The relationship between dyspnea and patient satisfaction with quality of life in advanced cancer

Long-Term Clinical, Radiological, and Mortality Outcomes Following Pneumonitis in Nonsmall Cell Lung Cancer Patients Receiving Immune Checkpoint Inhibitors: A Retrospective Analysis

AIMS

Despite known short-term mortality risk of immune checkpoint inhibitor (ICI) pneumonitis, its impact on 1-year mortality, long-term pulmonary function, symptom persistence, and radiological resolution remains unclear.

METHODS

We retrospectively analyzed 71 nonsmall cell lung cancer (NSCLC) patients treated with anti-PD(L)1 monoclonal antibodies between 2018-2021, who developed pneumonitis. Clinical and demographic covariates were collected from electronic medical record. Cox regression assessed associations with mortality, while logistic regression evaluated associations with persistent symptoms, hypoxemia, and radiological resolution.

RESULTS

Steroid-refractory pneumonitis (hazard ratio [HR] = 15.1, 95% confidence interval [95% CI]:3.9-57.8, P < .0001) was associated with higher 1-year mortality compared to steroid-responsive cases. However, steroid-resistant (odds ratio [OR] = 1.4, 95% CI: 0.4-5.1, P = .58) and steroid-dependent (OR = 0.4, 95% CI: 0.1-1.2, P = .08) pneumonitis were not. Nonadenocarcinoma histology (OR = 6.7, 95% CI: 1.6-46.6, P = .01), grade 3+ pneumonitis (OR = 4.6, 95% CI: 1.3-22.7, P = .03), and partial radiological resolution (OR = 6.3, 95% CI: 1.8-23.8, P = .004) were linked to increased pulmonary symptoms after pneumonitis resolution. Grade 3+ pneumonitis (OR = 8.1, 95% CI: 2.3-31.5, P = .001) and partial radiological resolution (OR = 5.45, 95% CI: 1.29-37.7, P = .03) associated with residual hypoxemia. Nonadenocarcinoma histology (OR = 3.6, 95% CI: 1.01-17.6, P = .06) and pretreatment ILAs (OR = 4.8, 95% CI: 1.14-33.09, P = .05) were associated with partial radiological resolution.

CONCLUSIONS

Steroid refractory pneumonitis increases 1-year mortality in NSCLC patients. Pretreatment ILAs may signal predisposition to fibrosis-related outcomes, seen as partial resolution, which in turn is associated with postresolution symptoms and residual hypoxemia. These findings offer insights for identifying patients at risk of adverse outcomes post-pneumonitis resolution.

Relationship between dyspnoea and related factors in patients with cancer: a cross-sectional study

OBJECTIVES

Dyspnoea is a common and distressing symptom in patients with cancer. We aimed to analyse the association between dyspnoea and related factors and to estimate their causal relationship.

METHODS

A cross-sectional study was conducted. Patients with cancer with dyspnoea and a mean Numerical Rating Scale (NRS) of ≥3 over 24 hours were enrolled at 10 institutions in Japan from December 2019 to February 2021. The outcomes included dyspnoea, cough and pain NRS over 24 hours, Eastern Cooperative Oncology Group Performance Status, Hospital Anxiety and Depression Scale, Somatosensory Amplification Scale, opioids for dyspnoea and respiratory failure. Path analyses were conducted to estimate the direct and indirect paths with reference to dyspnoea and related factors.

RESULTS

A total of 209 patients were enrolled and 208 patients were included in the analysis. Cough worsened dyspnoea (β=0.136), dyspnoea increased emotional distress (β=1.104), emotional distress increased somatosensory amplification (β=0.249) and somatosensory amplification worsened cough (β=0.053) according to path analysis.

CONCLUSION

There may be a vicious circle among dyspnoea and related factors: cough worsened dyspnoea, dyspnoea increased emotional distress, emotional distress increased somatosensory amplification and somatosensory amplification worsened cough. When treating dyspnoea in patients with cancer, managing these factors aimed at interrupting this vicious circle may be useful.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trials Registry (UMIN000038820).

Effect of heated humidified high-flow nasal cannula (HFNC) oxygen therapy in dyspnea patients with advanced cancer, a randomized controlled clinical trial

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), S_pO₂, P_aO₂, and P_aCO₂, 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). P_aO₂ and RR were statistically changed 2 h after HFNC treatment (P < 0.001). P_aCO₂ 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.

Italian Version of Cancer Dyspnea Scale: Cultural-Linguistic and Clinical Validation in Patients With Advanced Cancer Disease in Palliative Care Settings

CONTEXT

The Cancer Dyspnea Scale (CDS) is a self-reported multidimensional tool used for the assessment of dyspnea, a subjective experience of breathing discomfort, in patients with cancer. The scale describes dyspnea using three distinct factors: physical, psychological, and discomfort at rest.

OBJECTIVES

To crossculturally validate the Italian version of CDS (CDS-IT) and examine its content validity, feasibility, internal consistency, and construct validity in patients with advanced cancer.

METHODS

A cross-sectional study was conducted. CDS-IT was forward-backward translated, and its content was validated among a group of experts. Cronbach's α coefficients were used to assess the internal consistency. Construct validity was examined in terms of structural validity through confirmatory factor analysis, and convergent validity was examined with Visual Analogue Scale Dyspnea through the Pearson's correlation coefficient (r). Cancer Quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care) and Italian Palliative Outcome Scale were also tested.

RESULTS

The CDS-IT was crossculturally validated and showed satisfactory content validity. A total of 101 patients (mean age = 76 [SD = 12]; 53% females) were recruited in palliative care settings. CDS-IT reported a good internal consistency in the total score and its factors (α = 0.74-0.83). The factor analysis corresponded acceptably but not completely with the original study. CDS-IT strongly correlated with Visual Analogue Scale Dyspnea (r = 0.68) and moderately with Italian Palliative Outcome Scale and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative Care (r = 0.33-0.36, respectively).

CONCLUSION

The study findings supported the crosscultural validity of the CDS-IT. Its feasibility, internal consistency, and construct validity are satisfactory for clinical practice. The CDS-IT is available to health care professionals as a useful tool to assess dyspnea in patients with cancer.

Effects of Oral Morphine on Dyspnea in Patients with Cancer: Response Rate, Predictive Factors, and Clinically Meaningful Change (CJLSG1101)

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.

Prevalence and Intensity of Dyspnea in Advanced Cancer and its Impact on Quality of Life

CONTEXT

Dyspnea is a subjective, multidimensional experience of breathing discomfort, commonly seen in patients with advanced cancer. To find the impact of dyspnea on the quality of life in this population, it is important to understand the prevalence and factors influencing dyspnea.

AIMS

This study aimed to determine the prevalence, intensity, and factors influencing dyspnea in advanced cancer and determine its impact on overall quality of life.

SETTINGS AND DESIGN

This was a prospective cross-sectional study. The prevalence of dyspnea and its impact on quality of life was determined in 500 patients registered with palliative medicine outpatient department.

SUBJECTS AND METHODS

The patients were asked to fill a set of questionnaires, which included the Cancer Dyspnea Scale (translated and validated Hindi and Marathi versions), visual analog scale for dyspnea and EORTC QLQ C 15 PAL. Details of demographics, symptomatology, and medical data were collected from the case record sheets of the patients.

STATISTICAL ANALYSIS USED

Descriptive statistics, univariate, and multiple regression analysis were used to calculate the results.

RESULTS

About 44.37% of the patients experienced dyspnea. Dyspnea increased with worsening anxiety, depression, fatigue, appetite, well-being, pain, lung involvement by primary or metastatic cancer, performance status, and deteriorating overall quality of life and emotional wellbeing.

CONCLUSIONS

The prevalence of dyspnea in advanced cancer patients is as high as 44.37% and has a negative impact on their overall quality of life.

Validation of "Cancer Dyspnea Scale" in Patients With Advanced Cancer in a Palliative Care Setting in India

CONTEXT

Assessment of dyspnea in patients with advanced cancer is challenging. Cancer Dyspnea Scale (CDS) is a multidimensional scale developed for the measurement of dyspnea. It is available only in Japanese, English, and Swedish and has not been validated before in the Indian languages.

OBJECTIVE

The objective was to describe the process of validation and reliability testing of CDS in Indian advanced cancer patients.

METHODS

This is a prospective observational study conducted in the palliative care clinic of a tertiary cancer center in Mumbai. The English version of CDS was translated into Indian languages-Hindi (CDS-H) and Marathi (CDS-M). One hundred twenty newly registered eligible patients (60 for CDS-H and 60 for CDS-M) were enrolled into the study consecutively. They were asked to fill CDS (translated version) and Visual Analogue Scale for dyspnea. Only baseline measures were used.

RESULTS

Validity was separately analyzed for CDS-H and CDS-M. The results showed good construct validity between CDS-H and CDS-M. Intersubscale correlation was done by calculating the Pearson's correlation coefficient (mean r = 0.64 and 0.764 for CDS-H and CDS-M, respectively). Convergent validity was calculated by computing the correlation of each factor with VAS-D scores and was found statistically significant (P < 0.001; average r ranging from 0.706 to 0.714). Reliability of the scale was determined by its internal consistency (Cronbach's alpha coefficient ranging from 0.716 to 0.879).

CONCLUSION

This study demonstrates that CDS-H and CDS-M are valid and reliable multidimensional scales, which can be used to assess dyspnea in patients with advanced cancer.

Palliative Care in Lung Cancer

Lung cancer is the most common cancer worldwide and is the leading cause of cancer death for both men and women in the USA. Symptom burden in patients with advanced lung cancer is very high and has a negative impact on their quality of life (QOL). Palliative care with its focus on the management of symptoms and addressing physical, psychosocial, spiritual, and existential suffering, as well as medically appropriate goal setting and open communication with patients and families, significantly adds to the quality of care received by advanced lung cancer patients. The Provisional Clinical Opinion (PCO) of American Society of Clinical Oncology (ASCO) as well as the National Cancer Care Network's (NCCN) clinical practice guidelines recommends early integration of palliative care into routine cancer care. In this chapter, we will provide an overview of palliative care in lung cancer and will examine the evidence and recommendations with regard to a comprehensive and interdisciplinary approach to symptom management, as well as discussions of goals of care, advance care planning, and care preferences.

Intensive symptom control of opioid-refractory dyspnea in congestive heart failure: Role of milrinone in the palliative care unit

OBJECTIVE

We describe an exemplary case of congestive heart failure (CHF) symptoms controlled with milrinone. We also analyze the benefits and risks of milrinone administration in an unmonitored setting.

METHOD

We describe the case of a patient with refractory leukemia and end-stage CHF who developed severe dyspnea after discontinuation of milrinone. At that point, despite starting opioids, she had been severely dyspneic and anxious, requiring admission to the palliative care unit (PCU) for symptom control. After negotiation with hospital administrators, milrinone was administered in an unmonitored setting such as the PCU. A multidisciplinary team approach was also provided.

RESULTS

Milrinone produced a dramatic improvement in the patient's symptom scores and performance status. The patient was eventually discharged to home hospice on a milrinone infusion with excellent symptom control.

SIGNIFICANCE OF RESULTS

This case suggests that milrinone may be of benefit for short-term inpatient administration for dyspnea management, even in unmonitored settings and consequently during hospice in do-not-resuscitate (DNR) patients. This strategy may reduce costs and readmissions to the hospital related to end-stage CHF.

Sequential occurrence of dyspnea at the end of life in palliative care, according to the underlying cancer

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.

Comparison of the quality of life among persons with lung cancer, before and after the chemotherapy treatment

OBJECTIVE

this prospective study aimed to assess the quality of life related to health (QLRH) of patients with lung cancer after chemotherapy treatment.

METHOD

The QLRH was assessed using the questionnaires Quality-of-Life Questionnaire-Core 30 (QLQ-C30) and Lung Cancer Module (LC13), version 3.0.

RESULTS

the sample was made up of 11 women and 19 men, with an average age of 68 years (51-87 years). After the chemotherapy treatment, the authors observed a clinically-relevant improvement in general quality of life, as well as in the symptoms of dyspnea, insomnia, hemoptysis, cough, thoracic pain, pain in the arm/shoulder, and financial difficulty. There was a worsening on the functional scale which assesses role performance and symptoms of fatigue, nausea and vomiting, sensory neuropathy, pain in other parts, constipation, loss of appetite and alopecia.

CONCLUSION

although the patients have an improvement of their QLRH and symptoms related to the lung cancer after the chemotherapy treatment, there was a worsening of the symptoms which resulted from the toxicity of the chemotherapy medications.

Satisfaction with care among low-income women with breast cancer

BACKGROUND

Patient satisfaction is an important outcome measure in determining quality of care. There are few data evaluating patient satisfaction in nonwhite, low-income populations. The objective of this study was to identify the structure, process, and outcome factors that impact patient satisfaction with care in a low-income population of women with breast cancer.

METHODS

In a cross-sectional survey of low-income women newly diagnosed with breast cancer, eligible women enrolled in the California Breast and Cervical Cancer Treatment Program (BCCTP) from February 2003 through September 2005 were interviewed by phone 6 months after their enrollment. This was a population-based sample of women aged >or=18 years (n = 924) with a definitive diagnosis of breast cancer and enrolled in the BCCTP. The main outcome measure was satisfaction with care received.

RESULTS

Random effects logistic regression revealed that less acculturated Latinas were more likely (odds ratio, [OR] = 5.36, p < 0.000) to be extremely satisfied with their care compared with non-Hispanic white women. Women who believed they could have been diagnosed sooner were less likely to be extremely satisfied (OR = 0.61, p < 0.000). Women who had received or were receiving radiotherapy or chemotherapy had nearly twice the odds of being extremely satisfied (OR = 2.02, p < 0.000, and OR = 2.13, p < 0.000, respectively). Greater information giving was associated with greater satisfaction (OR = 1.17, p < 0.000). Women reporting greater physician emotional support were more likely to report being extremely satisfied (OR = 1.26, p < 0.000). A higher participatory treatment decision-making score was associated with greater satisfaction (OR = 1.78, p < 0.000).

CONCLUSIONS

In a low-income population, satisfaction is also reported at high levels. In addition to age, ethnicity/acculturation, receipt of chemotherapy and radiotherapy, physician emotional support, and collaborative decision making, perception of diagnostic delay is a predictor of dissatisfaction in this population.

Quality of life of patients after retropubic prostatectomy - pre- and postoperative scores of the EORTC QLQ-C30 and QLQ-PR25

BACKGROUND

Patients with newly diagnosed early stage prostate cancer (PCa) face a difficult choice of different treatment options with curative intention. They must consider both goals of optimising quantity and quality of life. The quality of life (QoL) is a psychometric outcome which is measured using validated questionnaires. Only few data are published concerning pre - and postoperative QoL.

METHODS

This study investigated pre perative QoL of 185 patients who consecutively underwent open radical retropubic prostatectomy for organ-confined PCa to postoperative QoL of another 185 patients. The EORTC QLQ-C30, EORTC QLQPR25 module and 24 h ICS pad test were used (mean follow-up 28.6 months).

RESULTS

The examined symptom scores of the EORTC QLQ-PR25 were on lowest level. In the dyspnoea symptom score differences of age emerged: the amount of patients who are short of breath rose significantly in older patients after surgery (p < 0.05 paired, two-tailed student's t-test).. Lastly, the urinary symptom score was found postal-therapeutically low; this fact was age independent. The results of sexual symptom score need to be taken into consideration, since prostatectomy resulted in a significant reduction of sexual activity independent of age. All functioning scales postoperatively reached high values without significant changes (p > 0.05 student's t-test ), which implies a high QoL after surgery. A reliable and satisfying status of continence was found in our patients after retropubic prostatectomy. A high rate of patients (89.2%) would choose retropubic prostatectomy again.

CONCLUSION

Retropubic prostatectomy represents a reliable and accepted procedure in the treatment of organ-confined PCa. For the first time it could be shown that patients` QoL remained on a high level after retropubic prostatectomy. Nevertheless, the primary avoidance or postoperative therapy of erectile dysfunction should be in the focus of surgeons.

Characteristics and correlates of dyspnea in patients with advanced cancer

BACKGROUND

Dyspnea is a very distressing symptom present in the vast majority of patients with advanced cancer. There are limited data on the characteristics and correlates of dyspnea in this population. The purpose of this study was to characterize dyspnea, explore the differences between breakthrough and continuous presentations, and to determine factors associated with its intensity.

METHODS

Prospective observational study among 70 patients with dyspnea referred to a palliative care service. Dyspnea was assessed using the Edmonton Symptom Assessment System (ESAS, 0-10) and the Oxygen Cost Diagram (OCD). Oximetry, pulmonary function tests, Hospital Anxiety and Depression Scale (HADS), and a detailed systematic evaluation of daily characteristics of dyspnea were performed. Other symptoms were recorded using the ESAS.

RESULTS

Of 30 patients, 70 (43%) were female, median age was 58 (range, 28-87), and the most frequent cancer diagnosis were lung (31/70; 44%) and urologic (15/70; 21%). Constant dyspnea occurred in 27 of 70 (39%) patients, with 14 of 70 (20%) presenting breakthrough episodes. Breakthrough-only dyspnea occurred in 43 of 70 (61%). The majority of patients with breakthrough episodes (39/57; 68%) presented fewer than 5 episodes daily, most frequently lasting for less than 10 minutes (50/57; 88%). In univariate analyses ESAS dyspnea was associated with fatigue (p < 0.0001), sleep (p = 0.002), anxiety (p = 0.006), depression (p = 0.01), sensation of well-being (p = 0.03), and with OCD (p = 0.001). In multivariate analysis, ESAS dyspnea was associated with fatigue (p = 0.001), forced expiratory volume (p = 0.004), pain (p = 0.01), and depression (p = 0.03). Dyspnea intensity significantly interfered with activities (general activity, p = 0.01, mood, p = 0.02, walking ability, p = 0.04, normal work p = 0.04, and enjoyment of life, p = 0.01).

CONCLUSION

Dyspnea in patients with advanced cancer more frequently had breakthrough characteristics, was of very short duration, and interfered with daily activities.