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Armato SG, Katz SI, Frauenfelder T, Jayasekera G, Catino A, Blyth KG, Theodoro T, Rousset P, Nackaerts K, Opitz I. Imaging in pleural Mesothelioma: A review of the 16th International Conference of the International Mesothelioma Interest Group. Lung Cancer 2024; 193:107832. [PMID: 38875938 DOI: 10.1016/j.lungcan.2024.107832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 06/16/2024]
Abstract
Imaging continues to gain a greater role in the assessment and clinical management of patients with mesothelioma. This communication summarizes the oral presentations from the imaging session at the 2023 International Conference of the International Mesothelioma Interest Group (iMig), which was held in Lille, France from June 26 to 28, 2023. Topics at this session included an overview of best practices for clinical imaging of mesothelioma as reported by an iMig consensus panel, emerging imaging techniques for surgical planning, radiologic assessment of malignant pleural effusion, a radiomics-based transfer learning model to predict patient response to treatment, automated assessment of early contrast enhancement, and tumor thickness for response assessment in peritoneal mesothelioma.
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Affiliation(s)
- Samuel G Armato
- Department of Radiology, The University of Chicago, Chicago, IL, USA.
| | - Sharyn I Katz
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Geeshath Jayasekera
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK and School of Cancer Sciences, University of Glasgow, UK
| | - Annamaria Catino
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II," BARI, Italy
| | - Kevin G Blyth
- Cancer Research UK Scotland Centre, Glasgow, UK and Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK and School of Cancer Sciences, University of Glasgow, UK
| | - Taylla Theodoro
- Institute of Computing, University of Campinas, Campinas, Brazil and Cancer Research UK Scotland Centre, Glasgow, UK
| | - Pascal Rousset
- Department of Radiology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon 1 University, Pierre-Bénite, France
| | - Kristiaan Nackaerts
- Department of Pulmonology/Respiratory Oncology, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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2
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Lo SB, Ruprecht AL, Post KE, Eche-Ugwu IJ, Cooley ME, Temel JS, Greer JA. Dyspnea-Related Dimensions And Self-Efficacy: Associations With Well-Being in Advanced Lung Cancer. J Pain Symptom Manage 2024; 67:366-374.e1. [PMID: 38307373 PMCID: PMC11032235 DOI: 10.1016/j.jpainsymman.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
CONTEXT Dyspnea is a complex, multidimensional symptom comprising sensory-perceptual, affective, and functional domains that commonly persists in patients with lung cancer and impairs mental health and quality of life (QOL). However, data are lacking on how dyspnea's dimensions or self-efficacy to manage dyspnea are associated with patient outcomes. OBJECTIVES To assess the associations of dyspnea dimensions (dyspnea-related sensory-perceptual experience, affective distress, and functional impact) and dyspnea self-efficacy with depression, anxiety, and QOL in patients with advanced lung cancer reporting dyspnea. METHODS We conducted a secondary analysis of baseline clinical trial data testing a supportive care intervention for dyspnea. Patients with advanced lung cancer reporting at least moderate dyspnea (≥2 on the Modified Medical Research Council Dyspnea Scale) self-reported dyspnea and patient outcome measures. Hierarchical regressions tested the associations of the dyspnea dimensions with depressive and anxiety symptoms (Hospital Anxiety and Depression Scale) and QOL (Functional Assessment of Cancer Therapy-Lung) while adjusting for variables known to affect these outcomes. RESULTS The sensory-perceptual experience of dyspnea (effort) was associated with worse depressive symptoms (b = 0.21, P < 0.01) and QOL (b = -0.53, P = 0.01). Dyspnea self-efficacy was associated with improved depressive (b = -1.26, P < 0.01) and anxiety symptoms (b = -1.72, P < 0.01) and QOL (b = 3.66, P < 0.01). The affective and functional dimensions of dyspnea were not associated with the patient outcomes in the final models. CONCLUSIONS Dyspnea-related sensory-perceptual experience and self-efficacy were associated with mental health and QOL outcomes in patients with lung cancer. Examining the individual contributions of dyspnea's multiple dimensions provides a nuanced understanding of its patient impact.
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Affiliation(s)
- Stephen B Lo
- Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital, Boston, MA, USA.
| | - Anna L Ruprecht
- Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital, Boston, MA, USA
| | - Kathryn E Post
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ijeoma Julie Eche-Ugwu
- Phyllis F. Cantor Center Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mary E Cooley
- Phyllis F. Cantor Center Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer S Temel
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph A Greer
- Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital, Boston, MA, USA
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Miura H, Goto Y. Comparison of the Life-Sustaining Treatment, Cardiopulmonary Resuscitation, and Palliative Care Implementation Rates between Homebound Patients with Malignant and Nonmalignant Disease Who Died in an Acute Hospital Setting: A Single-Center Retrospective Study. Healthcare (Basel) 2024; 12:136. [PMID: 38255025 PMCID: PMC10815562 DOI: 10.3390/healthcare12020136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE This study investigated and compared the implementation of life-support treatment (LST), cardiopulmonary resuscitation (CPR) implementation rates, and the influence of acute illnesses on the introduction of palliative care (PC) to homebound patients with malignant and nonmalignant disease, who subsequently died in an acute hospital setting. METHODS Among the homebound patients admitted to the ward in our hospital from 2011 to 2018, we investigated and compared the attributes, underlying diseases, causes of death, and rates of implementation of LST, CPR, and PC between patients with malignant and nonmalignant disease who died in the ward, using data obtained from hospitalization records. Furthermore, acute illnesses related to the introduction of PC were examined. RESULTS Of the 551 homebound patients admitted to the ward of an acute hospital, 119 died in the ward. Of the deceased patients, 60 had malignant disease and 59 had nonmalignant disease. Patients with nonmalignant disease had higher rates of LST implementation and CPR and a lower rate of PC. Patients with infectious disease, who required antimicrobial drugs, had significantly lower PC introduction rates. CONCLUSION Understanding the influence of the timing of PC introduction in acute care for homebound patients with advanced chronic illness are issues to be considered.
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Affiliation(s)
- Hisayuki Miura
- Department of Home Care and Regional Liaison Promotion, National Center for Geriatrics and Gerontology, Obu 474-8511, Aichi, Japan;
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Moran T, Zentner D, Wong J, Philip J, Smallwood N. Chronic breathlessness in advanced cardiorespiratory disease: patient perceptions of opioid use. BMJ Support Palliat Care 2023; 13:e334-e343. [PMID: 33837113 DOI: 10.1136/bmjspcare-2020-002853] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/13/2021] [Accepted: 03/13/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Low-dose oral opioids may improve severe chronic breathlessness in advanced cardiorespiratory diseases. Prescription of opioids for breathlessness occurs infrequently however, with little known about patients' attitudes towards their use in this setting. The aim of this qualitative study was to explore patients' perceptions regarding opioids for the management of severe chronic breathlessness in people with advanced cardiorespiratory disease. METHODS A cross-sectional, qualitative study was undertaken using outpatients with severe chronic breathlessness due to either severe chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF). Indepth, semistructured interviews were audio-recorded, transcribed verbatim and coded. Thematic analysis was undertaken to extrapolate recurring ideas from the data. RESULTS Twenty-four participants were purposively sampled from three different groups: opioid-naïve patients with COPD (n=7), opioid-naïve patients with CHF (n=7) and patients with COPD using opioids currently or previously for severe chronic breathlessness (n=10). Four major themes were shared by both the opioid-naïve and opioid-experienced cohorts: (1) stigmatised attitudes and beliefs regarding opioids, (2) limited knowledge and information-seeking behaviour regarding opioids, (3) the impact of the relationships with health professionals and continuity of care, and (4) the significance of past experiences with opioids. An additional theme that was unique to the opioid-experienced cohort was (5) the perception of benefit and improved quality of life. CONCLUSION Lack of knowledge regarding the role of opioids in managing severe chronic breathlessness, opioid misinformation and social stigmas are major barriers to opioid therapy that may be overcome by accurate information from trusted health professionals.
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Affiliation(s)
- Thomas Moran
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dominica Zentner
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- The University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Victoria, Australia
| | - James Wong
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- The University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Victoria, Australia
| | - Jennifer Philip
- The University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Victoria, Australia
- Palliative Care Service, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Natasha Smallwood
- The University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Gosselin C, Côté M, Tremblay L, Lacasse Y. Use of Palliative Oxygen in Cancer Patients. Am J Hosp Palliat Care 2023; 40:1087-1092. [PMID: 36452992 PMCID: PMC10507986 DOI: 10.1177/10499091221144005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background: Despite the lack of evidence to support the use of palliative oxygen to relieve dyspnea at the end of life, its prescription is widespread and often supported by local and national practice guidelines. Objectives: The objectives of this study were (1) to determine to what extent oxygen prescriptions meet the proposed prescription criteria in our institution, (2) to examine the indication of individual prescriptions in relation to the severity of dyspnea and (3) to review the utilization of opioids in patients receiving palliative oxygen. Methods: Retrospective chart review of cancer patients who were prescribed palliative oxygen between April 2015 and January 2020 through a respiratory home care program in Quebec City, Canada. According to provincial prescription guidelines, palliative oxygen was provided and reimbursed in case of severe hypoxemia (pulse oximetry saturation at rest < 88%) in cancer patients with an estimated prognosis of less than 3 months. Results: 134 patients receiving palliative oxygen were included; 25 (19%) did not fulfill reimbursement criteria. Median survival was 44 days. At initiation of palliative oxygen, 48 patients (36%) had only mild or moderate dyspnea (Medical Research Council dyspnea score 1-3), 26 (19%) did not receive opioids, and 9 (7%) were prescribed palliative oxygen without being dyspneic or receiving opioids. Conclusion: Most prescriptions of palliative oxygen met the proposed prescription criteria in our institution. Half of those who received palliative oxygen were only mildly dyspneic and/or were not receiving opioids at the time of the prescription.
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Affiliation(s)
- Caroline Gosselin
- Centre de Recherche, Université Laval, Institut universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
| | - Mélanie Côté
- Centre de Recherche, Université Laval, Institut universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
| | - Lise Tremblay
- Centre de Recherche, Université Laval, Institut universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
| | - Yves Lacasse
- Centre de Recherche, Université Laval, Institut universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
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Lo SB, Svensson AD, Presley CJ, Andersen BL. A cognitive-behavioral model of dyspnea: Qualitative interviews with individuals with advanced lung cancer. Palliat Support Care 2023; 21:1-8. [PMID: 37249018 DOI: 10.1017/s1478951523000640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Shortness of breath, or dyspnea, is the subjective experience of breathing discomfort and is a common, distressing, and debilitating symptom of lung cancer. There are no efficacious pharmacological treatments, but there is suggestive evidence that cognitive-behavioral treatments could relieve dyspnea. For this, understanding the psychological, behavioral, and social factors that may affect dyspnea severity is critical. To this end, patients with dyspnea were interviewed with questions framed by the cognitive-behavioral model-emphasizing thoughts, emotions, and behaviors as contributors and outcomes of dyspnea. METHODS Two trained individuals conducted semi-structured interviews with lung cancer patients (N = 15) reporting current dyspnea. Interviews assessed patients' cognitive-behavioral experiences with dyspnea. Study personnel used a grounded theory approach for qualitative analysis to code the interviews. Inter-rater reliability of codes was high (κ = 0.90). RESULTS Thoughts: Most common were patients' catastrophic thoughts about their health and receiving enough oxygen when breathless. Emotions: Anxiety about dyspnea was the most common, followed by anger, sadness, and shame related to dyspnea. Behaviors: Patients rested and took deep breaths to relieve acute episodes of dyspnea. To reduce the likelihood of dyspnea, patients planned their daily activity or reduced their physical activity at the expense of engagement in hobbies and functional activities. SIGNIFICANCE OF RESULTS Patients identified cognitive-behavioral factors (thoughts, emotions, and behaviors) that coalesce with dyspnea. The data provide meaningful insights into potential cognitive-behavioral interventions that could target contributors to dyspnea.
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Affiliation(s)
- Stephen B Lo
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Aubrey D Svensson
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Carolyn J Presley
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University Comprehensive Cancer Center and The James Cancer Hospital/Solove Research Institute, Columbus, OH, USA
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Obarzanek L, Wu W, Tutag-Lehr V. Opioid Management of Dyspnea at End of Life: A Systematic Review. J Palliat Med 2022; 26:711-726. [PMID: 36453988 DOI: 10.1089/jpm.2022.0311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: The objective of this systematic review is to consolidate the existing evidence on opioid use, including administration, dosing, and efficacy, for the relief of dyspnea at end of life. The overarching goal is to optimize clinical management of dyspnea by identifying patterns in opioid use, improving opioid management of dyspnea, and to prioritize future research. Background: Opioids are commonly used in the management of dyspnea at end of life, yet specific administration guidelines are limited. A greater understanding of the effectiveness of opioids in relieving end-of-life dyspnea with consideration of study design, patients, and opioids, including dyspnea evaluation tools and outcomes, will leverage development of standardized administration and dosing. Methods: A PRISMA-guided systematic review using six databases identified quality studies of opioid management for patients with dyspnea at end of life. Results: Twenty-three references met review inclusion criteria, which included terminally ill cancer and noncancer patients with various diagnoses. Studies included two randomized controlled trials, and three nonrandomized experimental, three prospective observational, one cross-sectional, and one case series. Thirteen retrospective chart reviews were also included due to the limited rigorous studies rendered by the search. Thirteen studies evaluated morphine, followed by fentanyl (6), oxycodone (5), general opioid use (4), and hydromorphone (2). Routes of administration were parenteral, oral, combination, and nebulization. Dyspnea was evaluated using self-reporting and non-self-reporting evaluation tools. Sedation was the most reported opioid-related adverse effect. Discussion: Challenges persist in conducting end-of-life research, preventing consensus on standardization of opioid treatment for dyspnea within this specific palliative time frame. Future robust prospective trials using specific, accurate assessment with reassessment of dyspnea/respiratory distress, and consideration of opioid tolerance, polypharmacy, and comorbidities are required.
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Affiliation(s)
| | - Wendy Wu
- Shiffman Medical Library, Wayne State University, Detroit, Michigan, USA
| | - Victoria Tutag-Lehr
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
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8
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Xu Z, Li P, Zhang C, Ma D. Effect of heated humidified high-flow nasal cannula (HFNC) oxygen therapy in dyspnea patients with advanced cancer, a randomized controlled clinical trial. Support Care Cancer 2022; 30:9093-9100. [PMID: 35984511 DOI: 10.1007/s00520-022-07330-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 08/11/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Heated humidified high-flow nasal cannula (HFNC) oxygen therapy is one of the most important oxygen therapy methods, which are commonly applied to relieve dyspnea in advanced cancer patients. Our study aims to observe the efficacy and safety of HFNC oxygen therapy on dyspnea patients with advanced cancer and explore the clinical application. METHODS Sixty subjects with advanced cancer requiring oxygen therapy from a grade 3, class A hospital in China were recruited and randomized (1:1) to traditional nasal catheter oxygen therapy or HFNC. Primary outcomes were dyspnea, oral dryness, and sleep condition, which were recorded after 72-h treatment. Secondary outcomes were heart rate (HR), respiration rate (RR), SpO2, PaO2, and PaCO2, which were recorded after 2, 6, 24, and 72 h treatment. RESULTS Seventy-two hours after treatment, there were significant improvements in all primary outcomes (P < 0.001). PaO2 and RR were statistically changed 2 h after HFNC treatment (P < 0.001). PaCO2 and HR were statistically changed 24 h after HFNC treatment (P < 0.001). CONCLUSION HFNC oxygen therapy has good effect, high safety, and is easy to be accepted by dyspnea patients with advanced cancer. It can be used as the first choice of oxygen therapy for these patients and has broad clinical prospects. TRIAL REGISTRATION This work was retrospectively registered in the Chinese Clinical Trials Registry (ChiCTR2100049582) on August 4, 2021.
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Affiliation(s)
- Zhaoning Xu
- Institute of Respiratory Monitoring and Support, Shandong University, Jinan, 250012, Shandong, China.,School of Nursing and Rehabilitation, Shandong University, Jinan, 250012, Shandong, China
| | - Pingping Li
- School of Nursing and Rehabilitation, Shandong University, Jinan, 250012, Shandong, China
| | - Chi Zhang
- School of Stomatology, Shandong University, Jinan, 250012, Shandong, China
| | - Dedong Ma
- Department of Pulmonary and Critical Care Medicine, Qilu Hospital, Shandong University, Jinan, 250012, Shandong, China.
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Campbell ML, Donesky D, Sarkozy A, Reinke LF. Treatment of Dyspnea in Advanced Disease and at the End of Life. J Hosp Palliat Nurs 2021; 23:406-420. [PMID: 33883525 DOI: 10.1097/njh.0000000000000766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations, varies in intensity, and can only be known through the patient's report. Dyspnea is akin to suffocation and is one of the most distressing symptoms experienced by patients with advanced illness and at the end of life. Common approaches to dyspnea management, such as pulmonary rehabilitation, breathing strategies, or supplemental oxygen, have become accepted through pragmatic use or because studies do not include dyspnea as a measured outcome. Patients and clinicians urgently need evidence-based treatments to alleviate this frightening symptom. To fill this gap, a group of dyspnea researchers with expertise to conduct a literature review of evidence-based interventions for dyspnea in patients with serious illness produced these guidelines. We present the evidence from the strongest recommendations for practice to the weakest recommendations and include practical considerations for clinical nurses.
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Matsuda Y, Matsunuma R, Suzuki K, Mori M, Watanabe H, Yamaguchi T. Physician-Perceived Predictive Factors for the Effectiveness of Drugs for Treating Cancer Dyspnea: Results of a Nationwide Survey of Japanese Palliative Care Physicians. Palliat Med Rep 2021; 1:97-102. [PMID: 34223464 PMCID: PMC8241347 DOI: 10.1089/pmr.2020.0050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Dyspnea is a common and distressing symptom in patients with advanced cancer. Opioids, benzodiazepines, and corticosteroids are commonly prescribed pharmacological treatments for cancer dyspnea. Objective: The objective of this survey was to investigate physician-perceived predictive factors for the effectiveness of opioids, benzodiazepines, and corticosteroids in treating cancer dyspnea. Design: This study involves a nationwide survey using self-report questionnaires. Setting/Subjects: Random sampling selected 268 Japanese certified palliative care physicians in Japan. Measurements: We inquired about the 12 physician-perceived predictive factors for the effectiveness of drugs (opioids, benzodiazepines, and corticosteroids) in treating cancer dyspnea. Results: The frequently selected physician-perceived predictive factors for the effectiveness of opioids were tachypnea, respiratory effort, opioid naive, Eastern Cooperative Oncology Group Performance Status 0–2, multiple lung tumors, dry cough, pleural effusion, and pleural lesion. Benzodiazepines were predicted to be effective against dyspnea in patients with depression and severe anxiety. Meanwhile, corticosteroids were predicted to be effective against dyspnea in patients with lymphangitis carcinomatosa, superior vena cava syndrome, major airway obstruction, and audible wheezing. Japanese palliative care physicians anticipate that different drug classes will be effective for treating dyspnea in patients with specific factors. Conclusions: Japanese palliative care physicians expect that different drugs will be effective for dyspnea in patients with specific predictive factors. Future prospective studies are required to assess the effectiveness of each drug class against specific dyspnea.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan
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Passiglia F, Cetoretta V, De Filippis M, Napoli V, Novello S. Exploring the immune-checkpoint inhibitors' efficacy/tolerability in special non-small cell lung cancer (NSCLC) populations: focus on steroids and autoimmune disease. Transl Lung Cancer Res 2021; 10:2876-2889. [PMID: 34295686 PMCID: PMC8264339 DOI: 10.21037/tlcr-20-635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 10/09/2020] [Indexed: 11/18/2022]
Abstract
The advent of immune-checkpoint inhibitors targeting the programmed cell death-1 (PD-1)/programmed death ligand-1 (PD-L1) axis, both as monotherapy and in combination strategies, produced a paradigm change of the treatment algorithm for metastatic, non-oncogene addicted, non-small cell lung cancer (NSCLC) patients. Although the great efficacy and the optimal tolerability emerging from clinical studies has been confirmed for the majority of patients treated in the real-word scenario, however the potential activity and safety profile of these agents in uncommon NSCLC populations remains still controversial. Particularly, patients with previously diagnosed autoimmune disease or concomitant steroids treatment at the time of immunotherapy initiation represent two special subgroups of patients not unusual in the real-word practice, to whom the clinical implication of immune-checkpoint inhibitors administration is largely unknown. In this review we provided an updated literature overview, summarizing available evidence and reporting practical suggestions, which may guide physicians in their clinical management of these NSCLC sub-populations.
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Affiliation(s)
- Francesco Passiglia
- Department of Oncology, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
| | - Valeria Cetoretta
- Department of Oncology, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
| | - Marco De Filippis
- Department of Oncology, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
| | - Valerio Napoli
- Department of Oncology, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
| | - Silvia Novello
- Department of Oncology, S. Luigi Gonzaga Hospital, University of Turin, Orbassano (TO), Italy
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12
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Gupta A, Sedhom R, Sharma R, Zhang A, Waldfogel JM, Feliciano JL, Day J, Gersten RA, Davidson PM, Bass EB, Dy SM. Nonpharmacological Interventions for Managing Breathlessness in Patients With Advanced Cancer: A Systematic Review. JAMA Oncol 2021; 7:290-298. [PMID: 33211072 DOI: 10.1001/jamaoncol.2020.5184] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Breathlessness is a frequent and debilitating symptom in patients with advanced cancer. Often, in the context of breathlessness, aggressive cancer treatment is not beneficial, feasible, or aligned with goals of care. Targeted symptom-focused interventions may be helpful in this scenario. Objective To evaluate the advantages and harms of nonpharmacological interventions for managing breathlessness in adults with advanced cancer. Evidence Review PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception through May 2020 for published randomized clinical trials (RCTs), nonrandomized controlled trials, and observational studies of the advantages and/or harms of nonpharmacological interventions on alleviating breathlessness in adults with advanced cancer. Only English-language studies were screened for eligibility, titles, abstracts, and full text. Risk of bias and strength of evidence (SOE) were independently assessed. The key outcomes reported in studies were breathlessness, anxiety, exercise capacity, health-related quality of life, and harms. Data were analyzed from October 1, 2019, to June 30, 2020. Findings A total of 29 RCTs (2423 participants) were included. These RCTs evaluated various types of interventions, such as respiratory (9 RCTs), activity and rehabilitation (7 RCTs), behavioral and psychoeducational (3 RCTs), integrative medicine (4 RCTs), and multicomponent (6 RCTs). Several nonpharmacological interventions were associated with improved breathlessness, including fan therapy (standardized mean difference [SMD], -2.09; 95% CI, -3.81 to -0.37; I2 = 94.3%; P for heterogeneity = .02; moderate SOE) and bilevel ventilation (estimated slope difference, -0.58; 95% CI, -0.92 to -0.23; low SOE), lasting for a few minutes to hours, in the inpatient setting. In the outpatient setting, nonpharmacological interventions associated with improved breathlessness were acupressure and reflexology (integrative medicine) (low SOE) and multicomponent interventions (combined activity and rehabilitation, behavioral and psychoeducational, and integrative medicine) (low SOE) lasting for a few weeks to months. Five of the 29 RCTs (17%) reported adverse events, although adverse events and study dropouts were uncommon. Conclusions and Relevance Findings of this review include the safety and association with improved breathlessness of several nonpharmacological interventions for adults with advanced cancer. Guidelines and clinical practice should evolve to incorporate nonpharmacological interventions as first-line treatment for adults with advanced cancer and breathlessness.
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Affiliation(s)
- Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ritu Sharma
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Allen Zhang
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Julie M Waldfogel
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Josephine L Feliciano
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Jeff Day
- Department of Art as Applied to Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca A Gersten
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Eric B Bass
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sydney M Dy
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Higginson IJ, Reilly CC, Maddocks M. Breathlessness. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Luo N, Tan S, Li X, Singh S, Liu S, Chen C, Huang Z, Feng S, Lin Y, Lin Y, Cen H, Liang M, Chen M. Efficacy and Safety of Opioids in Treating Cancer-Related Dyspnea: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials. J Pain Symptom Manage 2021; 61:198-210.e1. [PMID: 32730950 DOI: 10.1016/j.jpainsymman.2020.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/14/2020] [Accepted: 07/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dyspnea is one of the most distressing symptoms encountered by advanced cancer patients. In this study, we aimed to evaluate the role of opioids in the management of cancer-related dyspnea. METHODS A systematic review and meta-analysis based on Randomized Controlled Trials was conducted in the databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials testing the effect of opioids in relieving cancer-related dyspnea. Subgroup and sensitivity analyses were performed to evaluate various types of opioids in dyspnea management and stabilization of the study respectively. RESULTS Eleven RCTs fulfilled the eligibility criteria and had a total of 290 participants. Nine of these studies were included in meta-analyses. Compared with control, opioid therapy showed a small positive effect in dyspnea, SMD-0.82 (95%CI = -1.54 to -0.10) and Borg score, WMD-0.95 (95%CI = -1.83 to -0.06); Opioid therapy did not increase the risk of somnolence, OR0.93 (95%CI = 0.34 to 2.58), whereas a negative effect on respiratory rate was observed,WMD-1.89 (95%CI = -3.36 to -0.43); Also, there was no evidence to suggest improved performance of the 6MWT test, WMD6.49 (95%CI = -34.23 to 47.21), or the level of peripheral oxygen saturation, WMD0.33 (95%CI = -0.59 to 1.24) after opioid therapy. Subgroup analysis yielded a small positive effect for morphine on dyspnea, SMD-0.78 (95%CI = -1.45 to -0.10), whereas fentanyl showed no improvement in dyspnea, SMD-0.44 (95%CI = -0.89 to 0.02). Sensitivity analysis showed no changes in the direction of effect when any one study was excluded from the meta-analyses. CONCLUSIONS Our systematic review and meta-analysis indicated low quality evidence for a small positive effect of opioids in cancer-related dyspnea. Evidence for safety is insufficient as comprehensive adverse events were not adequately reported in studies.
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Affiliation(s)
- Ning Luo
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Shifan Tan
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Xiaocai Li
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | | | - Si Liu
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Chunjie Chen
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Zhuangzhi Huang
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Shuangshuang Feng
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Yacong Lin
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Yuemei Lin
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Hongdan Cen
- Department of Otolaryngology, Maoming People's Hospital, Maoming, China
| | - Min Liang
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China.
| | - Mafeng Chen
- Department of Otolaryngology, Maoming People's Hospital, Maoming, China.
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Hui D, Maddocks M, Johnson MJ, Ekström M, Simon ST, Ogliari AC, Booth S, Ripamonti C. Management of breathlessness in patients with cancer: ESMO Clinical Practice Guidelines †. ESMO Open 2020; 5:e001038. [PMID: 33303485 PMCID: PMC7733213 DOI: 10.1136/esmoopen-2020-001038] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Magnus Ekström
- Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
| | - Steffen T Simon
- Department of Palliative Medicine and Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Anna C Ogliari
- Pulmonary Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sara Booth
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, London, UK; Cambridge Breathlessness Intervention Service, Cambridge University Hospitals NHS Foundation Trust, University of Cambridge, Cambridge, UK
| | - CarlaI Ripamonti
- Oncology-Supportive Care in Cancer Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale dei Tumori Milano, Milan, Italy
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16
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Long DA, Koyfman A, Long B. Oncologic Emergencies: Palliative Care in the Emergency Department Setting. J Emerg Med 2020; 60:175-191. [PMID: 33092975 DOI: 10.1016/j.jemermed.2020.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 06/25/2020] [Accepted: 09/12/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Palliative care is an essential component of emergency medicine, as many patients with terminal illness will present to the emergency department (ED) for symptomatic management at the end of life (EOL). OBJECTIVE This narrative review evaluates palliative care in the ED, with a focus on the literature behind management of EOL symptoms, especially dyspnea and cancer-related pain. DISCUSSION As the population ages, increasing numbers of patients present to the ED with severe EOL symptoms. An understanding of the role of palliative care in the ED is crucial to effectively communicating with these patients to determine their goals and provide medical care in line with their wishes. Beneficence, nonmaleficence, and patient autonomy are essential components of palliative care. Patients without medical decision-making capacity may have an advance directive, do not resuscitate or do not intubate order, or Portable Medical Orders for Life-Sustaining Treatment available to assist clinicians. Effective and empathetic communication with patients and families is vital to EOL care discussions. Two of the most common and distressing symptoms at the EOL are dyspnea and pain. The most effective treatment of EOL dyspnea is opioids, with literature showing little efficacy for other therapies. The most effective treatment for cancer-related pain is opioids, with expeditious pain control achievable with a rapid fentanyl titration. It is also important to address nausea, vomiting, and secretions, as these are common at the EOL. CONCLUSIONS Emergency clinicians play a vital role in EOL patient care. Clear, empathetic communication and treatment of EOL symptoms are essential.
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Affiliation(s)
- Drew A Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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17
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Mori I, Maeda I, Morita T, Inoue S, Ikenaga M, Sekine R, Yamaguchi T, Hirohashi T, Tajima T, Watanabe H. Association Between Heart Rate and Reversibility of the Symptom, Refractoriness to Palliative Treatment, and Survival in Dyspneic Cancer Patients. J Pain Symptom Manage 2020; 60:87-93. [PMID: 32088356 DOI: 10.1016/j.jpainsymman.2020.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/12/2020] [Accepted: 02/12/2020] [Indexed: 10/25/2022]
Abstract
CONTEXT Dyspnea is one of the most distressing symptoms for terminally ill cancer patients and a predictor of poor prognosis. Identification of simple clinical signs, such as heart rate, indicating clinical course of each patient is of value. OBJECTIVES To explore the potential association between heart rate and reversibility of the symptom, treatment response to palliative intervention, and survival in terminally ill cancer patients with dyspnea at rest. METHODS This is a secondary analysis of a multicenter prospective cohort study of patients with advanced cancer to validate multiple prognostic tools. In the patients with dyspnea at rest at the baseline, we examined a potential association between heart rate and the reversibility of dyspnea and refractoriness to palliative treatment using logistic regression analysis. Survivals were compared using the Cox proportional hazards model among four groups with different levels of the heart rate (≤74, 75-84, 85-97, and ≥98). RESULTS A total of 2298 patients were enrolled, and 418 patients (18%) had dyspnea at rest. Reversibility of dyspnea was significantly higher in the patients with lower heart rate (P for trend = 0.008), and the refractoriness to palliative treatment tended to be higher in the patients with higher heart rate (P for trend = 0.101). The median survival for each heart rate quartile groups was significantly higher in the lower heart rate group (24 vs. 21 vs. 14 vs. 9 days; heart rate ≤74, 75-84, 85-97, and ≥98, respectively; log-rank P < 0.001). CONCLUSION Heart rate may help clinicians to make the prediction of the patient's clinical course more accurate.
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Affiliation(s)
- Ichiro Mori
- Gratia Hospital Hospice, Minoh, Osaka, Japan.
| | - Isseki Maeda
- Department of Palliative Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu City, Shizuoka, Japan
| | - Satoshi Inoue
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu City, Shizuoka, Japan
| | - Masayuki Ikenaga
- Hospice Children's Hospice Hospital, Yodogawa Christian Hospital, Osaka City, Japan
| | - Ryuichi Sekine
- Department of Pain and Palliative Care, Kameda Medical Center, Kamogawa City, Chiba, Japan
| | - Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Takeshi Hirohashi
- Department of Palliative Care, Mitui Memorial Hospital, Chiyoda-ku, Tokyo, Japan
| | - Tsukasa Tajima
- Department of Palliative Medicine, Tohoku University Hospital, Aobaku, Sendai, Japan
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19
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Henson LA, Maddocks M, Evans C, Davidson M, Hicks S, Higginson IJ. Palliative Care and the Management of Common Distressing Symptoms in Advanced Cancer: Pain, Breathlessness, Nausea and Vomiting, and Fatigue. J Clin Oncol 2020; 38:905-914. [PMID: 32023162 PMCID: PMC7082153 DOI: 10.1200/jco.19.00470] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2019] [Indexed: 12/27/2022] Open
Abstract
Good symptom management in oncology is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages. With population growth and aging, the proportion of patients with multiple symptoms-both related and unrelated to their cancer-is anticipated to increase, supporting calls for a more routine and integrated approach to symptom management. This article presents a summary of the literature for the use of symptom assessment tools and reviews the management of four common and distressing symptoms commonly experienced by people with advanced cancer: pain, breathlessness, nausea and vomiting, and fatigue. We also discuss the role of palliative care in supporting a holistic approach to symptom management throughout the cancer trajectory.
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Affiliation(s)
- Lesley A. Henson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Catherine Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Martin Davidson
- King’s College Hospital National Health Service Foundation Trust, Denmark Hill, London, United Kingdom
| | - Stephanie Hicks
- King’s College Hospital National Health Service Foundation Trust, Denmark Hill, London, United Kingdom
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
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20
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Yamaguchi T, Matsunuma R, Suzuki K, Matsuda Y, Mori M, Watanabe H. The Current Practice of Opioid for Cancer Dyspnea: The Result From the Nationwide Survey of Japanese Palliative Care Physicians. J Pain Symptom Manage 2019; 58:672-677.e2. [PMID: 31201876 DOI: 10.1016/j.jpainsymman.2019.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Morphine is recommended as the first-line pharmacological therapy for cancer dyspnea. However, the detailed practice of morphine has not been evaluated and consensus about other opioids for cancer dyspnea has not been established. OBJECTIVES To explore the physician-reported practice of opioid for cancer dyspnea. METHODS A nationwide mail-questionnaire survey was conducted among 536 Japanese certified palliative care physicians. We randomly selected 268 and asked the following: 1) how the physicians themselves initiate and use morphine for cancer dyspnea, 2) opioid choice for dyspnea in patients who have already used opioid other than morphine regularly, and 3) opioid choice for dyspnea in patients with various degrees of renal impairment in their daily practice. RESULTS Overall, 192 physicians responded (response rate, 71.6%). The major (58.3%) practice of initiating morphine was "immediate-release morphine as needed" in opioid-naïve patients, and the mean % increase when they titrate morphine for cancer dyspnea was 29.4 ± 11.3% of the baseline dose. Although "titrate baseline oxycodone" was the most frequent (42.3%) for low-to-moderate-dose regular oxycodone cases, "stepwise switch to morphine" (30.0%) and "add morphine on baseline oxycodone" (27.1%) were the more frequent practices for high-dose regular oxycodone. Regardless of the baseline dose, "add morphine on baseline fentanyl" was the most frequent practice for regular transdermal fentanyl cases. Oxycodone was the most frequent choice in renal insufficiency cases, regardless of its degree. CONCLUSIONS Among Japanese palliative care physicians, using oxycodone for cancer dyspnea was relatively popular practice, whereas fentanyl was not. Oxycodone was the most preferred opioid for cancer dyspnea in the setting of renal insufficiency among Japanese palliative care physicians. We should conduct studies to confirm the safety and effectiveness of these opioid practices for cancer dyspnea.
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Affiliation(s)
- Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan.
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
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Chin-Yee N, Taylor J, Downar J, Tanuseputro P, Saidenberg E. Red Blood Cell Transfusion in Palliative Care: A Survey of Palliative Care Physicians. J Palliat Med 2019; 22:1139-1142. [DOI: 10.1089/jpm.2018.0605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nicolas Chin-Yee
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Taylor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James Downar
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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22
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Hashimoto H, Kanda K. Development and validation of the Total Dyspnea Scale for Cancer Patients. Eur J Oncol Nurs 2019; 41:120-125. [DOI: 10.1016/j.ejon.2019.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/23/2019] [Accepted: 05/30/2019] [Indexed: 11/12/2022]
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Maddocks M, Brighton LJ, Farquhar M, Booth S, Miller S, Klass L, Tunnard I, Yi D, Gao W, Bajwah S, Man WDC, Higginson IJ. Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background
Breathlessness is a common and distressing symptom of many advanced diseases, affecting around 2 million people in the UK. Breathlessness increases with disease progression and often becomes chronic or refractory. Breathlessness-triggered services that integrate holistic assessment and specialist palliative care input as part of a multiprofessional approach have been developed for this group, offering tailored interventions to support self-management and reduce distress.
Objectives
The aim was to synthesise evidence on holistic breathlessness services for people with advanced disease and chronic or refractory breathlessness. The objectives were to describe the structure, organisation and delivery of services, determine clinical effectiveness, cost-effectiveness and acceptability, identify predictors of treatment response, and elicit stakeholders’ evidence-based priorities for clinical practice, policy and research.
Design
The mixed-methods evidence synthesis comprised three components: (1) a systematic review to determine the clinical effectiveness, cost-effectiveness and acceptability of holistic breathlessness services; (2) a secondary analysis of pooled individual data from three trials to determine predictors of clinical response; and (3) a transparent expert consultation (TEC), comprising a stakeholder workshop and an online consensus survey, to identify stakeholders’ priorities.
Results
Thirty-seven papers reporting on 18 holistic breathlessness services were included in the systematic review. Most studies enrolled people with thoracic cancer, were delivered over 4–6 weeks, and included breathing training, relaxation techniques and psychological support. Meta-analysis demonstrated significant reductions in the Numeric Rating Scale (NRS) distress due to breathlessness, significant reductions in the Hospital Anxiety and Depressions Scale (HADS) depression scores, and non-significant reductions in the Chronic Respiratory Disease Questionnaire (CRQ) mastery and HADS anxiety, favouring the intervention. Recipients valued education, self-management interventions, and expertise of the staff in breathlessness and person-centred care. Evidence for cost-effectiveness was limited and inconclusive. The responder analysis (n = 259) revealed baseline CRQ mastery and NRS distress to be strong predictors of the response to breathlessness services assessed by these same measures, and no significant influence from baseline breathlessness intensity, patient diagnosis, lung function, health status, anxiety or depression. The TEC elicited 34 priorities from stakeholders. Seven priorities received high agreement and consensus, reflecting stakeholders’ (n = 74) views that services should be person-centred and multiprofessional, share their breathlessness management skills with others, and recognise the roles and support needs of informal carers.
Limitations
The evidence synthesis draws predominantly from UK services and may not be generalisable to other settings. Some meta-analyses were restricted by reporting biases and statistical heterogeneity.
Conclusions
Despite heterogeneity in composition and delivery, holistic breathlessness services are highly valued by recipients and can lead to significant improvements in the distress caused by breathlessness and depression. Outcomes of improved mastery and reduced distress caused by breathlessness are not influenced by patient diagnosis, lung function or health status. Stakeholders highlighted the need for improved access to person-centred, multiprofessional breathlessness services and support for informal carers.
Future work
Our research suggests that key therapeutic components of holistic breathlessness services be considered in clinical practice and models of delivery and educational strategies to address stakeholders’ priorities tested.
Study registration
This study is registered as PROSPERO CRD42017057508.
Funding
The National Institute for Health Research (NIHR) Health Services and Delivery programme. Matthew Maddocks, Wei Gao and Irene J Higginson are supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London; Matthew Maddocks is supported by a NIHR Career Development Fellowship (CDF-2017-009), William D-C Man is supported by the NIHR CLAHRC Northwest London and Irene J Higginson holds a NIHR Emeritus Senior Investigator Award.
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Affiliation(s)
- Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Sara Booth
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Sophie Miller
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lara Klass
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - India Tunnard
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - William D-C Man
- National Heart and Lung Institute, Imperial College London, London, UK
- Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
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Ambrosino N, Fracchia C. Strategies to relieve dyspnoea in patients with advanced chronic respiratory diseases. A narrative review. Pulmonology 2019; 25:289-298. [PMID: 31129045 DOI: 10.1016/j.pulmoe.2019.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The management of symptoms in patients with advanced chronic respiratory diseases needs more attention. This review summarizes the latest evidence on interventions to relieve dyspnoea in these patients. METHODS We searched randomised controlled trials, observational studies, systematic reviews, and meta-analyses published between 1990 and 2019 in English in PubMed data base using the keywords. Dyspnoea, Breathlessness AND: pharmacological and non pharmacological therapy, oxygen, non invasive ventilation, pulmonary rehabilitation, alternative medicine, intensive care, palliative care, integrated care, self-management. Studies on drugs (e.g. bronchodilators) or interventions (e.g. lung volume reduction surgery, lung transplantation) to manage underlying conditions and complications, or tools for relief of associated symptoms such as pain, are not addressed. RESULTS Relief of dyspnoea has received relatively little attention in clinical practice and literature. Many pharmacological and non pharmacological therapies are available to relieve dyspnoea, and improve patients' quality of life. There is a need for greater knowledge of the benefits and risks of these tools by doctors, patients and families to avoid unnecessary fears which might reduce or delay the delivery of appropriate care. We need services for multidisciplinary care in early and late phases of diseases. Early integration of palliative care with respiratory, primary care, and rehabilitation services can help patients and caregivers. CONCLUSION Relief of dyspnoea as well as of any distressing symptom is a human right and an ethical duty for doctors and caregivers who have many potential resources to achieve this.
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Affiliation(s)
- N Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, Istituto di Montescano, Pneumologia Riabilitativa, Montescano (PV), Italy.
| | - C Fracchia
- Istituti Clinici Scientifici Maugeri IRCCS, Istituto di Montescano, Pneumologia Riabilitativa, Montescano (PV), Italy
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Haywood A, Duc J, Good P, Khan S, Rickett K, Vayne-Bossert P, Hardy JR. Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. Cochrane Database Syst Rev 2019; 2:CD012704. [PMID: 30784058 PMCID: PMC6381295 DOI: 10.1002/14651858.cd012704.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Dyspnoea is a common symptom in advanced cancer, with a prevalence of up to 70% among patients at end of life. The cause of dyspnoea is often multifactorial, and may cause considerable psychological distress and suffering. Dyspnoea is often undertreated and good symptom control is less frequently achieved in people with dyspnoea than in people with other symptoms of advanced cancer, such as pain and nausea. The exact mechanism of action of corticosteroids in managing dyspnoea is unclear, yet corticosteroids are commonly used in palliative care for a variety of non-specific indications, including pain, nausea, anorexia, fatigue and low mood, despite being associated with a wide range of adverse effects. In view of their widespread use, it is important to seek evidence of the effects of corticosteroids for the management of cancer-related dyspnoea. OBJECTIVES To assess the effects of systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Science Citation Index Web of Science, Latin America and Caribbean Health Sciences (LILACS) and clinical trial registries, from inception to 25 January 2018. SELECTION CRITERIA We included randomised controlled trials that included adults aged 18 years and above. We included participants with cancer-related dyspnoea when randomised to systemic corticosteroids (at any dose) administered for the relief of cancer-related dyspnoea or any other indication, compared to placebo, standard or alternative treatment. DATA COLLECTION AND ANALYSIS Five review authors independently assessed trial quality and three extracted data. We used means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). We assessed the risk of bias and quality of evidence using GRADE. We extracted primary outcomes of sensory-perceptual experience of dyspnoea (intensity of dyspnoea), affective distress (quality of dyspnoea) and symptom impact (burden of dyspnoea or impact on function) and secondary outcomes of serious adverse events, participant satisfaction with treatment and participant withdrawal from trial. MAIN RESULTS Two studies met the inclusion criteria, enrolling 157 participants (37 participants in one study and 120 in the other study), of whom 114 were included in the analyses. The studies compared oral dexamethasone to placebo, followed by an open-label phase in one study. One study lasted seven days, and the duration of the other study was 15 days.We were unable to conduct many of our predetermined analyses due to different agents, dosages, comparators and outcome measures, routes of drug delivery, measurement scales and time points. Subgroup analysis according to type of cancer was not possible.Primary outcomesWe included two studies (114 participants) with data at one week in the meta-analysis for change in dyspnoea intensity/dyspnoea relief from baseline. Corticosteroid therapy with dexamethasone resulted in an MD of lower dyspnoea intensity compared to placebo at one week (MD -0.85 lower dyspnoea (scale 0-10; lower score = less breathlessness), 95% CI -1.73 to 0.03; very low-quality evidence), although we were uncertain as to whether corticosteroids had an important effect on dyspnoea as results were imprecise. We downgraded the quality of evidence by three levels from high to very low due to very serious study limitations and imprecision.One study measured affective distress (quality of dyspnoea) and results were similar between groups (29 participants; very low-quality evidence). We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Both studies assessed symptom impact (burden of dyspnoea or impact on function) (113 participants; very low-quality evidence). In one study, it was unclear whether dexamethasone had an effect on dyspnoea as results were imprecise. The second study showed more improvement for physical well-being scores at days eight and 15 in the dexamethasone group compared with the control group, but there was no evidence of a difference for FACIT social/family, emotional or functional scales. We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Secondary outcomesDue to the lack of homogenous outcome measures and inconsistency in reporting, we could not perform quantitative analysis for any secondary outcomes. In both studies, the frequency of adverse events was similar between groups, and corticosteroids were generally well tolerated. The withdrawal rates for the two studies were 15% and 36%. Reasons for withdrawal included lost to follow-up, participant or carer (or both) refusal, and death due to disease progression. We downgraded the quality of evidence for these secondary outcomes by three levels from high to very low due to serious study limitations, inconsistency and imprecision.Neither study examined participant satisfaction with treatment. AUTHORS' CONCLUSIONS There are few studies assessing the effects of systemic corticosteroids on cancer-related dyspnoea in adults with cancer. We judged the evidence to be of very low quality that neither supported nor refuted corticosteroid use in this population. Further high-quality studies are needed to determine if corticosteroids are efficacious in this setting.
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Affiliation(s)
- Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
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Takahashi K, Kondo M, Ando M, Shiraki A, Nakashima H, Wakayama H, Kataoka K, Yamamoto M, Sugino Y, Nishikawa M, Imaizumi K, Kojima E, Sumida A, Takeyama Y, Saito H, Hasegawa Y. Effects of Oral Morphine on Dyspnea in Patients with Cancer: Response Rate, Predictive Factors, and Clinically Meaningful Change (CJLSG1101). Oncologist 2019; 24:e583-e589. [PMID: 30659079 DOI: 10.1634/theoncologist.2018-0468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/07/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although the efficacy of parenteral morphine for alleviating dyspnea has been previously demonstrated in several studies, little is known regarding the efficacy of oral morphine for dyspnea among patients with cancer, including its response rate and predictive factors of effectiveness. Therefore, the aim of this study was to clarify the effectiveness of oral morphine on dyspnea in patients with cancer and elucidate the predictive factors of its effectiveness. SUBJECTS, MATERIALS, AND METHODS In this multicenter prospective observational study, we investigated the change in dyspnea intensity in patients with cancer before and after the administration of oral morphine by using a visual analog scale (VAS). We also administered a self-assessment questionnaire to determine whether the patients believed oral morphine was effective. RESULTS Eighty patients were enrolled in the study, and 71 of these patients were eligible. The least square mean of the VAS scores for dyspnea intensity was 53.5 at baseline, which decreased significantly to 44.7, 40.8, and 35.0 at 30, 60, and 120 minutes after morphine administration, respectively. Fifty-four patients (76.1%) reported that oral morphine was effective on the self-assessment questionnaire. Among the background factors, a high score for "sense of discomfort" on the Cancer Dyspnea Scale (CDS) and a smoking history of fewer pack-years were associated with greater effectiveness. CONCLUSION Oral morphine was effective and feasible for treating cancer-related dyspnea. A higher score for "sense of discomfort" on the CDS and a smaller cumulative amount of smoking may be predictive factors of the effectiveness of oral morphine. IMPLICATIONS FOR PRACTICE This study demonstrated that oral morphine was effective in alleviating cancer-related dyspnea due to multiple factors including primary lung lesions, airway narrowing, and pleural effusion. Approximately 76% of patients reported that oral morphine was effective. A higher score for "sense of discomfort" on the Cancer Dyspnea Scale and a lower cumulative amount of smoking may be predictive factors for the effectiveness of oral morphine. Interestingly, respiratory rates in patients who reported the morphine to be effective decreased significantly after oral morphine administration, unlike the respiratory rates in "morphine-ineffective" patients.
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Affiliation(s)
- Kosuke Takahashi
- Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masashi Kondo
- Department of Respiratory Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Akira Shiraki
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Harunori Nakashima
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Hisashi Wakayama
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Masashi Yamamoto
- Department of Respiratory Medicine, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Yasuteru Sugino
- Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Mitsunori Nishikawa
- Department of Palliative Care, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Kazuyoshi Imaizumi
- Department of Respiratory Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Eiji Kojima
- Department of Respiratory Medicine, Komaki Municipal Hospital, Komaki, Japan
| | - Atsushi Sumida
- Department of Respiratory Medicine, Tsushima City Hospital, Tsushima, Japan
| | - Yoshihiro Takeyama
- Department of Respiratory Medicine, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Hiroshi Saito
- Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Collis SP. Literature review of clinical benefits and reasons to prescribe palliative oxygen therapy in non-hypoxaemic patients. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2018; 27:1255-1260. [PMID: 30457378 DOI: 10.12968/bjon.2018.27.21.1255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
AIMS: to review current guidelines and studies available to health professionals in the UK and explore the literature to identify reasons for the prescription of palliative oxygen therapy in non-hypoxaemic patients. BACKGROUND: oxygen therapy is often associated with the palliative treatment for breathlessness. Although prescription guidelines are available and the risks of oxygen therapy are known, the therapy is still prescribed for non-hypoxaemic patients. DESIGN: a literature search was conducted using relevant databases. Cited evidence from published guidelines was also consulted. RESULTS: the findings suggest that oxygen is no more effective than room air for treating dyspnoea for non-hypoxaemic patients, although two small studies of self-reported benefits from patients and carers indicate different perceptions of need. CONCLUSION: the findings suggest that there is a knowledge gap with regards understanding the reasons for the prescription of oxygen therapy for non-hypoxaemic patients.
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Affiliation(s)
- Steven P Collis
- Senior Lecturer, College of Health and Social Care, University of Derby, UK
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Management of Dyspnea in the Terminally Ill. Chest 2018; 154:925-934. [DOI: 10.1016/j.chest.2018.04.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 04/05/2018] [Accepted: 04/05/2018] [Indexed: 11/21/2022] Open
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Yamaguchi T, Matsuda Y, Matsuoka H, Hisanaga T, Osaka I, Watanabe H, Maeda I, Imai K, Tsuneto S, Wagatsuma Y, Kizawa Y. Efficacy of immediate-release oxycodone for dyspnoea in cancer patient: cancer dyspnoea relief (CDR) trial. Jpn J Clin Oncol 2018; 48:1070-1075. [DOI: 10.1093/jjco/hyy139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 09/04/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hiromichi Matsuoka
- Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Takayuki Hisanaga
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Iwao Osaka
- Department of Palliative Medicine, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Isseki Maeda
- Gratia Hospice, Gratia Research and Clinical Education (GRACE) Center, Gratia Hospital, Minoh, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukiko Wagatsuma
- Department of Clinical Trial and Clinical Epidemiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Abstract
Patients with cancer continue to have unmet palliative care needs. Concurrent palliative care is tailored to the needs of patients as well as their families to relieve suffering. Specialty palliative care referral is associated with improved symptom management, improved end-of-life quality, and higher family-rated satisfaction. Optimal timing for palliative care referral has not been determined. Barriers to palliative care referral include workforce limitations, provider attitudes and perceptions, and potential ethnic and racial disparities in access to palliative care. Future work should focus on novel, patient-centered approaches to identify and address unmet palliative care needs for patients living with cancer.
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Affiliation(s)
- Kathleen M Akgün
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, VA Connecticut Healthcare System, Yale University School of Medicine, 950 Campbell Avenue, MS11 ACSLG, West Haven, CT 06516, USA.
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Maeda T, Hayakawa T. Corticosteroids for alleviating dyspnea in patients with terminal cancer. PROGRESS IN PALLIATIVE CARE 2017. [DOI: 10.1080/09699260.2017.1392674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Tsuyoshi Maeda
- Department of Pharmacy, Kasugai Municipal Hospital, 1-1-1, Takaki-cho, Kasugai, Aichi 486-8510, Japan
| | - Toru Hayakawa
- Department of Pharmacotherapy, Hokkaido Pharmaceutical University School of Pharmacy, 7-15-4-1 Maeda, Teine, Sapporo Hokkaido 006-8590, Japan
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Abstract
This article focuses on the symptoms of dyspnea and delirium, which can be extremely distressing to patients with cancer at the end of life. Oncology nurses are well suited to detect and treat these symptoms.
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Affiliation(s)
- Barton Bobb
- Virginia Commonwealth University Massey Cancer Center
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Haywood A, Duc J, Good P, Khan S, Rickett K, Vayne-Bossert P, Hardy JR. Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. Hippokratia 2017. [DOI: 10.1002/14651858.cd012704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University; Gold Coast Australia
- Mater Research Institute - The University of Queensland; Brisbane Australia
| | - Jacqueline Duc
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
- Faculty of Medicine; University of Brisbane Brisbane Australia
- Children's Health Queensland; Paediatric Palliative Care Service; Brisbane Australia
| | - Phillip Good
- Mater Research Institute - The University of Queensland; Brisbane Australia
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
- St Vincent's Private Hospital; Department of Palliative Care; 411 Main Street Kangaroo Point Brisbane Queensland Australia 4169
| | - Sohil Khan
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University; Gold Coast Australia
- Mater Research Institute - The University of Queensland; Brisbane Australia
| | - Kirsty Rickett
- UQ/Mater McAuley Library; The University of Queensland Library; Raymond Terrace Brisbane Queensland Australia 4101
| | - Petra Vayne-Bossert
- University Hospitals of Geneva; Department of Readaptation and Palliative Medicine; 11 chemin de la Savonnière Collonge-Bellerive Geneva Switzerland 1245
| | - Janet R Hardy
- Mater Research Institute - The University of Queensland; Brisbane Australia
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
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O'Driscoll BR, Howard LS, Earis J, Mak V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72:ii1-ii90. [DOI: 10.1136/thoraxjnl-2016-209729] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/03/2017] [Accepted: 02/12/2017] [Indexed: 12/15/2022]
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Maeda T, Hayakawa T. Retrospective analysis of corticosteroid doses administered to patients with terminal cancer for dyspnea alleviation and survival. PROGRESS IN PALLIATIVE CARE 2017. [DOI: 10.1080/09699260.2017.1304609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Maeda T, Hayakawa T. Range of Effective Corticosteroid Doses for Alleviating Dyspnea in Terminal Cancer Patients: A Retrospective Review. J Pain Palliat Care Pharmacother 2017; 31:10-15. [PMID: 28287356 DOI: 10.1080/15360288.2017.1279501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study aimed to determine the range of mean cumulative corticosteroid doses that could effectively palliate dyspnea in opioid-treated patients with terminal cancer and to investigate the demographic or biochemical factors predictive of corticosteroid responsiveness. To this end, responders and nonresponders were compared with regard to corticosteroid dose and whether they had initiated opioid use before or concomitantly with corticosteroid use. A logistic regression analysis was conducted to assess the impacts of demographic and biochemical factors on corticosteroid effectiveness. The final sample comprised 20 patients who satisfied the selection criteria. The responders accounted for 70% of the total sample (n = 14) and experienced the strongest effect with regard to dyspnea palliation at a mean cumulative dose equivalent to 64.4 mg prednisolone. However, no factors predictive of response were identified. In summary, this retrospective study identified effective corticosteroid doses for dyspnea alleviation in terminal cancer patients. Although our study sample was limited in size, the results support further prospective research.
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Tian C, Wang JY, Wang ML, Jiang B, Zhang LL, Liu F. Morphine versus methylprednisolone or aminophylline for relieving dyspnea in patients with advanced cancer in China: a retrospective study. SPRINGERPLUS 2016; 5:1945. [PMID: 27917339 PMCID: PMC5102996 DOI: 10.1186/s40064-016-3651-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 11/04/2016] [Indexed: 12/12/2022]
Abstract
Context Dyspnea is one of the most common and distressing symptoms that occurs in terminal cancer patients. However, there are no existing treatment guidelines for this condition in China. Objective This single-center, retrospective, observational study aimed to compare the efficacy of using morphine, methylprednisolone, or aminophylline to relieve the symptom of breathlessness in patients with advanced malignant tumors and to investigate the safety of these regimens during the treatment of dyspnea. Methods Between August 2011 and January 2015 we retrospectively reviewed the medical records of 343 terminally ill cancer patients with dyspnea who received morphine, methylprednisolone, or aminophylline. The therapeutic effect of each treatment by means of visual analogue scale (VAS) scores was assessed and compared. Statistical methods included Chi square and analysis of variance tests. Differences were considered significant when P < 0.05. Results VAS scores after treatment were (16.82 ± 10.89), (25.72 ± 15.03), and (31.95 ± 16.00) points in the morphine, methylprednisolone, and aminophylline group, respectively. These differences were found to be significantly different (P < 0.05). The effectiveness ratings were 86.44, 62.16, and 49.12%, respectively (P < 0.05). Conclusions We found that morphine subcutaneous injection for advanced cancer patients with dyspnea was safe and typically more effective than methylprednisolone or aminophylline. Therefore, morphine treatment could significantly improve the quality of life in terminal cancer patients with short life expectancies who are experiencing shortness of breath.
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Affiliation(s)
- Cong Tian
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Jiong-Yi Wang
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Mei-Ling Wang
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Bin Jiang
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Lu-Lu Zhang
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
| | - Feng Liu
- Department of Medical Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University of Medicine, Shanghai, 201900 China
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Abstract
The high prevalence of dyspnea at the end of life carries with it significant health and economic burden. Given the complex mechanism of dyspnea, management should be tailored to the individual patient experience and the underlying disease process. No clear role for supplemental oxygen has been established in the treatment of dyspnea in patients without no hypoxemia, and providers should consider the negative effects of oxygen supplementation. Symptom control with medications, exercise, behavioral therapy, treatment of associated anxiety, and the use of fans may be more effective and less costly than oxygen therapy. Further research is needed in the assessment and treatment of this symptom to more effectively treat patients.
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Affiliation(s)
- Jennifer Baldwin
- University of Connecticut, 263 Farmington Avenue, Farmington, CT 06032, USA.
| | - Jaclyn Cox
- University of Connecticut, 263 Farmington Avenue, Farmington, CT 06032, USA
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Hui D, Kilgore K, Frisbee-Hume S, Park M, Tsao A, Delgado Guay M, Lu C, William W, Pisters K, Eapen G, Fossella F, Amin S, Bruera E. Dexamethasone for Dyspnea in Cancer Patients: A Pilot Double-Blind, Randomized, Controlled Trial. J Pain Symptom Manage 2016; 52:8-16.e1. [PMID: 27330023 PMCID: PMC4958556 DOI: 10.1016/j.jpainsymman.2015.10.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Dexamethasone is often used to treat dyspnea in cancer patients, but evidence is lacking. OBJECTIVES We determined the feasibility of conducting a randomized trial of dexamethasone in cancer patients and estimated the efficacy of dexamethasone in the treatment of dyspnea. METHODS In this double-blind, randomized, controlled trial, patients with dyspnea ≥4 were randomized to receive either dexamethasone 8 mg twice daily × four days then 4 mg twice daily × three days or placebo for seven days, followed by an open-label phase for seven days. We documented the changes in dyspnea (0-10 numeric rating scale), spirometry measures, quality of life, and toxicities. RESULTS A total of 41 patients were randomized and 35 (85%) completed the blinded phase. Dexamethasone was associated with a significant reduction in dyspnea numeric rating scale of -1.9 (95% CI -3.3 to -0.5, P = 0.01) by Day 4 and -1.8 (95% CI -3.2 to -0.3, P = 0.02) by Day 7. In contrast, placebo was associated with a reduction of -0.7 (95% CI -2.1 to 0.6, P = 0.38) by Day 4 and -1.3 (95% CI -2.4 to -0.2, P = 0.03) by Day 7. The between-arm difference was not statistically significant. Drowsiness improved with dexamethasone. Dexamethasone was well tolerated with no significant toxicities. CONCLUSION A double-blind, randomized, controlled trial of dexamethasone was feasible with a low attrition rate. Our preliminary data suggest that dexamethasone may be associated with rapid improvement in dyspnea and was well tolerated. Further studies are needed to confirm our findings. TRIAL REGISTRATION ClinicalTrials.govNCT01670097.
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Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - Kelly Kilgore
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Susan Frisbee-Hume
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Anne Tsao
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Marvin Delgado Guay
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Charles Lu
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - William William
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Pisters
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - George Eapen
- Department of Pulmonary Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Frank Fossella
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Sapna Amin
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
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Bauml J, Haas A, Simone CB, Li SQ, Cohen RB, Langer CJ, Mao JJ. Acupuncture for Dyspnea in Lung Cancer: Results of a Feasibility Trial. Integr Cancer Ther 2016; 15:326-32. [PMID: 27114385 PMCID: PMC5739187 DOI: 10.1177/1534735415624138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose. Dyspnea is a common and distressing symptom for patients with lung cancer (LC) because of disease burden, therapy toxicity, and comorbid illnesses. Acupuncture is a centuries-old therapy with biological plausibility for relief of dyspnea in this setting. This pilot study aimed to evaluate the feasibility and preliminary effectiveness of acupuncture for dyspnea among patients with LC. Methods. Eligible patients had a diagnosis of LC and clinically significant dyspnea without a clear organic cause. The treatment consisted of 10 weekly acupuncture sessions, with a follow-up visit 4 weeks after therapy. The primary outcome was dyspnea severity as measured using a validated Numerical Rating Scale (NRS) of 0 to 10 (10 being “most severe shortness of breath imaginable”). Results. We enrolled 12 patients in the study. The median age was 64.5 years; 66.7% of the patients were female, and 66.7% were Caucasians. Among those enrolled, 10 (83.3%) were able to complete all 10 acupuncture sessions. Acupuncture was well tolerated; adverse events were mild and self-limited. Mean (SD) dyspnea scores on the NRS improved from 6.3 (1.7) at baseline to 3.6 (1.9; P = .003) at the end of treatment and 3.2 (2.3; P = .008) at follow-up. Fatigue and quality of life also improved significantly with acupuncture (P < .05). Conclusion. Among patients with LC, acupuncture was well tolerated and exhibited promising preliminary beneficial effects in the treatment of dyspnea, fatigue, and quality of life. Performing a trial in this population appears feasible.
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Affiliation(s)
- Joshua Bauml
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew Haas
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Charles B Simone
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Susan Q Li
- Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Roger B Cohen
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Corey J Langer
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jun J Mao
- Abramson Cancer Center at the University of Pennsylvania, Philadelphia, PA Department of Family Medicine and Community Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Maeda T, Hayakawa T. Combined Effect of Opioids and Corticosteroids for Alleviating Dyspnea in Terminal Cancer Patients: A Retrospective Review. J Pain Palliat Care Pharmacother 2016; 30:106-10. [PMID: 27093633 DOI: 10.3109/15360288.2016.1167803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Dyspnea is a prognostic factor that affects the quality of life of terminal cancer patients, and many reports have described opioid treatment for dyspnea alleviation. Here, we retrospectively evaluated differences in the effects of various opioids administered concomitantly with corticosteroids on dyspnea in 20 terminal-stage cancer patients (13 men, 7 women; mean age [range]: 71 [49-94] years) who received opioids concomitantly with corticosteroids. Effectiveness was assessed throughout administration using the Support Team Assessment Schedule, Japanese version (STAS-J), particularly the subscale indicating how strongly a patient is affected by symptoms. The effectiveness of combined opioid and corticosteroid therapy against dyspnea and the opioid dose comprised the primary and secondary foci, respectively. Among concomitantly treated patients, STAS-J scores at initiation (mean ± SD: 3.1 ± 0.24) and lowest recorded STAS-J scores (1.4 ± 0.22) differed significantly (P = .0034) among those receiving morphine, but not among those receiving oxycodone (P = .068) or fentanyl (P = .18). Concomitant opioid and corticosteroid treatment was associated with a ≥2-point STAS-J score improvement in 14/20 patients (effectiveness: 70%). The opioid dose did not significantly affect dyspnea alleviation. We conclude that concomitant opioid and corticosteroid treatment can effectively alleviate dyspnea in terminal cancer patients.
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Schmitz A, Schulz C, Friebel U, Hohlfeld T, Bausewein C. Patient-Controlled Therapy of Breathlessness in Palliative Care: A New Therapeutic Concept for Opioid Administration? J Pain Symptom Manage 2016; 51:581-8. [PMID: 26578404 DOI: 10.1016/j.jpainsymman.2015.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/28/2015] [Accepted: 11/03/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Breathlessness is one of the most distressing symptoms experienced by patients with advanced cancer and noncancer diagnoses alike. Often, severity of breathlessness increases quickly, calling for rapid symptom control. Oral, buccal, and parenteral routes of provider-controlled drug administration have been described. It is unclear whether patient-controlled therapy (PCT) systems would be an additional treatment option. OBJECTIVES To investigate whether intravenous opioid PCT can be an effective therapeutic method to reduce breathlessness in patients with advanced disease. Secondary aims were to study the feasibility and acceptance of opioid PCT in patients with refractory breathlessness. METHODS This was a pilot observational study with 18 inpatients with advanced disease and refractory breathlessness receiving opioid PCT. Breathlessness was measured on a self-reported numeric rating scale. Richmond Agitation Sedation Scale scores, Palliative Performance Scale scores, vital signs, and a self-developed patient satisfaction questionnaire were used for measuring secondary outcomes. Descriptive and interference analyses (Friedman test) and post hoc analyses (Wilcoxon tests and Bonferroni corrections) were performed. RESULTS Eighteen of 815 patients (advanced cancer; median age = 57.5 years [range 36-81]; 77.8% female) received breathlessness symptom control with opioid PCT; daily morphine equivalent dose at Day 1 was median = 20.3 mg (5.0-49.6 mg); Day 2: 13.0 mg (1.0-78.5 mg); Day 3: 16.0 mg (8.3-47.0 mg). Numeric rating scale of current breathlessness decreased (baseline: median = 5 [range 1-10]; Day 1: median = 4 [range 0-8], P < 0.01; Day 2: median = 4 [range 0-5], P < 0.01). Physiological parameters were stable over time. On Day 3, 12/12 patients confirmed that this mode of application provided relief of breathlessness. CONCLUSION Opioid PCT is a feasible and acceptable therapeutic method to reduce refractory breathlessness in palliative care patients.
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Affiliation(s)
- Andrea Schmitz
- Interdisciplinary Center for Palliative Medicine, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany; Department of Anesthesiology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christian Schulz
- Interdisciplinary Center for Palliative Medicine, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
| | - Uta Friebel
- Department of Anesthesiology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Thomas Hohlfeld
- Institute of Pharmacology and Clinical Pharmacology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Claudia Bausewein
- Department for Palliative Medicine, Munich University Hospital, Ludwig-Maximilians-University, Munich, Germany
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Abstract
The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course.
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Vargas-Bermúdez A, Cardenal F, Porta-Sales J. Opioids for the Management of Dyspnea in Cancer Patients: Evidence of the Last 15 Years--A Systematic Review. J Pain Palliat Care Pharmacother 2015; 29:341-52. [PMID: 26523974 DOI: 10.3109/15360288.2015.1082005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The objective of this study was to review the evidence on the use of opioids for treatment of the dyspnea in adult cancer patients. A systematic literature review was conducted in the databases MEDLINE, CINAHL (EBSCO), ScienceDirect, and Cochrane Library of trials testing the effect of opioids in relieving dyspnea in cancer patients. Fourteen trials met the criteria for inclusion in the review. Eight randomized trials and six nonrandomized trials. All randomized clinical trials analyzed present risks of bias. Morphine has been the most studied strong opioid showing efficacy in alleviating dyspnea when administered, either orally or subcutaneously, in cancer patients. The potential benefit of the strong opioids in the alleviation of dyspnea in cancer patients is modest and limited to some opioids. More studies are needed to sufficiently support the role of opioids in dyspnea at rest, at exertion, and for breakthrough dyspnea and to clarify the safety issues.
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Medication use during end-of-life care in a palliative care centre. Int J Clin Pharm 2015; 37:767-75. [PMID: 25854310 PMCID: PMC4594093 DOI: 10.1007/s11096-015-0094-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 03/04/2015] [Indexed: 11/03/2022]
Abstract
Background In end-of-life care, symptoms of discomfort are mainly managed by drug therapy, the guidelines for which are mainly based on expert opinions. A few papers have inventoried drug prescriptions in palliative care settings, but none has reported the frequency of use in combination with doses and route of administration. Objective To describe doses and routes of administration of the most frequently used drugs at admission and at day of death. Setting Palliative care centre in the Netherlands. Method In this retrospective cohort study, prescription data of deceased patients were extracted from the electronic medical records. Main outcome measure Doses, frequency and route of administration of prescribed drugs Results All regular medication prescriptions of 208 patients, 89 % of whom had advanced cancer, were reviewed. The three most prescribed drugs were morphine, midazolam and haloperidol, to 21, 11 and 23 % of patients at admission, respectively. At the day of death these percentages had increased to 87, 58 and 50 %, respectively. Doses of these three drugs at the day of death were statistically significantly higher than at admission. The oral route of administration was used in 89 % of patients at admission versus subcutaneous in 94 % at the day of death. Conclusions Nearing the end of life, patients in this palliative care centre receive discomfort-relieving drugs mainly via the subcutaneous route. However, most of these drugs are unlicensed for this specific application and guidelines are based on low level of evidence. Thus, there is every reason for more clinical research on drug use in palliative care.
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Abstract
Dyspnea is the most prevalent symptom among patients with cardiac and respiratory diseases. It is an independent predictor of mortality in patients with heart disease, COPD, and the elderly. Studies using naloxone to block opioid-receptor signaling demonstrate that endogenous opioids modulate dyspnea in patients with COPD. Neuroimaging studies support a cortical-limbic network for dyspnea perception. A 2012 American Thoracic Society statement recommended that dyspnea be considered across three different constructs: sensory (intensity), affective (distress), and impact on daily activities. The 2013 GOLD (Global Initiative for Chronic Obstructive Lung Disease) executive summary recommended a treatment paradigm for patients with COPD based on the modified Medical Research Council dyspnea score. The intensity and quality of dyspnea during exercise in patients with COPD is influenced by the time to onset of critical mechanical volume constraints that are ultimately dictated by the magnitude of resting inspiratory capacity. Long-acting bronchodilators, either singly or in combination, provide sustained bronchodilation and lung deflation that contribute to relief of dyspnea in those with COPD. Opioid medications reduce breathing discomfort by decreasing respiratory drive (and associated corollary discharge), altering central perception, and/or decreasing anxiety. For individuals suffering from refractory dyspnea, a low dose of an opioid is recommended initially, and then titrated to achieve the lowest effective dose based on patient ratings. Acupuncture, bronchoscopic volume reduction, and noninvasive open ventilation are experimental approaches shown to ameliorate dyspnea in patients with COPD, but require confirmatory evidence before clinical use.
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Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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Singer AE, Meeker D, Teno JM, Lynn J, Lunney JR, Lorenz KA. Symptom trends in the last year of life from 1998 to 2010: a cohort study. Ann Intern Med 2015; 162:175-83. [PMID: 25643305 PMCID: PMC4346253 DOI: 10.7326/m13-1609] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Calls for improvement in end-of-life care have focused attention on the management of pain and other troubling symptoms at the end of life. OBJECTIVE To describe changes in pain intensity and symptom prevalence during the last year of life from 1998 to 2010. DESIGN Observational study. SETTING The HRS (Health and Retirement Study), a nationally representative longitudinal survey of community-dwelling U.S. residents aged 51 years or older. PARTICIPANTS 7204 HRS participants who died while enrolled in the study and their family respondents. MEASUREMENTS Proxy-reported pain during the last year of life and other symptoms for at least 1 month during the last year of life. Trends in pain intensity and symptom prevalence were analyzed for all decedents and within the categories of sudden death, cancer, congestive heart failure or chronic lung disease, and frailty. RESULTS Between 1998 and 2010, proxy reports of the prevalence of any pain increased for all decedents from 54.3% (95% CI, 51.6% to 57.1%) to 60.8% (CI, 58.2% to 63.4%), an increase of 11.9% (CI, 3.1% to 21.4%). Reported prevalences of depression and periodic confusion also increased for all decedents by 26.6% (CI, 14.5% to 40.1%) and 31.3% (CI, 18.6% to 45.1%), respectively. Individual symptoms increased in prevalence among specific decedent categories, except in cancer, which showed no significant changes. The prevalence of moderate or severe pain did not change among all decedents or in any specific decedent category. LIMITATION Use of proxy reports and limited information about some patient and surrogate variables. CONCLUSION Despite national efforts to improve end-of-life care, proxy reports of pain and other alarming symptoms in the last year of life increased from 1998 to 2010. PRIMARY FUNDING SOURCE National Institute of Nursing Research.
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Affiliation(s)
- Adam E. Singer
- Pardee RAND Graduate School, RAND Corporation, Santa Monica, California
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | | | - Joan M. Teno
- Center for Gerontology and Health Care Research, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Joanne Lynn
- Center for Elder Care and Advanced Illness, Altarum Institute, Washington, DC
| | - June R. Lunney
- Hospice and Palliative Nurses Association, Pittsburgh, Pennsylvania
| | - Karl A. Lorenz
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
- RAND Corporation, Santa Monica, California
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
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Guirimand F, Sahut d'izarn M, Laporte L, Francillard M, Richard JF, Aegerter P. Sequential occurrence of dyspnea at the end of life in palliative care, according to the underlying cancer. Cancer Med 2015; 4:532-9. [PMID: 25644607 PMCID: PMC4402068 DOI: 10.1002/cam4.419] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/22/2014] [Accepted: 12/28/2014] [Indexed: 12/15/2022] Open
Abstract
Dyspnea is a symptom that severely affects the quality of life of terminally ill patients. Its frequency differs considerably between studies. We aimed to characterize the frequency of dyspnea in a palliative care hospital (PCH) and to identify factors predisposing to dyspnea, particularly during the very last days of life, as a function of the underlying disease. Episodes of dyspnea were identified by the computerized extraction of prospectively collected data from the reports of care assistants or from medical observations recorded in the medical files for all stays at our PCH during the last 6 years. There were 6455 hospital stays, 88% ending in the death of the patient; 13,282 episodes of dyspnea were recorded during 2608 hospital stays (40%). Dyspnea was more frequently observed in cases of cancer than in other conditions (RR = 1.30; 95% CI: 1.14–1.48). Pulmonary metastasis increased the risk of dyspnea from 37% to 51% (RR = 1.37; 95% CI: 1.29–1.46). Dyspnea frequency varied with the primary cancer site, from 24% (brain cancer) to 60% (esophageal cancer). The data for cancer patients staying for more than 6 days who subsequently died indicated that 8% of patients experienced dyspnea exclusively during the last 4 days of the life, independently of the site of the primary cancer. Dyspnea during the last few days of life requires systematic assessment. Exclusively terminal dyspnea should be distinguished from more precocious dyspnea, as the pathophysiological mechanisms and treatments of these two forms are probably different.
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Affiliation(s)
- Frédéric Guirimand
- Pôle Recherche SPES ("Soins Palliatifs En Société"), Maison Médicale Jeanne Garnier, Paris, 75015, France
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Pang GS, Qu LM, Tan YY, Yee ACP. Intravenous Fentanyl for Dyspnea at the End of Life: Lessons for Future Research in Dyspnea. Am J Hosp Palliat Care 2014; 33:222-7. [PMID: 25425740 DOI: 10.1177/1049909114559769] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To determine the efficacy of intravenous (IV) Fentanyl in dyspnoeic patients with advanced cancer. METHODS Dyspnoeic patients with advanced cancer satisfying the selection criteria received (IV) Fentanyl and were evaluated for response 24 hours post-administration in a prospective observational study. RESULTS Altogether 36 patients were enrolled into the study. However, data from only 16 patients could be analysed as 20 patients had died or were too sick to self-report scores. Seven out of 16 patients responded to IV Fentanyl although the result was not statistically significant (non-responders versus responders: 56.3% vs 43.8%, p = 0.33). The strongest correlations for variables predictive of responder status were the absence of anxiety and lung metastases. CONCLUSIONS This exploratory study shows that IV Fentanyl can alleviate dyspnea in some patients but is an example of the difficulties conducting dyspnea research. Future studies would benefit from novel developments in the areas of measuring dyspnea in dying patients and statistical analysis of small sample sizes.
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Affiliation(s)
- G S Pang
- Department of Palliative Medicine, National Cancer Centre Singapore, Singapore
| | - L M Qu
- Department of Palliative Medicine, National Cancer Centre Singapore, Singapore
| | - Y Y Tan
- Department of Palliative Medicine, National Cancer Centre Singapore, Singapore
| | - A C P Yee
- Department of Palliative Medicine, National Cancer Centre Singapore, Singapore
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