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Acute Superior Vena Cava Occlusion After Stenting of Tracheoesophageal Fistula. Ann Thorac Surg 2009; 87:1260-2. [DOI: 10.1016/j.athoracsur.2008.08.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 08/16/2008] [Accepted: 08/26/2008] [Indexed: 11/21/2022]
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52
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Zhao I, Yates P. Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review. Palliat Med 2008; 22:693-701. [PMID: 18715967 DOI: 10.1177/0269216308095024] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim is to review the published scientific literature for studies evaluating non-pharmacological interventions for breathlessness management in patients with lung cancer. The following selection criteria were used to systematically search the literature: studies were to be published research or systematic reviews; they were to be published in English and from 1990 to 2007; the targeted populations were adult patients with dyspnoea/breathlessness associated with lung cancer; and the study reported on the outcomes from use of non-pharmacological strategies for breathlessness. This review retrieved five studies that met all inclusion criteria. All the studies reported the benefits of non-pharmacological interventions in improving breathlessness regardless of differences in clinical contexts, components of programmes and methods for delivery. Analysis of the available evidence suggests that tailored instructions delivered by nurses with sufficient training and supervision may have some benefits over other delivery approaches. Based on the results, non-pharmacological interventions are recommended as effective adjunctive strategies in managing breathlessness for patients with lung cancer. In order to refine such interventions, future research should seek to explore the core components of such approaches that are critical to achieving optimal outcomes, the contexts in which the interventions are most effective, and to evaluate the relative benefits of different methods for delivering such interventions.
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Affiliation(s)
- I Zhao
- Institute of Health and Biomedical Innovation, School of Nursing, Queensland University of Technology, Queensland, Australia
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53
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Dy SM, Lorenz KA, Naeim A, Sanati H, Walling A, Asch SM. Evidence-Based Recommendations for Cancer Fatigue, Anorexia, Depression, and Dyspnea. J Clin Oncol 2008; 26:3886-95. [DOI: 10.1200/jco.2007.15.9525] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The experience of patients with cancer often involves symptoms of fatigue, anorexia, depression, and dyspnea. Methods We developed a set of standards through an iterative process of structured literature review and development and refinement of topic areas and standards and subjected recommendations to rating by a multidisciplinary expert panel. Results For fatigue, providers should screen patients at the initial visit, for newly identified advanced cancer, and at chemotherapy visits; assess for depression and insomnia in newly identified fatigue; and follow up after treatment for fatigue or a secondary cause. For anorexia, providers should screen at the initial visit for cancer affecting the oropharynx or gastrointestinal tract or advanced cancer, evaluate for associated symptoms, treat underlying causes, provide nutritional counseling for patients undergoing treatment that may affect nutritional intake, and follow up patients given appetite stimulants. For depression, providers should screen newly diagnosed patients, those started on chemotherapy or radiotherapy, those with newly identified advanced disease, and those expressing a desire for hastened death; document a treatment plan in diagnosed patients; and follow up response after treatment. For general dyspnea, providers should evaluate for causes of new or worsening dyspnea, treat or symptomatically manage underlying causes, follow up to evaluate treatment effectiveness, and offer opioids in advanced cancer when other treatments are unsuccessful. For dyspnea and malignant pleural effusions, providers should offer thoracentesis, follow up after thoracentesis, and offer pleurodesis or a drainage procedure for patients with reaccumulation and dyspnea. Conclusion These standards provide a framework for evidence-based screening, assessment, treatment, and follow-up for cancer-associated symptoms.
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Affiliation(s)
- Sydney M. Dy
- From the Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles; and RAND Health, Santa Monica; and University of California, Irvine, CA
| | - Karl A. Lorenz
- From the Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles; and RAND Health, Santa Monica; and University of California, Irvine, CA
| | - Arash Naeim
- From the Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles; and RAND Health, Santa Monica; and University of California, Irvine, CA
| | - Homayoon Sanati
- From the Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles; and RAND Health, Santa Monica; and University of California, Irvine, CA
| | - Anne Walling
- From the Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles; and RAND Health, Santa Monica; and University of California, Irvine, CA
| | - Steven M. Asch
- From the Johns Hopkins University, Baltimore, MD; Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles; and RAND Health, Santa Monica; and University of California, Irvine, CA
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Abstract
Oncology care has changed markedly in the past decade. With new therapies, patients are experienced in living with life-threatening illness and believe in the abilities of science and the health care system to find new therapies. Changes in the treatment paradigm have altered oncology nursing practice. The integration of newer targeted therapies with their specific side-effect profiles also has changed end-of-life care. Strategies used to manage patients during the active treatment phase of illness can inform and improve nursing practice when active care has been set aside. Evidence-based practice provides a guide to identify, critically appraise, and use evidence to solve clinical problems.
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Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G, Sibbald WJ, Wilfond B, Yankaskas JR. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912-27. [PMID: 18390964 DOI: 10.1164/rccm.200605-587st] [Citation(s) in RCA: 491] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Greillier L, Dutau H, Astoul P. [Specific emergencies in thoracic oncology: pleurisy, superior vena cava syndrome, and tracheobronchial obstruction]. REVUE DE PNEUMOLOGIE CLINIQUE 2008; 64:69-75. [PMID: 18589286 DOI: 10.1016/j.pneumo.2008.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
In patients with lung cancer, the appearance of pleurisy, superior vena cava syndrome, or tracheobronchial obstruction are complications that require specialized care, often in an emergency context. Our objective is to present the different therapeutic options available in each of these three complications and to suggest recommendations on the care to provide in everyday clinical practice.
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Affiliation(s)
- L Greillier
- Pôle Cardiovasculaire et Thoracique, Université de la Méditerranée, Hôpital Sainte-Marguerite, 270 Boulevard Sainte-Marguerite, 13009 Marseille, France
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57
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Bonnichon A, Le Floch H, Rivière F, Staub E, Mairovitz A, Marotel C, Vaylet F, Margery J. [Dyspnea in lung cancer]. REVUE DE PNEUMOLOGIE CLINIQUE 2008; 64:62-68. [PMID: 18589285 DOI: 10.1016/j.pneumo.2008.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Dyspnea is a subjective symptom defined as an experience of uncomfortable and difficult breathing which strongly affects the quality of life. It is the most common symptom in lung cancer but its physiopathology remains unclear. Dyspnea is due to cancer itself, specific therapies or comorbidities. To evaluate intensity of dyspnea, analogue visual and verbal rating scales need to be preferred. Diagnosis of underlying cause, based on rational and non invasive strategy is needed to perform effective treatment if possible. Despite its frequency, few therapies are really effective, except nonpharmacologic measures: only morphine can be actually recommend, especially with naive patients. In palliative cases, if dyspnea is uncontrolled, benzodiazepine can be used and may represent ethic approach.
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Affiliation(s)
- A Bonnichon
- Service des Maladies Respiratoires, Hôpital d'Instruction des Armées Percy, 101 Avenue Henri-Barbusse, 92140 Clamart, France.
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59
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Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer 2008; 98:294-9. [PMID: 18182991 PMCID: PMC2361446 DOI: 10.1038/sj.bjc.6604161] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 11/28/2007] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to determine the efficacy of palliative oxygen for relief of dyspnoea in cancer patients. MEDLINE and EMBASE were searched for randomised controlled trials, comparing oxygen and medical air in cancer patients not qualifying for home oxygen therapy. Abstracts were reviewed and studies were selected using Cochrane methodology. The included studies provided oxygen at rest or during a 6-min walk. The primary outcome was dyspnoea. Standardised mean differences (SMDs) were used to combine scores. Five studies were identified; one was excluded from meta-analysis due to data presentation. Individual patient data were obtained from the authors of the three of the four remaining studies (one each from England, Australia, and the United States). A total of 134 patients were included in the meta-analysis. Oxygen failed to improve dyspnoea in mildly- or non-hypoxaemic cancer patients (SMD=-0.09, 95% confidence interval -0.22 to 0.04; P=0.16). Results were stable to a sensitivity analysis, excluding studies requiring the use of imputed quantities. In this small meta-analysis, oxygen did not provide symptomatic benefit for cancer patients with refractory dyspnoea, who would not normally qualify for home oxygen therapy. Further study of the use of oxygen in this population is warranted given its widespread use.
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Affiliation(s)
- H E Uronis
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Health Services Research and Development, Durham Veteran's Affairs Medical Center, Durham, NC, USA
| | - D C Currow
- Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - D C McCrory
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC, USA
| | - G P Samsa
- Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - A P Abernethy
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia
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60
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The management of dyspnea in cancer patients: a systematic review. Support Care Cancer 2008; 16:329-37. [DOI: 10.1007/s00520-007-0389-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Accepted: 12/05/2007] [Indexed: 10/22/2022]
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61
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Podnos YD, Borneman TR, Koczywas M, Uman G, Ferrell BR. Symptom concerns and resource utilization in patients with lung cancer. J Palliat Med 2007; 10:899-903. [PMID: 17803411 DOI: 10.1089/jpm.2006.0232] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Lung cancer remains a major source of death in the United States. With the aging of the population, health policy makers are challenged to develop systems of care for the complex needs of these patients. This study sought to determine quality of life and symptom concerns in lung cancer patients. The study also sought to determine how supportive care resources were being used to address these concerns. METHODS One hundred consecutive patients with newly diagnosed lung cancer presenting over a 12-month period were selected from the tumor registry. Charts were reviewed for demographic data, treatment history, treatment received, number and type of practitioner encounters, readmissions, and complications for a 6-month period. RESULTS Of the 100 charts retrospectively reviewed, 4 patients had small cell and 96 patients had non-small cell lung cancer. The median age was 67 years. Fifty-three patients were men. The most common symptoms were pain, cough, dyspnea, and fatigue. A total of 114 referrals in 57 patients were made. Nutrition consultation was the most common. CONCLUSIONS This study serves to guide the institution in the development of more effective support services for patients with lung cancer to address quality of life concerns through collaboration between clinicians and researchers.
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Affiliation(s)
- Yale D Podnos
- Department of Surgery, Duke University, Raleigh, North Carolina, USA
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62
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Ostgathe C, Walshe R, Wolf J, Hallek M, Voltz R. A cost calculation model for specialist palliative care for patients with non-small cell lung cancer in a tertiary centre. Support Care Cancer 2007; 16:501-6. [PMID: 17909863 DOI: 10.1007/s00520-007-0337-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Accepted: 09/12/2007] [Indexed: 10/22/2022]
Abstract
GOALS OF WORK Five-year survival of patients with non-small cell lung cancer (NSCLC) is below 15%. Therefore, an early integration of palliative care according to the 2002 WHO definition is indispensable. In this paper, we describe methodical and financial aspects of prospective pricing of palliative care within a concept of integrated care for patients with NSCLC in Germany. MATERIALS AND METHODS Four structures of palliative care services were defined (hospital support, home care, day care and in-patient care). Prospectively, resource use was estimated, using real cost data from the finance department of the University Hospital. Resource use was forecasted on the basis of operating experience, data of the national core documentation of palliative care patients and recommendations from the European Commission. RESULTS Expected average hospital support team services were priced at 483 euros and budgeted for 10% (stage 1) to 90% (stage 4) of patients. Home care (60 visits, 4,573 euros) and day-care (5 visits) services were budgeted for between 5% (stage 1) and 30% (stage 4). The resulting prospective reimbursements range from 393 euros (stage 1) to 2,503 euros (stage 4). In-patient care was excluded from the prospective payments and reimbursed separately. CONCLUSIONS For the first time, global reimbursements covering palliative care hospital support, home care and day care for patients with NSCLC were prospectively calculated and successfully negotiated. The contractual specification of palliative care services may contribute to transparency and quality in cancer care.
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Affiliation(s)
- Christoph Ostgathe
- Department of Palliative Medicine, University of Cologne, Cologne, Germany.
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63
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Grieco CA, Simon CJ, Mayo-Smith WW, Dipetrillo TA, Ready NE, Dupuy DE. Image-guided percutaneous thermal ablation for the palliative treatment of chest wall masses. Am J Clin Oncol 2007; 30:361-7. [PMID: 17762436 DOI: 10.1097/coc.0b013e318033e76a] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To evaluate the palliative benefits of image-guided thermal ablation for the treatment of painful tumors affecting the chest wall. METHODS Thirty-nine patients, median age 65 years, underwent percutaneous thermal ablation of 44 chest wall masses. Thirty-eight radiofrequency ablations (RFAs), 3 microwave ablations (MWAs), and 3 cryoablations were performed. Subjective pain reports at 1 week and 1 month postablation were scored from 0 to 4 based on a standard Likert pain relief scale, with 2 or higher representing clinically significant pain relief. RESULTS Patients were followed for a median of 6 months. Overall, 31 of 44 procedures (70.5%) resulted in significant pain relief. Improvement followed 15 of 15 (100%) of ablations that were performed within 90 days of treatment with palliative external-beam radiation therapy (XRT), compared with 16 of 29 (55.2%) of the remaining procedures. Mean pain relief score at 1 month was 3.86 for the 15 combined procedures versus 1.96 for the 29 remaining procedures (P < 0.001). Local pain recurred after 5 of 31 positive responses (16.1%). Median survival was 11.2 +/- 2.3 months for patients with significant pain relief and 4.3 +/- 1.4 months for nonresponders (P < 0.001). Adverse events included a transient symptom "flare" (n = 5, 11.4%) and the exacerbation of a preexisting brachial plexopathy. CONCLUSIONS Thermal ablation results in significant pain relief for the majority of patients and shows evidence of synergistic benefit when temporally combined with XRT. This minimally invasive technique appears to be a safe and durable alternative for the palliation of chest wall masses.
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Affiliation(s)
- C Alexander Grieco
- Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI 02903, USA
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64
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Abstract
OBJECTIVES To review the current state of evidence for the nursing treatment of cancer-related dyspnea. DATA SOURCES Nursing and medical literature, published guidelines, and Cochrane Systematic reviews. CONCLUSION Limited evidence exists for the current strategies used to treat dyspnea among persons with cancer. IMPLICATIONS FOR NURSING PRACTICE Nurses must be cognizant of the level of evidence or the lack of scientific evidence supporting treatment strategies used. Keeping abreast of the developments in the area of dyspnea management is imperative as research adds to the current body of evidence. Nurses are uniquely positioned to add to the body of evidence through collaboration with nurse researchers.
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65
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Albrand G, Biron E, Boucot I, Couderc LJ, Crestani B, Dombret MC, Guenard H, Grivaux M, Hervy MP, Housset B, Jougon J, Orvoen-Frija E, Piette F, Pignon T, Pinganaud G, Puisieux F, Quoix E, Sauty E, Vaylet F, Wary B, Weill-Engerer S, Westeel V, Wislez M. Cancer bronchique du sujet âgé. Rev Mal Respir 2007; 24:703-23. [PMID: 17632431 DOI: 10.1016/s0761-8425(07)91146-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION In France, the average age for the diagnosis of bronchial carcinoma is 64. It is 76 in the population of over 70. In fact, its incidence increases with age linked intrinsic risk of developing a cancer and with general ageing of the population. Diagnosis tools are the same for elderlies than for younger patients, and positive diagnosis mainly depends on fibreoptic bronchoscopy, complications of which being comparable to those observed in younger patients. STATE OF THE ART The assessment of dissemination has been modified in recent years by the availability of PET scanning which is increasingly becoming the examination of choice for preventing unnecessary surgical intervention, a fortiori in elderly subjects. Cerebral imaging by tomodensitometry and nuclear magnetic resonance should systematically be obtained before proposing chirurgical treatment. An assessment of the general state of health of the elderly subject is an essential step before the therapeutic decision is made. This depends on the concept of geriatric evaluation: Geriatric Multidimensional Assessment, and the Comprehensive Geriatric Assessment which concerns overall competence of the elderly. PERSPECTIVES This is a global approach that allows precise definition and ranking of the patient's problems and their impact on daily life and social environment. Certain geriatric variables (IADL, BADL, MMSE, IMC etc) may be predictive of survival rates after chemotherapy or the incidence of complications following thoracic surgery. The main therapeutic principles for the management of bronchial carcinoma are applicable to the elderly subject; long term survival without relapse after surgical resection is independent of age. Whether the oncological strategy is curative or palliative, the elderly patient with bronchial carcinoma should receive supportive treatments. They should be integrated into a palliative programme if such is the case. In fact, age alone is not a factor that should detract from optimal oncological management. CONCLUSIONS The development of an individual management programme for an elderly patient suffering from bronchial carcinoma should be based on the combination of oncological investigation and comprehensive geriatric assessment.
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Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med 2007; 356:1862-9. [PMID: 17476012 DOI: 10.1056/nejmcp067190] [Citation(s) in RCA: 257] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Lynn D Wilson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06520, USA.
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Tomimoto H, Yano S, Muguruma H, Kakiuchi S, Sone S. Levels of soluble vascular endothelial growth factor receptor 1 are elevated in the exudative pleural effusions. THE JOURNAL OF MEDICAL INVESTIGATION 2007; 54:146-53. [PMID: 17380026 DOI: 10.2152/jmi.54.146] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
PURPOSE Vascular endothelial growth factor (VEGF) plays a critical role in the production of malignant pleural effusions. In the present study, we examined the levels of soluble VEGF receptor-1 (sVEGFR-1) and angiopoietin-2 (Ang-2), as possible regulators of VEGF activity, in transudative and exudative pleural effusions. METHODS Forty-two patients were included in this study: 4 with transudative pleural effusions due to heart failure (HF), 38 with exudative pleural effusions (lung cancer [LC], 22; other malignant diseases [MD], 10; tuberculosis [TB], 6). The levels of VEGF, Ang-2, and sVEGFR-1 in the pleural effusions were measured by an enzyme-linked immunosorbent assay. RESULTS The levels of VEGF, Ang-2, and sVEGFR-1 in exudative effusions were higher than those in transudative effusions. Interestingly, the levels of VEGF and Ang-2 in bloody effusions were significantly higher than those in non-bloody effusions (p < 0.05), but the level of sVEGFR-1 in bloody effusions was lower than that in non-bloody effusions. The levels of VEGF and Ang-2 were significantly higher in the malignant effusions, compared with effusion from HF and TB (p < 0.05). In addition, sVEGFR-1 was significantly higher in the effusion from LC, MD, and TB compared with effusion from HF (p < 0.05). In the malignant effusions, direct correlations were observed among VEGF, sVEGFR-1, and Ang-2. CONCLUSIONS The sVEGFR-1 levels were elevated in exudative pleural effusions, and were lower in bloody effusions than in non-bloody effusions, thus suggesting the regulatory role of sVEGFR-1 in the exudative pleural effusions.
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Affiliation(s)
- Hideki Tomimoto
- Department of Internal Medicine and Molecular Therapeutics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
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68
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Liss D. Getting what we pay for. Chest 2007; 131:338-9. [PMID: 17296629 DOI: 10.1378/chest.06-2612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Skaug K, Eide GE, Gulsvik A. Prevalence and Predictors of Symptoms in the Terminal Stage of Lung Cancer. Chest 2007; 131:389-94. [PMID: 17296638 DOI: 10.1378/chest.06-1233] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is little knowledge concerning the prevalence and predictors of symptoms in the terminal stage of lung cancer. METHODS We examined, retrospectively, all cases of lung cancer diagnosed from 1990 to 1996 in a defined hospital area in Norway. All medical records from general practitioners, nursing homes, and hospitals were investigated. A total of 271 cases were diagnosed, and 247 of 253 deaths (98%) were analyzed. RESULTS In the terminal 8 weeks, pain was recorded in 85% of the patients, psychological symptoms (anxiety, insomnia, and/or depression) in 71%, dyspnea in 54%, neurologic symptoms in 28%, cough in 24%, nausea in 21%, and hemoptysis in 9%. Young age (p = 0.02) and small cell lung carcinoma (p = 0.03) were risk factors for psychological symptoms. Terminal dyspnea was more frequent in patients with stage III (p = 0.002) and nausea in stage IV (p = 0.02) at the time of diagnosis, while cough (p = 0.04) occurred more often in non-small cell lung carcinoma. Terminal pain was independent of gender, age, performance status, stage, and histology. CONCLUSION In a community health service encompassing all lung cancer patients, pain, psychological symptoms, and dyspnea were frequent complaints in the terminal phase. Terminal dyspnea and nausea were associated with staging at the time of diagnosis, and terminal cough and nausea were associated with histology.
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Affiliation(s)
- Knut Skaug
- Department of Medicine, Haugesund Hospital, Health Region of Fonna, PO Box 2170, N-5104 Haugesund, Norway.
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70
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Painful Disorders of the Respiratory System. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50079-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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71
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Cuéllar Raya MDP, Andreo F, Monsó Molas E. [Migration of an esophageal stent to the trachea]. Arch Bronconeumol 2006; 42:560. [PMID: 17067525 DOI: 10.1016/s1579-2129(06)60585-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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72
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73
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del Pilar Cuéllar Raya M, Andreo F, Monsó Molas E. Migración de una prótesis esofágica a la tráquea. Arch Bronconeumol 2006. [DOI: 10.1157/13093401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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74
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Goldman A, Hewitt M, Collins GS, Childs M, Hain R. Symptoms in children/young people with progressive malignant disease: United Kingdom Children's Cancer Study Group/Paediatric Oncology Nurses Forum survey. Pediatrics 2006; 117:e1179-86. [PMID: 16740818 DOI: 10.1542/peds.2005-0683] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
AIM The purpose of this study was to survey symptoms in children/young people with progressive cancer and identify which are the most important and which are the most difficult to treat effectively. PATIENTS AND METHODS This was a questionnaire survey of 22 United Kingdom Children's Cancer Study Group centers. Data were collected by clinical nurse specialists in pediatric oncology regarding children/young people between 0 and 20 years of age, using 2 questionnaires. The first collected demographic details and the second data about the occurrence and perceived impact of symptoms. RESULTS There were 185 children/young people from 20 centers registered in the study, aged 4 months to 19 years (mean: 8.7 years), who received palliative care for a median of 34 days (range: 0-354 days). Data were analyzed for 164 children/young people who died during the study. Between referral to palliative care and death, there were significant increases in the number of symptoms reported and children/young people experiencing pain (70.6% vs 91.5%). Symptoms included some that often go unrecognized in children/young people, for example, anorexia, weight loss, and weakness. The nature of the underlying malignancy significantly influenced the prevalence of some symptoms. There were significant differences between the symptoms associated with central nervous system tumors and other groups. Pain other than headache occurred more commonly in children with solid tumors (98.4%) than in others (87%). Neurologic symptoms, including headache, were universal among those with central nervous system tumors. CONCLUSION This study documents the frequency of symptoms and contrasts the experiences of children/young people with different groups of malignant disease. With access to skilled symptom control, pain can be effectively treated in most children/young people. Some other symptoms often remain intractable. The study highlights the need for further research to establish the effectiveness of therapeutic interventions for symptom control and their impact on the quality of life for children/young people dying from cancer.
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Affiliation(s)
- Ann Goldman
- Symptom Care Team, Great Ormond Street Hospital, London, United Kingdom
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75
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Sawhney MS, Kratzke RA, Lederle FA, Holmstrom AM, Nelson DB, Kelly RF. EUS-guided FNA for the diagnosis of advanced lung cancer. Gastrointest Endosc 2006; 63:959-65. [PMID: 16733110 DOI: 10.1016/j.gie.2005.11.061] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Accepted: 11/08/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND A majority of patients with lung cancer are incurable but are symptomatic and may benefit from palliative therapy. Currently available diagnostic methods are either too risky or unsuccessful in obtaining a tissue diagnosis in up to 30% of patients. OBJECTIVE To evaluate the role of EUS-guided FNA in obtaining a tissue diagnosis in patients with advanced lung cancer. DESIGN Prospective, uncontrolled. SETTING Veterans Administration Medical Center. SUBJECTS AND METHODS Patients with suspected lung cancer who were not candidates for curative therapy were prospectively identified. CT scans were reviewed, and patients with lesions considered suitable for sampling by EUS were enrolled. Outcomes were analyzed by a final tissue diagnosis or by serial imaging. RESULTS Sixty-nine patients met inclusion criteria, of which 3 refused participation. The remaining 66 patients constituted the study population. EUS was technically successful in 95% of patients. A final diagnosis was based on tissue in 63 of 66 patients, serial imaging in 1 of 66 patients, and was unavailable in 2 of 66 patients. A lung mass was sampled in 21 patients, and a metastatic lesion was sampled in 45 patients. EUS made a correct diagnosis in 55 of 64 patients (86%, 95% confidence interval [CI] 77%-93%), including 24% that had undergone a failed prior attempt at diagnosis. The sensitivity of EUS was 86%, and the specificity was 100%. Sampling a metastasis was more likely to yield a correct diagnosis than sampling a lung mass (P = .02). Two self-limited complications were noted during the study. CONCLUSIONS EUS was an accurate and a safe method for obtaining a tissue diagnosis in patients with advanced incurable lung cancer.
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Affiliation(s)
- Mandeep S Sawhney
- Section of Gastroenterology, Center for Epidemiological and Clinical Research, Minneapolis VA Medical Center, One Veterans Drive, Minneapolis, MN 55417, USA
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Sasaki T, Yasuda H, Nakayama K, Asada M, Okinaga S, Suzuki T, Yoshida M, Yamanda S, Yamaya M. Pleurodesis with carboplatin in elderly patients with malignant pleural effusion and lung adenocarcinoma. J Am Geriatr Soc 2006; 54:722-3. [PMID: 16686896 DOI: 10.1111/j.1532-5415.2006.00668_9.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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78
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Abstract
Dyspnea is a common symptom at the end of life. It occurs as the result of a complex mix of physical, biochemical, and perceptual components. When patients and their healthcare providers focus on the "numbers" related to oxygenation, rather than comfort, the individual's quality of life can suffer.
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79
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Abstract
Microwave ablation is the most recent development in the field of tumor ablation. The technique allows for flexible approaches to treatment, including percutaneous, laparoscopic, and open surgical access. With imaging guidance, the tumor is localized, and a thin (14.5-gauge) microwave antenna is placed directly into the tumor. A microwave generator emits an electromagnetic wave through the exposed, noninsulated portion of the antenna. Electromagnetic microwaves agitate water molecules in the surrounding tissue, producing friction and heat, thus inducing cellular death via coagulation necrosis. The main advantages of microwave technology, when compared with existing thermoablative technologies, include consistently higher intratumoral temperatures, larger tumor ablation volumes, faster ablation times, and an improved convection profile. Microwave ablation has promising potential in the treatment of primary and secondary liver disease, primary and secondary lung malignancies, renal and adrenal tumors, and bone metastases. The technology is still in its infancy, and future developments and clinical implementation will help improve the care of patients with cancer.
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Affiliation(s)
- Caroline J Simon
- Department of Diagnostic Imaging, Brown Medical School, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903, USA
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80
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Abstract
Lung cancer is the leading cause of cancer-related mortality in the USA. Until recently, lung cancer treatment options (dependent upon the tumor grading and staging at presentation, and patient comorbidities) included surgical resection (lobar or sublobar), chemotherapy and external-beam radiation therapy. While these options are still viewed as the primary standard of care, newer minimally invasive percutaneous ablative techniques such as radiofrequency ablation, microwave ablation and cryoablation are currently being examined as treatment alternatives, especially in the setting of the nonsurgical candidate. This review will focus on these three distinct thermoablative techniques in the percutaneous setting of lung cancer treatment.
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Affiliation(s)
- Caroline J Simon
- Department of Diagnostic Imaging, Brown Medical School, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.
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81
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Abstract
UNLABELLED GOALS/OBJECTIVES: To review the scientific evidence on cough associated with tumors in the lungs. METHODS MEDLINE literature review (through March 2004) for all studies published in the English language, including case series and case reports, since 1966 using the medical subject heading terms "cough" and "lung neoplasms." RESULTS Primary bronchogenic carcinoma is the most common lethal neoplasm in the United States. Malignancies that arise in other organs will often metastasize to the lungs. Any form of cancer involving the lungs may be associated with cough. However, cough is far more likely to indicate involvement of the airways than the lung parenchyma because of the location of cough receptors. Cough is present in >65% of patients at the time lung cancer is diagnosed, and productive cough is present in >25% of patients. While cough as a presenting symptom of lung cancer is common, many studies have shown that lung cancer is the cause of chronic cough in <or=2% of all patients who present with a chronic cough. CONCLUSIONS Bronchoscopy is usually indicated when there is suspicion of airway involvement by a malignancy. Conversely, bronchoscopy usually should not be performed to assess a cough for the possibility of lung cancer when there is little risk for lung cancer (nonsmokers) and when there are normal findings on a plain chest radiograph. If the lung cancer can be removed surgically, cough will usually abate. Radiation therapy, chemotherapy (especially with gemcitabine), and endobronchial treatment methods likely will improve cough caused by lung cancer. Centrally acting narcotic antitussive agents are usually administered for the control of cough caused by lung cancer when other treatment methods fail.
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82
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Abstract
OBJECTIVES To discuss the evidence-based practice process for palliative care, from defining a clinical problem to implementation and evaluation of an evidence-based practice change. DATA SOURCES Professional experience, literature, practice guidelines, and web sites related to evidence-based practice and palliative care. CONCLUSION Nurses caring for patients needing palliative care need evidence from multiple sources. Using a systematic process to find and appraise evidence followed by strategically planning for implementation and evaluation of evidence-based practice changes optimizes the likelihood of enhanced patient care. IMPLICATIONS FOR NURSING PRACTICE The integration of evidence-based practices into palliative care nursing will empower nurses to promote optimal patient outcomes and decrease practice variability.
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83
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Ratsimanohatra H, Barlesi F, Doddoli C, Robitail S, Gimenez C, Kleisbauer JP, Astoul P. 153Samarium-EDTMP et contrôle de la douleur liée aux métastases osseuses des cancers bronchiques. Rev Mal Respir 2005; 22:317-20. [PMID: 16092169 DOI: 10.1016/s0761-8425(05)85484-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The treatment of bone metastasis from lung cancer is palliative in nature with elimination of pain being the primary goal. Management is based on pharmacologicalmethods (steroids, morphine, and pamidronate) and radiotherapy. However, other treatments have been developed including the systemic radiopharmaceutical 153Sm-EDTMP. CASE REPORTS We report data from 6 lung cancer patients with bone metastases treated with 153Sm-EDTMP. Demographic and therapeutic data, pain evaluation by visual analogue scale (VAS) and change in opioid analgesia requirements (expressed as intravenous morphine equivalent) as well as survival were studied. Pain associated with bone metastasis (median VAS = 8 [7-9], median morphine dose = 167 mg [100-800 mg]) did not significantly improve (median VAS after 153Sm-EDTMP = 8.5 [5-10], median morphine dose after 153Sm-EDTMP = 185 mg [30-2 200 mg]) in this group of patients. CONCLUSION Our results combined with current data in the literature concerning the use of this treatment in the treatment of bone pain associated with metastatic lung cancer suggest that at present its use cannot be recommended outside the context of clinical of clinical trials.
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Affiliation(s)
- H Ratsimanohatra
- Service des Maladies Respiratoires, Hôpital Général de Befelatanana, CHU Antananarivo, Madagascar
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84
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Gandhi NS, Dupuy DE. Image-guided radiofrequency ablation as a new treatment option for patients with lung cancer. Semin Roentgenol 2005; 40:171-81. [PMID: 15898413 DOI: 10.1053/j.ro.2005.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Namita S Gandhi
- Department of Diagnostic Imaging, Brown Medical School, Rhode Island Hospital, Providence, RI, USA
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85
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Abstract
Lung cancer often is associated with significant morbidity, which has a detrimental effect on quality of life. Supportive care plays a central role in the multimodal treatment of lung cancer. Palliation of symptoms often improves quality of life and compliance with therapy. New developments in supportive care, reviewed here, include management of symptoms of the disease, such as respiratory problems, pain, and cachexia, as well as effects of treatment, including chemotherapy-induced nausea and vomiting, neutropenia, anemia, and mucositis. In the past few years, significant advances have been made in this field; however, palliation of the symptoms of lung cancer remains an area of active investigation.
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Affiliation(s)
- Michelle Boyar
- Department of Medicine, Columbia University Medical Center, 177 Fort Washington Avenue, MHB6-435, New York, NY 10032, USA
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86
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Abernethy AP, Currow DC, Frith P, Fazekas B. Prescribing palliative oxygen: a clinician survey of expected benefit and patterns of use. Palliat Med 2005; 19:168-70. [PMID: 15810762 DOI: 10.1177/026921630501900219] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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87
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Lung: Ablative Therapy. J Vasc Interv Radiol 2005. [DOI: 10.1016/s1051-0443(05)70028-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
OBJECTIVES To review the four sets of symptom clusters commonly seen in patients with advanced illness, and their definitions, associated symptomatology, and management. DATA SOURCES Research and review articles and textbooks. CONCLUSION Symptoms of patients with advanced illness tend to occur not isolation, but in symptom clusters. The ability to cluster symptoms in both assessment and management reduces the use of polypharmacy, systemic toxicities, and improves the patient's quality of life. IMPLICATIONS FOR NURSING PRACTICE It is important that the nurse providing symptom management for the oncology patient understand the importance of clustering certain symptoms together.
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Affiliation(s)
- Peg Esper
- University of Michigan Comprehensive Cancer Center, Ann Arbor, USA.
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89
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Abstract
Bleeding occurs in up to 10% of patients with advanced cancer. It can present in many different ways. This article provides a qualitative review of treatment options available to manage visible bleeding. Local modalities, such as hemostatic agents and dressings, radiotherapy, endoscopic ligation and coagulation, and transcutaneous arterial embolization, are reviewed in the context of advanced cancer, as are systemic treatments such as vitamin K, vasopressin/desmopressin, octreotide/somatostatin, antifibrinolytic agents (tranexamic acid and aminocaproic acid), and blood products. Considerations at the end of life are described.
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Affiliation(s)
- Jose Pereira
- Department of Oncology, University of Calgary, Palliative Care Office, Room 710, South Tower, Foothills Medical Centre, 1403-29th Avenue NW, Calgary, Alberta, T2N 2T9, Canada.
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90
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Affiliation(s)
- Sam H Ahmedzai
- Academic Palliative Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
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91
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Gralla RJ. Quality‐of‐Life Considerations in Patients with Advanced Lung Cancer: Effect of Topotecan on Symptom Palliation and Quality of Life. Oncologist 2004; 9 Suppl 6:14-24. [PMID: 15616146 DOI: 10.1634/theoncologist.9-90006-14] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Key goals in the treatment of lung cancer are to improve both survival and quality of life (QOL). While formal techniques are frequently used to evaluate survival and response, such rigor is used less often in assessing the impact of treatment on quality of life. Many patients with lung cancer are elderly and have complex medical histories and a myriad of comorbidities. In these patients, with limited survival expectations, symptom palliation, quality of life, and convenience of therapy are especially important end points. Indeed, clinical trials are now incorporating symptom scores and QOL outcomes in their designs (now combined as "patient reported outcomes" or PROs). Moreover, symptom palliation correlates well with QOL and survival duration, providing further rationale for therapy selection based on these parameters. The potential palliative and QOL benefits of chemotherapy have been investigated for several agents in lung cancer trials. Of these, topotecan (Hycamtin; GlaxoSmithKline; Philadelphia, PA) is the best characterized in relapsed small cell lung cancer (SCLC). In a phase III trial of topotecan versus cyclophosphamide, doxorubicin (Adriamycin; Bedford Laboratories; Bedford, OH), and vincristine (Oncovin; Eli Lilly and Company; Indianapolis, IN) (CAV) in patients with recurrent SCLC, topotecan was associated with statistically significant (p < 0.05) improvements in general symptoms (e.g., fatigue and interference with daily activity) and disease-specific symptoms (e.g., dyspnea and hoarseness). Moreover, the introduction of oral therapies, such as oral topotecan, may increase the convenience of therapy by reducing the time needed for therapy and the need for frequent venipuncture. This review summarizes the role of chemotherapy in symptom palliation, with an emphasis on the impact of topotecan therapy on symptom parameters in patients with relapsed SCLC and the emerging role of oral therapy in this setting.
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Affiliation(s)
- Richard J Gralla
- New York Lung Cancer Alliance, 459 Columbus Avenue (PMB-187), New York, New York 10024-5129, USA.
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Dutau H, Toutblanc B, Lamb C, Seijo L. Use of the Dumon Y-stent in the management of malignant disease involving the carina: a retrospective review of 86 patients. Chest 2004; 126:951-8. [PMID: 15364778 DOI: 10.1378/chest.126.3.951] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To study the efficacy of symptom relief and the safety of the Dumon Y-stent for central airway obstruction in malignant main carinal involvement and in malignant tracheoesophageal fistulas. DESIGN A retrospective review. SETTING Thoracic endoscopy referral center. PATIENTS AND METHODS The medical records of 86 patients who had undergone the placement of a Dumon Y-stent at our institution were reviewed and analyzed. RESULTS Ninety Dumon Y-stents were placed in 86 patients to relieve symptoms of dyspnea, cough, and/or hemoptysis. Four of these patients required removal of that stent and replacement with a longer Dumon Y-stent due to tumor progression. There were only two instances of procedure-related adverse effects, which included coughing following stent placement lasting 1 week in one patient and stent migration in another patient. In the case of stent migration, the stent required immediate removal, and the patient experienced no adverse consequences. The remaining patients tolerated the stent well, and all experienced subjective symptomatic relief. There were no stent-related deaths. The average duration of a stent after placement was 133 days. The median time of survival following stent insertion was 181 days. Forty-five percent of all patients died at 3 months, and 72% died at 6 months. CONCLUSION The Dumon Y-stent proved to be useful and was well-tolerated in the management of malignant disease involving the main carina. It also provided successful palliation in patients with malignant tracheoesophageal fistulas.
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Affiliation(s)
- Hervé Dutau
- Thoracic Endoscopy Center, Hôpital Sainte Marguerite, 270 Blvd de Sainte Marguerite, 13009 Marseille, France.
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Poon ANY, Ho SSM, Yeo W, Mok TSK. Brain Metastasis Responding to Gefitinib Alone. Oncology 2004; 67:174-8. [PMID: 15539923 DOI: 10.1159/000081005] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2003] [Accepted: 02/18/2004] [Indexed: 11/19/2022]
Abstract
A woman with stage IIIb non-small cell lung cancer (NSCLC) developed disease progression with brain metastases during chemotherapy. Due to unusual circumstances, the patient received gefitinib alone, without the use of corticosteroid treatment or radiotherapy. There was a dramatic clinical improvement within 1 week. Follow-up magnetic resonance imaging of the brain 1 month later showed decreases in both the size and number of brain metastases. The patient remains well 9 months after initiation of gefitinib. It is proposed that gefitinib may have a role in treatment of brain metastases from NSCLC.
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Affiliation(s)
- Annette N Y Poon
- Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong, China
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94
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Abstract
Primary and metastatic thoracic malignancies are often incurable. Surgeons caring for these patients must be familiar with the options,indications, techniques, and limitations of interventions for palliative treatments in these patients. This article is an overview of the current practices for palliation of a broad spectrum of complaints relating to patients with carcinomas of the lung, esophagus,and mesothelium. The information can be used for treatment of patients with complaints secondary to less common malignancies and metastatic disease of the thorax.
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Affiliation(s)
- Adam Berger
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111, USA
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