Pain and its treatment in outpatients with metastatic cancer

BACKGROUND AND METHODS

Pain is often inadequately treated in patients with cancer. A total of 1308 outpatients with metastatic cancer from 54 treatment locations affiliated with the Eastern Cooperative Oncology Group rated the severity of their pain during the preceding week, as well as the degree of pain-related functional impairment and the degree of relief provided by analgesic drugs. Their physicians attributed the pain to various factors, described its treatment, and estimated the impact of pain on the patients' ability to function. We assessed the adequacy of prescribed analgesic drugs using guidelines developed by the World Health Organization, studied the factors that influenced whether analgesia was adequate, and determined the effects of inadequate analgesia on the patients' perception of pain relief and functional status.

RESULTS

Sixty-seven percent of the patients (871 of 1308) reported that they had had pain or had taken analgesic drugs daily during the week preceding the study, and 36 percent (475 of 1308) had pain severe enough to impair their ability to function. Forty-two percent of those with pain (250 of the 597 patients for whom we had complete information) were not given adequate analgesic therapy. Patients seen at centers that treated predominantly minorities were three times more likely than those treated elsewhere to have inadequate pain management. A discrepancy between patient and physician in judging the severity of the patient's pain was predictive of inadequate pain management (odds ratio, 2.3). Other factors that predicted inadequate pain management included pain that physicians did not attribute to cancer (odds ratio, 1.9), better performance status (odds ratio, 1.8), age of 70 years or older (odds ratio, 2.4), and female sex (odds ratio, 1.5). Patients with less adequate analgesia reported less pain relief and greater pain-related impairment of function.

CONCLUSIONS

Despite published guidelines for pain management, many patients with cancer have considerable pain and receive inadequate analgesia.

Breast cancer: 1. Screening and early management

A 53-year-old woman presented to her physician one month after she had noticed an area of "thickening" in the upper outer quadrant of her right breast. The patient had had her last menstrual period two years earlier. She had never had a mammogram. A mammogram was performed. It showed an area of clustered microcalcifications suggestive of cancer in the area of the palpable abnormality.

Increased systemic, but not regional, neopterin production following intraperitoneal administration of interleukin-2 and lack of effect of pterins upon the lymphokine-activated killer cell phenomenon

Circulating neopterin is derived from monocytes and/or macrophages that produce it upon stimulation by interferon-gamma released from activated T cells. Neopterin production has been proposed as a marker of biological response in the clinical administration of a number of cytokines. Changes in neopterin production as indicated by urinary neopterin excretion were studied in four patients with ovarian carcinoma receiving intraperitoneal interleukin-2 and lymphokine-activated killer cells. Neopterin production increased approximately threefold during treatment with interleukin-2 at doses which represent or exceed the maximum tolerated dose by this route of administration. Increased neopterin apparently was derived from systemic, not regional, tissues. The physiologic role(s) of pterins in immune responses is uncertain. In an in vitro system, the presence of neopterin or tetrahydrobiopterin or the pterin synthesis inhibitor, N-acetyl serotonin, did not modulate cytotoxic effects of lymphokine-activated killer cells.

A multicentre randomized study of single-unit dose package of EMLA patch vs EMLA 5% cream for venepuncture in children

Eutectic mixture of local anaesthetics (EMLA) cream with Tegaderm was compared with pre-packaged EMLA patch with regard to analgesic effect, adhesiveness and local reactions during venepuncture in 178 children from three to ten years. One EMLA patch, or half the contents of a 5 g tube of EMLA cream plus Tegaderm was applied to the dorsum of one hand or antecubital fossa for a minimum of 60 min before venepuncture. The subject and observer assessed the degree of pain on a three-point verbal rating scale. The adhesion of the patch vs Tegaderm to the skin and local reactions were recorded. There was no difference between the two groups in pain associated with venepuncture; 95% of the EMLA patch group and 94% of the EMLA cream group reported no or slight pain. There was no difference between the two treatment groups in terms of overall local reactions. The patch was less adhesive (P < 0.001), but this had no apparent influence on its effectiveness. In conclusion, EMLA patch is equivalent to 5% EMLA cream (2.5 g) in cutaneous pain relief when used for venepuncture in children.

Milk and fat yields decline in bovine leukemia virus-infected Holstein cattle with persistent lymphocytosis

Effects of bovine leukemia virus (BLV) infection on milk and fat yields were studied by using data collected from Holstein cows over a 6-year period. Milk and fat yields in BLV-infected cows with persistent lymphocytosis (PL) declined significantly relative to their BLV-infected non-PL herdmates. Declines were most pronounced in cows older than 6 years. The estimated loss to the dairy industry due to PL is more than $42 million annually. A major histocompatibility complex class I (BoLA-A) allele that has been previously associated with resistance to PL was associated with longevity and realization of milk production potentials, indicating that genetic resistance to PL will have an economic benefit in herds where BLV is endemic.

Cytomegalovirus seroprevalence in women bearing children in Jefferson County, Kentucky

Symptomatic congenital cytomegalovirus (CMV) disease occurs almost exclusively in infants born to seronegative mothers who acquire the virus during pregnancy. This study sought to determine patterns of CMV immunity in women of childbearing age at one center participating in a national study. Cord blood specimens from 100 consecutive deliveries at each of three hospitals were tested for CMV-specific IgG. Mean age of women in this sample was 25.7 years; 76% were white, 60% were from middle and upper socioeconomic status, 64% were married, and 57% had other living children. Overall seroprevalence rate was 62%. Univariate analysis showed strong associations between seropositivity and lower socioeconomic status, non-white race, and age younger than 25 years (odds ratios, 4.4, 3.9, and 2.5, respectively). Stratification by socioeconomic status and race eliminated the effect of age. Stratification by socioeconomic status markedly reduced the effect of race, whereas stratification by race only moderately reduced the effect of lower socioeconomic status, which was the strongest predictor of seropositivity (odds ratio, 3.4). Seroprevalence was lowest among older white women of middle and upper socioeconomic status (47% seropositive). Development of longitudinal regional seroprevalence data will facilitate interpretation of data generated by the National CMV Registry.

A method of dynamic analysis of iodine-123-metaiodobenzylguanidine scintigrams in cardiac mechanical overload hypertrophy and failure

Cardiac sympathetic neuronal degeneration accompanies mechanical overload heart failure. We hypothesized that sympathetic nerve and myocyte failure share a common etiology and that 123I-metaiodobenzylguanidine (MIBG) might provide a precise method of detecting failure in chronic mechanical overload. Our aim was to develop a method for the dynamic analysis of 123I-MIBG scintigrams which could yield a quantitative index of myocardial sympathetic neuronal function in this condition. We performed serial 123I-MIBG scintigraphy in 33 volunteers, 10 orthotopic cardiac transplant recipients and 26 patients with chronic mechanical overload of the left ventricle. We constructed a compartmental model in which total heart activity represents the sum of cardiac sympathetic vesicular and cytosolic pools. Patients with antecedent mechanical overload heart failure or myocardial dysfunction had accelerated myocardial egress of tracer that we ascribed to a specific impairment in vesicular storage rather than to a more rapid turnover of an intact vesicular pool.

AIDS dementia complex complicated by cytomegalovirus encephalopathy

We have studied longitudinally ten patients with AIDS encephalopathy with respect to pathogenetic roles of human immunodeficiency virus (HIV) and cytomegalovirus (CMV). Three patients manifested typical AIDS dementia complex (ADC) (initially without retinitis and with slowly progressive cognitive, motor and behavioral abnormalities which were zidovudine-responsive, and relatively preserved CD4+ T cells), and seven patients presented with AIDS dementia complex complicated by CMV encephalopathy (ACE) (with CMV retinitis, peripheral neuropathy, altered sensorium, and rapidly declining clinical and immunological status). Whereas only HIV antibody was elevated in the spinal fluid of patients with ADC, both virus infections were active in the central nervous system of patients with ACE as shown by HIV p24 antigenemia and antigenrrhachia, elevated HIV and CMV antibody in the spinal fluid, disseminated CMV infection with retinitis, and basilar ventriculoencephalitis with multinucleated cytomegalic cells containing CMV and HIV proteins and CMV DNA. The recognition of ADC and ACE is important, since some patients with ACE may respond to ganciclovir or foscarnet.

A phase II trial of CI-921 in advanced malignancies

CI-921, (9-[[2-methoxy-4-[(methylsulfonyl)amino]phenyl]amino]- N,5-dimethyl-4-acridinecarboxamide 2-hydroxyethanesulfonate (1:1)), an anilinoacridine derivative with activity in experimental solid tumors was studied in a multicenter phase II trial in patients with solid tumors. Eligible tumor types included cancers of the breast, stomach, pancreas, nonsmall cell lung, small cell lung, colon, head and neck area, and melanoma. Prestudy requirements included an ECOG performance status of < or = 2, no CNS metastases, and measurable disease. CI-921 was administered intravenously over 1-2 hours on days 1, 8, and 15 of a 35-day course at an initial dose of 270 mg/M2, with modification in subsequent courses based upon tolerance. Principal toxicities included leukopenia, marked phlebitis, and mild nausea and vomiting. One hundred fifty patients were entered of whom 132 were evaluable for response. There was one complete and one partial response among 19 patients with breast cancer, and two partial responses, one each among 14 head and neck and 36 nonsmall cell lung cancer patients.

The effect of stimulus duration upon the components of fluctuation in static automated perimetry

We studied the effect of varying the stimulus duration time on the components of fluctuation in static automated perimetry by testing 20 healthy subjects on the Humphrey Field Analyser within the central 20 degrees of vision. We found the total fluctuation at a stimulus duration of 0.065 s, to be 3.22 decibels (dB); 0.1 s, 3.22 dB; 0.2 s, 3.34 dB; 0.3 s, 2.95 dB; 0.4 s, 3.24 dB; and 0.5 s, 3.22 dB. Little difference was observed in the individual components (short-term, long-term homogeneous, long-term heterogeneous and inter-individual) or total fluctuation with an increasing stimulus presentation time when evaluated over the entire visual field or in a pointwise fashion. This study suggests that the stimulus duration within the range of times studied has little effect on the components or total fluctuation in healthy individuals.

Surveillance of congenital cytomegalovirus disease, 1990-1991. Collaborating Registry Group

In January 1990, a registry was initiated for surveillance of infants with the often severe symptoms of congenital cytomegalovirus (CMV) disease. In the first 2 years, 100 cases were reported to the registry. Petechiae, the most commonly noted clinical sign, were reported for approximately 50% of infants, usually accompanied by hepatomegaly and splenomegaly. Of the various severe neurologic conditions that can result from congenital CMV infection, the most frequent was intracranial calcifications, which were noted in 43% of the cases. The most common laboratory abnormality was low platelet count, which was observed in 52% of the cases. Infants with severe neurologic damage were about twice as likely as infants with less severe damage to have most other clinical signs and laboratory abnormalities. Databases will be developed to facilitate comparisons among symptomatically infected infants and asymptomatically infected as well as noninfected infants.

Herpesvirus antibody levels in the etiologic diagnosis of the acute retinal necrosis syndrome

Quantitative antibody levels to three herpesviruses in acute and chronic sera from six patients with clinical signs of the acute retinal necrosis syndrome were consistent with a specific etiologic diagnosis only in the two cases associated with cutaneous herpes zoster. Available data on acute and convalescent antibody titers to herpes group viruses from these six patients in addition to data from 27 acute retinal necrosis cases from the literature disclosed that only 13 of the 33 patients (39%) had a diagnostic increase or decrease in herpes group viral antibody levels on serial sampling. Three patients had nondiagnostic changes in viral antibody levels despite positive vitreous cultures for herpesviruses. In contrast, a review of 25 cases from the literature with paired antiviral serum and intraocular fluid antibody levels suggested a more promising approach to the etiologic diagnosis of the acute retinal necrosis syndrome. By calculating the ratio of antiviral antibodies in intraocular fluid and serum, an etiologic diagnosis could be made in 12 of 14 (86%) of subacute and convalescent samples. The sensitivity of this method decreased to 72% (13 of 18) when fluids were obtained earlier in the course of the disease.

Paraneoplastic encephalomyelitis. Dramatic response to chemotherapy alone

Neurologic paraneoplastic syndromes are usually a debilitating and untreatable manifestation of malignancy. The case is presented of a woman with severe paraneoplastic encephalomyelitis that was characterized predominantly by cerebellar degeneration associated with small cell lung cancer, both of which responded rapidly to cytotoxic chemotherapy alone. She is alive with some neurologic residua but no signs of recurrent cancer more than 2 years after diagnosis. Recommendations for aggressive management of this rare but disabling syndrome are outlined.

A phase I clinical trial of didemnin B

Didemnin B is a depsipeptide extracted from the marine tunicate Trididemnin cyanophorum. This agent is a potent inhibitor of L1210 growth in vitro and has activity against murine B16 melanoma, P388 leukemia, and M5076 sarcoma in vivo. The results of preclinical toxicologic tests demonstrated abnormalities in clotting parameters thought to be secondary to drug-induced liver dysfunction. Thirty-five patients with advanced cancer received didemnin B according to a 5-day bolus schedule with dose levels ranging from 0.03 to 2.00 mg/m2/d. The dose-limiting toxicity was nausea and vomiting. Sporadic elevation of the hepatic enzyme level occurred but was not dose limiting. Two patients had anaphylactic symptoms possibly related to the 5% polyoxyethylated castor oil (Cremophor EL, BASF, Ludwigshafen, Germany) vehicle during the drug infusion. Clinical bleeding was not observed and myelosuppression was not significant. No partial or complete tumor responses were seen. The recommended Phase II dose for the 5-day schedule is 1.6 mg/m2/d.

Prevalence of measles antibodies in asymptomatic human immunodeficiency virus-infected adults

One hundred five asymptomatic human immunodeficiency virus-seropositive adults were screened for measles antibody. Ages ranged from 21 to 59 years (mean, 35.7). CD4+ lymphocyte counts (range, 76-1137/mm3), percentage of CD4+ cells (6-42), CD4:CD8 ratio (0.08-1.3), measles antibody titers by EIA, and undocumented history of prior measles or immunization were obtained. Forty-six patients gave a history of measles but no immunization, 18 of immunization but no measles, 26 of immunization and measles, and 15 of neither measles nor vaccination. Only one patient (less than 1%) lacked levels of antibody considered protective. Neither the presence nor the level of antibody were predictable from patient age, history of measles or immunization, CD4+ lymphocyte count, percentage of CD4+ cells, or CD4:CD8 ratio. Nearly all subjects had antibody to measles, regardless of immunization or measles history. Whether these antibodies are truly protective is unknown.

Evaluation of monoclonal antibody-based capture enzyme immunoassays for detection of specific antibodies to measles virus

Monoclonal antibodies to the hemagglutinin protein, fusion protein, phosphoprotein, matrix protein, and nucleoprotein of measles virus were evaluated as detector antibodies in capture enzyme immunoassays (EIAs) for the detection of specific serum immunoglobulin G (IgG), IgA, and IgM antibodies to measles virus. A pool of monoclonal antibodies to hemagglutinin protein and nucleoprotein proved optimal and was further evaluated. Specific IgM was detected in 97% of adolescents with clinical measles, 97% of infants 3 weeks postvaccination, and less than 1% of normal serum specimens. Specific IgA antibodies were found in 97% of adolescents with clinical measles, 97% of infants 3 weeks postvaccination, and less than 1% of normal serum specimens. Specific IgA antibodies were found in 97% of clinical measles cases and vaccinees, in 26% of healthy persons, and in 36% of infants 8 months postvaccination; consequently, IgA antibodies were not a useful indicator of recent measles infection. A significant increase in IgG antibodies between paired specimens was detected in 92% of clinical cases and all vaccinees. Only 59% of infant specimens had persistent IgG antibodies as detected by capture EIA at 8 months postvaccination, whereas all specimens had antibodies as detected by hemagglutination inhibition and plaque neutralization. An alternative indirect EIA, in which antigen was directly absorbed to the solid phase, was more sensitive than the capture design, detecting IgG antibodies in all infants postvaccination. When standardized with a microneutralization assay for the detection of persistent antibodies, the indirect IgG EIA gave predictive values for positive and negative tests exceeding 90%. Our capture IgM and indirect IgG EIAs provide a practical combination of serologic tests for the determination of acute measles virus infection and past exposure to measles virus or vaccine, respectively.