Wadih Rhondali

Access to Palliative Care Among Patients Treated at a Comprehensive Cancer Center

BACKGROUND Palliative care (PC) is a critical component of comprehensive cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually receive PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center and the predictors of PC referral. METHODS We reviewed the charts of consecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center who died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death. RESULTS In total, 366 of 816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range, 0.5-4.2 months) and the median number of medical team encounters before PC was 20 (interquartile range, 6-45). On multivariate analysis, older age, being married, and specific cancer types (gynecologic, lung, and head and neck) were significantly associated with a PC referral. Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between an advanced cancer diagnosis and PC consultation (median, 16 months), the shortest interval between PC consultation and death (median, 0.4 months), and one of the largest numbers of medical team encounters (median, 38) before PC. CONCLUSIONS We found that a majority of cancer patients at our cancer center did not access PC before they died. PC referral occurs late in the disease process with many missed opportunities for referral.

Frequency and Predictors of Patient Deviation From Prescribed Opioids and Barriers to Opioid Pain Management in Patients With Advanced Cancer

CONTEXT Approximately 80% of patients with advanced cancer report pain and receive opioids. Information is limited about deviations from prescribed opioid doses and barriers to pain control, but poor opioid adherence has been reported in 49%-70% of patients. OBJECTIVES To evaluate the frequency and severity of self-reported opioid deviation and barriers to opioid pain management in outpatients with advanced cancer. METHODS We surveyed 198 patients and collected pain scores (0-10), prescribed opioid dose, confidential patient-reported opioid prescription dose and intake (as long as there was no severe opioid deviation), barriers to pain management (Barriers Questionnaire-II [BQ-II]) scores, and adherence scores. Opioid deviation was defined as <70% or >130% of the prescribed dose. RESULTS Median patient age was 55 years; 91 (46%) were female. Median pain intensity and morphine equivalent daily dose were 4 (interquartile range=3-7) and 120mg (interquartile range=45-270mg), respectively. Prescribed and patient-reported prescribed doses were highly correlated for regular (r=0.90, P<0.001) and regular plus breakthrough opioid intake (r=0.94, P<0.001). Nineteen (9.6%) patients deviated. Deviation was more frequent in males (P=0.039) and nonwhites (P=0.0270). Nonwhite patients had higher scores on the BQ-II than white patients (P=0.038). Low adherence scores were significantly associated with higher BQ-II scores (1.99±0.80) for lower motivation score vs. 1.61±0.77 for higher score, P=0.007; and 2.13±0.79 for lower knowledge score vs. 1.57±0.72 for higher score, P=0.001. CONCLUSION Very few patients reported dose deviations, which were mostly toward lower dose. More research is necessary to better characterize the frequency and predictors of opioid deviation in this population.

Frequency of depression among oncology outpatients and association with other symptoms

PurposeDepression occurs among an estimated 15% of cancer patients (range, 1–77.5%). Our main objective was to identify the frequency of reported depression by using the Brief Edinburgh Depression Scale (BEDS) among cancer outpatients. Our secondary objective was to identify associated symptoms of cancer using the Edmonton Symptom Assessment System (ESAS) and to evaluate the screening performance of depression between ESAS and BEDS.MethodsIn this multicenter prospective study conducted, we used the ESAS to collect information on nine symptoms: pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, lack of appetite, and feeling of well-being (each rated from 0 to 10). The BEDS was used to assess for “probable depression” (score >6). Data were analyzed using a parametric and nonparametric test.ResultsA total of 146 patients completed the study. The prevalence of probable depression was 43/146 (29%). Probable depression was associated with increased fatigue (p = 0.008), depression (p < 0.0001), anxiety (p < 0.0001), shortness of breath (p = 0.01), and decreased feeling of well-being (p < 0.001). Among patients with probable depression, 42 (98%) patients were not using antidepressants. Regarding the sensitivity and the specificity, we determined that the optimal cutoff for using the ESAS as a depression screening tool was ≥2.ConclusionWe found significant associations between probable depression as determined with the BEDS and five symptoms as detected with the ESAS. The vast majority of patients with probable depression were not receiving pharmacological treatment. Depression should be suspected in patients with higher symptom distress as for any one of these 5 ESAS items.

Art therapy among palliative care inpatients with advanced cancer

Art therapy is a clinical intervention that uses the expressive qualities of art making with the aim of improving well-being and psychological functioning.1 The creative process involved in art making allows the expression of concerns and feelings that might otherwise be difficult to express verbally.2,3 Art therapy has demonstrated evidence for its efficacy in reducing common symptoms experienced by cancer inpatients.4 However, art therapy is a complex intervention, and its evaluation can be challenging because of the multiple components involved. The objectives of our study were to evaluate the feasibility of mixed methods to quantitatively determine the short-term effect of an art therapy session on symptoms commonly experienced by patients with advanced cancer and to qualitatively assess these patients’ perceptions of the impact and value of the session on their physical and psychological distress. Consecutive inpatients were recruited from a palliative care unit. Patients involved in art therapy sessions were systematically proposed to participate in the study before their first session. Participants were provided a 1-h art therapy session by a professional art therapist. The day before the session, each patient was invited to discuss the topic they wanted to explore. The art therapy sessions (painting) took place in the palliative care department twice weekly. The choice of painting allowed patients to express their feelings through colors and drawing and to produce an artwork. Guidance from art therapists was mainly toward technical aspects. We used the Edmonton Symptom Assessment Scale (ESAS) to assess physical and psychological distress. We recorded the ESAS results collected 1 h before and after the art therapy session. A Wilcoxon test was used to compare preand postintervention ESAS scores. A p value less than 0.05 indicated statistical significance. We also conducted semidirected interviews the day after the art therapy session. The interview questions were geared toward eliciting open-ended responses to acquire information about the patient’s thoughts associated with the art therapy session. We used a grounded theory approach in analyzing the transcripts and applied a thematic analysis to the data to extrapolate results. Twelve patients were included in our study. All the participants were female and had metastasis. One hour before and 1 h after the art therapy session, there were statistically significant improvements in pain (p = 0.002), fatigue (p = 0.001), depression (p = 0.022), anxiety (p = 0.027), and diminished feeling of well-being (p = 0.015). During the semiqualitative interviews, patients expressed that they had experienced relief from physical pain during the art therapy session. They mainly explained the relief by the fact that they were doing something else (distraction).

Development and Cross-Validation of the In-Hospital Mortality Prediction in Advanced Cancer Patients Score: A Preliminary Study

PURPOSE Acute palliative care units (APCUs) provide intensive symptom support and transition of care for advanced cancer patients. Better understanding of the predictors of in-hospital mortality is needed to facilitate program planning and patient care. In this prospective study, we identified predictors of APCU mortality, and developed a four-item In-hospital Mortality Prediction in Advanced Cancer Patients (IMPACT) predictive model. METHODS Between April and July 2010, we documented baseline demographics, the Edmonton Symptom Assessment Scale (ESAS), 80 clinical signs including known prognostic factors, and 26 acute complications on admission in consecutive APCU patients. Multivariate logistic regression analysis was used to identify factors for inclusion in a nomogram, which was cross-validated with bootstrap analysis. RESULTS Among 151 consecutive patients, the median age was 58, 13 (9%) had hematologic malignancies, and 52 (34%) died in the hospital. In multivariate analysis, factors associated with in-hospital mortality were advanced education (odds ration [OR]=11.8, p=0.002), hematologic malignancies (OR=8.6, p=0.02), delirium (OR=4.3, p=0.02), and high ESAS global distress score (OR=20.8, p=0.01). In a nomogram based on these four factors, total scores of 6, 10, 14, 17, and 21 corresponded to a risk of death of 10%, 25%, 50%, 75%, and 90%, respectively. The model has 92% sensitivity and 88% specificity for predicting patients at low/high risk of dying in the hospital, and a receiver-operator characteristic curve concordance index of 83%. CONCLUSIONS Higher education was associated with increased utilization of the interdisciplinary palliative care unit until at the end of life. Patients with higher symptom burden, delirium, and hematologic malignancies were also more likely to require APCU care until death.

Self-Reported Constipation in Patients with Advanced Cancer: A Preliminary Report

CONTEXT Constipation is often inadequately assessed and underdiagnosed in patients with advanced cancer. Many studies use patient-reported constipation (PRC) as an outcome. OBJECTIVES The aim was to compare the accuracy of PRC as compared with the modified Rome III (ROME) criteria and to determine the agreement between PRC, physician assessment of constipation, and objective assessment of constipation by modified ROME criteria among outpatients with advanced cancer. METHODS Patients with advanced cancer attending a supportive care clinic were screened. Constipation was assessed using the modified ROME criteria, patient report (yes or no and rated 0-10; 10=worst possible symptom), and physician assessments (yes or no and rated 0-10). RESULTS One hundred patients were enrolled, and 50 of 100 patients (50%) met the modified ROME criteria for constipation. Disagreement between ROME criteria and the patient report (yes/no) was found in 33 patients (33%) and between ROME criteria and the physician assessment (yes/no) in 39 patients (39%). The best combination of sensitivity (0.84) and specificity (0.62) was found with scores ≥3/10 for PRC. CONCLUSION We found a high frequency of constipation. The limited agreement with modified ROME criteria suggests that a patients self-report as yes or no is not useful for clinical practice. Patient self-rating on a 0 to 10 scale (score of three or greater) seems to be the best tool for constipation screening among this population. More research is needed to identify the best way to assess constipation in patients with advanced cancer.

Screening for body image dissatisfaction in patients with advanced cancer: A pilot study

BACKGROUND Cancer and its treatment can significantly affect appearance and body integrity. A number of studies have explored the impact of cancer and its treatment on body image, primarily in head and neck and breast cancer. The aim of this pilot study was to examine the construct of body image dissatisfaction and its measurement using a single question in patients with advanced cancer. METHODS Outpatients with advanced cancer were recruited (n=81). Assessments included Body Image Scale (BIS), Appearance Schema Inventory (ASI-R), Edmonton Symptom Assessment System (ESAS) with a total symptom distress score (TSDS) and two subscales scores (physical distress [PHS] and psychological distress [PSS]), Hospital Anxiety Depression Scale (HADS), and one question assessing the overall appearance satisfaction from the Multidimensional Body-Self Relations Questionnaire (MBSRQ). We also asked patients to rate the body image changes importance compared with five symptoms (pain, fatigue, depression, insomnia, lack of appetite). RESULTS Forty-seven (58%) patients had a BIS score >10 (body image dissatisfaction) with a median of 11 (first-third quartiles, Q1-Q3; 5-16) and a median ASI-R of 3.1 (Q1-Q3; 2.8-3.5). Sensitivity and specificity of ≤3 for body image dissatisfaction in the single overall appearance question using the BIS as a standard was 0.70 and 0.71, respectively. BIS score was significantly correlated with ASI-R (r=0.248; p=0.025), age (r=-0.225; p=0.043), HADS-A (r=0.522, p<0.001), HADS-D (r=0.422, p<0.001), PSS score (r=0.371, p=0.001), PHS score (r=0.356, p=0.001), TSDS score (r=0.416, p<0.001), and the overall appearance question (MBSRQ; r=-0.449, p<0.001). CONCLUSION Body image dissatisfaction was frequent and associated with symptom burden. A single item ≤3 has a sensitivity of 70% for body image satisfaction screening.

Agreement for depression diagnosis between DSM-IV-TR criteria, three validated scales, oncologist assessment, and psychiatric clinical interview in elderly patients with advanced ovarian cancer

Background Depression, a major outcome in cancer patients, is often evaluated by physicians relying on their clinical impressions rather than patient self-report. Our aim was to assess agreement between patient self-reported depression, oncologist assessment (OA), and psychiatric clinical interview (PCI) in elderly patients with advanced ovarian cancer (AOC). Methods This analysis was a secondary endpoint of the Elderly Women AOC Trial 3 (EWOT3), designed to assess the impact of geriatric covariates, notably depression, on survival in patients older than 70 years of age. Depression was assessed using the Geriatric Depression Scale-30 (GDS), the Hospital Anxiety Depression Scale, the distress thermometer, the mood thermometer, and OA. The interview guide for PCI was constructed from three validated scales: the GDS, the Hamilton Depression Rating Scale, and the Montgomery Asberg Depression Rating Scale (MADRS). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, revised (DSM) criteria for depression were used as a gold standard. Results Out of 109 patients enrolled at 21 centers, 99 (91%) completed all the assessments. Patient characteristics were: mean age 78, performance status ≥2: 47 (47%). Thirty six patients (36%) were identified as depressed by the PCI versus 15 (15%) identified by DSM. We found moderate agreement for depression identification between DSM and GDS (κ=0.508) and PCI (κ=0.431) and high agreement with MADRS (κ=0.663). We found low or no agreement between DSM with the other assessment strategies, including OA (κ=−0.043). Identification according to OA (yes/no) resulted in a false-negative rate of 87%. As a screening tool, GDS had the best sensitivity and specificity (94% and 80%, respectively). Conclusion The use of validated tools, such as GDS, and collaboration between psychologists and oncologists are warranted to better identify emotional disorders in elderly women with AOC.

Burnout among physicians in palliative care: Impact of clinical settings.

OBJECTIVE Burnout syndrome is a work-related professional distress. Palliative care physicians often have to deal with complex end-of-life situations and are at risk of presenting with burnout syndrome, which has been little studied in this population. Our study aims to identify the impact of clinical settings (in a palliative care unit (PCU) or on a palliative care mobile team (PCMT)) on palliative care physicians. METHOD We undertook a cross-sectional study using a questionnaire that included the Maslach Burnout Inventory (MBI), and we gathered sociodemographic and professional data. The questionnaire was sent to all 590 physicians working in palliative care in France between July of 2012 and February of 2013. RESULTS The response rate was 61, 8% after three reminders. Some 27 (9%) participants showed high emotional exhaustion, 12 (4%) suffered from a high degree of depersonalization, and 71 (18%) had feelings of low personal accomplishment. Physicians working on a PCMT tended (p = 0.051) to be more likely to suffer from emotional exhaustion than their colleagues. Physicians working on a PCMT worked on smaller teams (fewer physicians, p < 0.001; fewer nonphysicians, p < 0.001). They spent less time doing research (p = 0.019), had fewer resources (p = 0.004), and their expertise seemed to be underrecognized by their colleagues (p = 0.023). SIGNIFICANCE OF RESULTS The prevalence of burnout in palliative care physicians was low and in fact lower than that reported in other populations (e.g., oncologists). Working on a palliative care mobile team can be a more risky situation, associated with a lack of medical and paramedical staff.

Methadone Rotation for Cancer Patients with Refractory Pain in a Palliative Care Unit: An Observational Study

BACKGROUND Methadone has been reported to be as effective as morphine for cancer pain management. It is commonly used as an alternative opioid in case of insufficient relief. OBJECTIVE Our aim was to assess efficacy and tolerance of opioid rotation to methadone for refractory cancer pain management in palliative care unit (PCU) inpatients. METHODS All the patients undergoing opioid rotation to methadone from 2008 to 2011 in two PCUs (Lyon and Nice, France) were included. Pain assessments were undertaken on day 0 (D0), day 3 (D3), day 7 (D7), and day 14 (D14) using a visual analogue scale (VAS; 0-10) and the Douleur Neuropathique 4 (DN4) scale for neuropathic pain. Patients reported pain relief using a 4-point Likert scale (1=no relief; 4=important relief ). RESULTS Nineteen patients (7 females) with a median age of 55 (Q1-Q3; 44-58) underwent methadone rotation. The most common type of cancer was gastrointestinal. Seventeen patients had a diagnosis of mixed pain syndromes. Morphine equivalent daily dose (MEDD) prior to switching was 480 mg (Q1-Q3; 100-1021), and at least two nonmethadone opioid rotations had already been done for 13 patients. Between D0 and D7, the VAS score decreased by 4 points (p<0.001). The DN4 score became negative on D7 for 11 of 17 patients (65%). On D7, 16 of 18 patients (89%) expressed moderate to greater than moderate pain relief. Methadone was discontinued in one patient on D7 because it was deemed ineffective and for 8 patients, who were unable to take oral drugs, it was discontinued after D14. CONCLUSION Our results suggest that methadone is effective and well tolerated for refractory cancer pain.