polish literature. Maeda et al. [2] and Kozakiewicz et al. [3] both report cases of tracheobronchial stenosis due to MCL in which symptoms of dyspnea and tachypnea resolved after radiation treatment and stent placement, respectively. Verde and McGeehan [4] report a similar case to ours, but do not describe whether the patient suffered any symptoms due to the underlying lesion. Their case also differs in that the patient only developed a single lesion in the trachea, compared with the present case where multiple lesions, including the one in respiratory airway, were evident on serial imaging. Our patient is remarkable in that he did not complain of any dyspnea, tachypnea or stridor despite the rather large underlying lesion present in his upper airway.

The symptom burden of cancer

A set of common cancer‐related and treatment‐related symptoms has been proposed for quality of care assessment and clinical research. Using data from a large, multicenter, prospective study, the authors assessed the effects of disease site and stage on the percentages of patients rating these proposed symptoms as moderate to severe.

A comparison of patients with liver cancer receiving palliative care at two Veterans Affairs (VA) Medical Centers.

75 Background: Liver cancer is a leading cause of death. Lack of data exists on palliative care in this group, and care varies by location. We aim to determine if there are differences in palliative care for patients (pts) with liver cancer by VA site. METHODS In an IRB approved protocol, we reviewed medical records of pts at 2 VA medical centers (S1, S2) with liver cancer, who were seen by Palliative Care between 2006 and 2012. Veterans were compared by 1) demographics: Karnofsky performance status > 50 (KPS), marital status, DNR/DNI, 2) palliative intervention: goals of care discussion, referrals to psychology and PT/OT, and 3) outcomes: ED visit within 1 month (mo) of death, ED visit within 6 mo of death, ICU within 30 days of death, and hospice as site of death, time from diagnosis to palliative care, and time from DNR to death. Chi-square, Fishers Exact, and T-test were performed with Stata. RESULTS here were 82 men, 30 from S1 and 52 from S2, median age 61 (35-87) and 63 (54-88) yrs, respectively. Pts were Caucasian 30 (36%), African American 47 (57%), and other 5 (0.1%). Cancer stages were locoregional 15 (50%), metastatic 13 (43%), and unknown 2 (0.1%) at S1 and 28 (54%), 20 (38%), 5 (0.1%) at S2. Differences were seen in KPS > 50: (S1, S2) [10 (33%), 15(29%) p = 0.010], married: (S1, S2) [7 (23%), 24(46%) p = 0.024], DNR/DNI: (S1, S2) [19 (63%), 13(25%), p = 0.001]. Regarding palliative intervention: goals of care discussion (S1, S2) [26 (87%), 44 (85%), p = 0.044], referral to psych (S1, S2) [16 (53%), 42 (81%) p = 0.014], referral to PT/OT (S1, S2) [17 (57%), 15 (29%), p = 0.007]. Finally in regards to outcome: ED visit within 1 mo of death (S1, S2) [7 (23%), 31 (60%), p = 0.001], ED visit within 6 mos of death (S1, S2) [18 (56%), 35 (67%) p = 0.031], ICU within 30 days of death (S1, S2) [0 (0%), 9 (17%) p = 0.019}, and hospice as site of death (S1, S2) [19 (63%), 21 (40%), p < .0001]. Other key differences included median number of days from diagnosis to initial palliative care consult (S1, S2) [97, 39, p = 0.001] and median number of days from DNR to death (S1, S2) [33, 14, p = 0.001]. CONCLUSIONS Results show there are site-specific differences between VA medical centers. These data may be important in the comparison of other centers and provide a baseline for future studies.

Palliative care interventions and end-of-life care outcomes for hepatocellular patients (pts) at two Veterans Affairs (VA) medical centers.

164 Background: Palliative care interventions and their effect on EOL outcomes for liver cancer pts have not been described. We investigated the association between palliative care intervention and EOL care outcomes. METHODS We reviewed the charts of pts with hepatocellular carcinoma and who were seen by palliative care at 2 VA medical centers from 2006 to 2012. We investigated the association between EOL outcomes (number of ER visits, ICU visits, chemotherapy, place of death, number of hospitalizations during their last 30 days), and interventions such as early referral (within 30 days of diagnosis), defined goals of care, holding a family meeting, and symptom assessment and management. The protocol was reviewed by the IRB of both VAs and analyses were done with SAS Studio v3.4. RESULTS 82 charts were reviewed (30 from EOVA and 52 from BVA). All Pts were men; 30 (39%) were white and 47(61%) African American. Interval from diagnosis to palliative care consult was 68 days (median). 72 (90%) pts were not aware of their diagnosis. 48 (65%) were not aware of prognosis. 65 (88%) had decision making capacity. 32 (39%) pts were DNR/DNI. 60 (86%) pts chose symptom management and 10 (14%) life prolongation. 47 pts (50%) had family meeting. In the last month, 35 pts (48%) had ER visit. 9 pts (12%) had ICU visits, 4 pts (5%) had chemotherapy and 48 pts (71%) had at least 1 hospitalization. 68 (85%) underwent symptom assessment. Most frequently treated symptoms were pain (78%), nausea (27%), constipation (46%), dyspnea (34%). Significant associations were found for early referral and ER admissions (OR = 3.2, p = 0.0178), family meeting and site of death (OR = 0.136 p = 0.0037), family meeting and number of hospitalizations (OR = 0.2652, p = 0.0169). Pts choosing symptom management and who had family meetings associated with hospice/home as place of death (chisq = 5.7368, p = 0.016). Knowledge of prognosis was not associated with site of death. CONCLUSIONS In this population, many palliative care interventions were performed. Early referral, family meetings were significantly associated with site of death, ER admissions, and number of hospitalizations. These results should be replicated in larger studies.

Giant malignant melanoma of the anterior chest wall with widespread metastasis

Introduction: Giant melanomas are defined as lesions greater than 10 cm; independent of their depth of invasion; these entities are rarely encountered in clinical practice and they represent a real treatment challenge as many patients are diagnosed with advanced disease. Herein, we document our experience with the first reported giant melanoma of the anterior chest wall and the 5th largest melanoma of any anatomic site. case report: A 63-year-old caucasian male presented with an irregular, pigmented, non-healing ulcer, measuring 1.5x1.5 cm on his chest. He was referred for a skin biopsy but was lost to follow-up. He returned one year later complaining of fatigue, night sweats, and unintentional weight loss in addition to further growth of the skin lesion. His skin lesion was now a large, fungating mass, fixed to the chest wall and measuring 15x13x2.5 cm. there were multiple satellite lesions on the chest wall and palpable left axillary lymphadenopathy. skin biopsy confirmed the diagnosis of malignant melanoma. computed tomography scan demonstrated innumerable pulmonary nodules, retroperitoneal and peri

Patient-reported outcomes for determining prognostic groups in veterans with stage IV solid tumors starting systemic therapy.

48 Background: A Recursive Partitioning Analysis (RPA) prognostic algorithm based on quality of life and symptoms predicted 4 groups with distinct median survivals in patients with metastatic solid tumors receiving chemotherapy (ASCO 2013, Abst 9567). We update our findings. METHODS The RPA algorithm is based upon Karnofsky performance status (KPS), Functional Assessment of Cancer Therapy (FACT) physical well-being (PWB) subscale, and Memorial Symptom Assessment Scale Short Form (MSAS-SF) physical symptom distress (PHYS) subscale. Starting in 2007, a convenience sample of Veterans who were prescribed systemic treatment for their cancer was enrolled in an IRB approved protocol, and completed quality of life (FACT- G) and symptom (MSAS SF) questionnaires at the first cycle of treatment. We analyzed records of patients with stage IV metastatic solid tumors enrolled through June 2013, and determined survival as of June 15, 2014. Analyses were performed with STATA 11.0. RESULTS There were 97 patients(pts). The median age was 64 yrs, range 27-88. Males comprised 95 (98%) pts. First line chemotherapy was given to 78 (80%) pts. The most common primary sites were lung cancer 33 (35%), prostate 17 (17%) and colon 11 (11%) pts. Median KPS was 90% range 40-100%, PWB median 23 (range 6-28), and MSAS SF median PHYS 0.76 (range 0-3.2). Overall median survival was 285 days (range 6-2,358) and 80 pts (82%) had died. There was 1 pt in group 1, 58 in group 2, 12 in group 3, and 23 in group 4. The patient in group 1 had uterine sarcoma. Median survival (days) by RPA group was 155 for group 1, 177 for group 2, 292 for group 3, and 674 for group 4 (p=.011). CONCLUSIONS These preliminary findings suggest that this algorithm is capable of dividing patients with metastatic solid tumor who are starting systemic therapy into prognostic groups. Further development is indicated.

Symptom burden among young adults with breast or colorectal cancer: Symptom Burden in Young Adult Oncology

Cancer incidence has increased among young adults (YAs) and survival rates have not improved compared with other age groups. Patient‐reported outcomes may enhance our understanding of this vulnerable population.