Experience with palliative care in patients with advanced cancer at a tertiary care hospital in a developing country

Opioid Prescribing Patterns Before and After an Inpatient Palliative Care Consultation

BACKGROUND

To the best of our knowledge, the change in opioid prescription patterns upon referral to a palliative care team (PCT) was not previously investigated in the Middle East.

OBJECTIVE

This study aimed to explore the change in the pattern of opioid prescription and the pain scores before and after referring inpatients to a PCT.

METHODS

We conducted a retrospective review of patients' records including all inpatients ≥15 years newly referred to the PCT over a period of 21 months at King Faisal Specialist Hospital and Research Center, Riyadh.

RESULTS

Of 631 patients, 52.3% were females, the median age was 54 years, and 96.7% had cancer. The proportion of patients on opioids before referral (83.4%) increased to 93.3% in the postreferral period, P < .0001. Patients receiving opioids on a regular basis increased from 31.9% before referral to 49.9% after referral to the PCT, P < .0001. Morphine was the most commonly prescribed opioid on a regular basis pre- and postreferral. Upon referral, the administration of opioids through the subcutaneous route increased from 3.7% to 10.9%, P < .0001. On average, pain scores were reduced by 1 point on a 0 to 10 numeric scale within 48 hours of seeing a patient by the PCT, P < .0001.

CONCLUSION

Patients referred to a PCT are likely to get their opioid prescription optimized and pain scores improved shortly after the PCT involvement. Patients with cancer-related pain requiring opioids should be referred to a PCT as early as possible.

Assessment of psychological distress among cancer patients undergoing radiotherapy in Saudi Arabia

Background

Cancer patients under psychological distress have reduced compliance with treatment and prolonged hospitalizations. Identifying cancer patients who may be more likely to suffer from psychological distress over the disease trajectory is essential to targeting the proper interventions and providing the best care. In this descriptive cross-sectional study, we aim to assess the levels of emotional and physical distress, depressive symptoms, and social concerns of cancer patients undergoing radiotherapy treatment in Saudi Arabia.

Methods

A total of 148 cancer patients undergoing radiotherapy from five different public tertiary-level hospitals in Saudi Arabia participated in this study. The survey was conducted by a trained researcher from November 2015 through April 2016. The Psycho-Oncology Screening Tool was used to identify levels of distress of cancer patients undergoing radiotherapy. Emotional and physical distress, depressive symptoms, and social concerns in receiving psychosocial services were assessed.

Results

The findings show above average levels of physical and emotional distress was (342.07±78.9) and social concerns was (7.27±1.68). Age was a significant predictor of psychological distress and in social concerns (P<0.05). Marital status and employment status emerged as significant predictors of depressive symptoms and social concerns (<0.05), (P<0.001), respectively. The patients’ type of cancer was significantly associated with the level of physical distress, emotional distress, and depressive symptoms (P<0.05).

Conclusion

Cancer patients undergoing radiotherapy displayed above-average levels of distress. This may have significant implications on their adherence for treatment and patient outcomes. Routine screening and support services or psychosocial care for patients are warranted among cancer patients undergoing radiotherapy.

Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis

CONTEXT

Cancer pain has a severe impact on quality of life and is associated with numerous psychosocial responses. Recent studies suggest that treatment of cancer pain has improved during the last decade.

OBJECTIVES

The aim of this review was to examine the present status of pain prevalence and pain severity in patients with cancer.

METHODS

A systematic search of the literature published between September 2005 and January 2014 was performed using the databases PubMed, Medline, Embase, CINAHL, and Cochrane. Articles in English or Dutch that reported on the prevalence of cancer pain in an adult population were included. Titles and abstracts were screened by two authors independently, after which full texts were evaluated and assessed on methodological quality. Study details and pain characteristics were extracted from the articles with adequate study quality. Prevalence rates were pooled with meta-analysis; meta-regression was performed to explore determinants of pain prevalence.

RESULTS

Of 4117 titles, 122 studies were selected for the meta-analyses on pain (117 studies, n = 63,533) and pain severity (52 studies, n = 32,261). Pain prevalence rates were 39.3% after curative treatment; 55.0% during anticancer treatment; and 66.4% in advanced, metastatic, or terminal disease. Moderate to severe pain (numerical rating scale score ≥5) was reported by 38.0% of all patients.

CONCLUSION

Despite increased attention on assessment and management, pain continues to be a prevalent symptom in patients with cancer. In the upcoming decade, we need to overcome barriers toward effective pain treatment and develop and implement interventions to optimally manage pain in patients with cancer.

A Prospective Evaluation of Symptom Prevalence and Overall Symptom Burden Among Cohort of Critically Ill Cancer Patients

Background:

Gross physiological perturbations necessitating the Intensive Care Unit (ICU) admission might exacerbate the already existing or initiate bothersome symptoms among cancer patients. There is a lack of conclusive evidence concerning the symptomatic experience among this subgroup of cancer patients particularly so in the Indian population. The aim of this prospective observational study was to elucidate the symptom prevalence and overall symptomatic distress among critically ill cancer patients at the time of admission to a medical ICU.

Methods:

We prospectively evaluated 110 consecutive cancer patients at the time of admission to our medical ICU for the presence and intensity of symptoms using a modified Edmonton Symptom Assessment Scale (ESAS). The patients/caregivers were also enquired regarding the most bothersome symptom in the past 1 week and the presence of “symptom associated sleep disturbance.” The primary outcome was the prevalence of patients with moderate (ESAS ≥ 40) and severe (ESAS ≥ 70) symptomatic distress.

Results:

The average age was 52.49 years with 75.45% of the respondents in the economically productive age group (21–60 years). Carcinoma breast (19.35%) and lung (14.58%) were the most common cancers among females and males, respectively. 87.27% and 60% of the patients had advanced cancer and multi-organ dysfunction, respectively. About 76.36% patients were able to complete ESAS either by themselves or with caregiver's assistance within first 24 h of ICU admission. The mean ESAS distress score was 48.04 (0–81) with 72.72% of the patients having moderate-severe symptomatic distress. Loss of appetite (92.73%) and nausea (54.55%) were the most common and the least common reported symptoms, respectively. Pain was the most common and “most distressing symptom” reported by 40% of patients with 64.55% patients reporting one or more symptoms severe enough to interfere with their sleep.

Conclusion:

ESAS is a user-friendly cognitive aid to make the healthcare team cognizant of the symptom existence and overall symptomatic burden among cancer patients with gross physiological perturbations. The high prevalence of moderate-severe symptom distress requires the concomitant provision of palliative and intensive care among this group of cancer patients.

Challenges and opportunities to advance pediatric neuro-oncology care in the developing world

PURPOSE

As the morbidity and mortality associated with communicable diseases continue to decrease in the developing world, the medical burden of childhood cancer continues to expand. Although international aid and relief groups such as the World Health Organization recognize the importance of childhood cancer, their main emphasis is on the more easily treated malignancies, such as leukemias and lymphomas, and not pediatric brain tumors, which are the second most common malignancy in children and the leading cause of cancer-related deaths in the pediatric population. Addressing the needs of these children is a growing concern of several professional neuro-oncology-related societies. Thus, the goal of this review is to describe the current state of pediatric neuro-oncology care in the developing world, address the current and future needs of the field, and help guide professional societies' efforts to contribute in a more holistic and multidisciplinary manner.

METHODS

We reviewed the literature to compare the availability of neuro-oncology care in various regions of the developing world with that in higher income nations, to describe examples of successful initiatives, and to present opportunities to improve care.

RESULTS

The current challenges, previous successes, and future opportunities to improve neuro-oncology care are presented. The multidisciplinary nature of neuro-oncology depends on large teams of highly specialized individuals, including neuro-oncologists, neurosurgeons, neurologists, radiologists, radiation oncologists, pathologists, palliative care specialists, oncology nurses, physical therapists, occupational therapists, speech therapists, pediatric intensivists, and social workers, among others.

CONCLUSION

Pediatric neuro-oncology is one of the most complex types of medical care to deliver, as it relies on numerous specialists, subspecialists, support staff, and physical resources and infrastructure. However, with increasing collaboration and advancing technologies, developed nations can help substantially improve neuro-oncology care for children in developing nations.

Prevalence and severity of pain in cancer patients in an outpatient palliative care setting in Saudi Arabia

Background: The prevalence and severity of cancer pain in the outpatient palliative care (PC) setting have not been explored previously in Saudi Arabia (SA). Exploration of this basic information may help in evaluating pain severity in patients new to PC as compared to those with previous PC exposure. Objective: This paper aims to determine the prevalence and severity of cancer pain among new and follow-up patients attending a PC outpatient clinic. Methods: In a PC outpatient setting in a major tertiary hospital in SA, we interviewed adult patients with cancer during their attendance to the clinic. Patients were requested to score the severity of their pain on a 0 to 10 numerical scale. Results: A total of 124 patients were interviewed, of whom 73 (59%) were females. The majority of patients (82.3%) had metastatic disease. The most common cancers were breast (27.4%) and head and neck (15.3%). The majority of patients (85.5%) reported pain, with a median intensity score of 5 and a mean of 4.6. Of those who reported pain, 54 (51%) scored above 4. The mean pain score did not differ between groups of patients according to various characteristics such as age, sex, performance status, type of cancer or encounter type. Conclusion: Pain is a prevalent symptom in new and follow-up cancer patients seen in a PC outpatient setting in SA. Further research on a larger scale is needed to evaluate the magnitude of the problem more comprehensively with emphasis on detailed pain assessment and exploration of the adopted management approaches.

Nonpain Symptoms of New and Follow-up Cancer Patients Attending a Palliative Care Outpatient Clinic in Saudi Arabia

BACKGROUND

Epidemiology of cancer-related nonpain symptoms receives less attention in literature as compared with cancer pain.

OBJECTIVE

This paper aims at exploring the prevalence and severity of nonpain symptoms in cancer patients attending a palliative care (PC) outpatient clinic.

MATERIALS AND METHODS

Over a 5 months period, consecutive adult cancer patients attending PC outpatient clinic at a tertiary hospital were evaluated for the presence and severity of 10 nonpain symptoms. Patients were grouped to new or follow-up cases and were also grouped according to performance status and cancer type. Prevalence and severity of symptoms were compared between groups using t test or analysis of variance as appropriate.

RESULTS

Fifty-one males and 73 females were interviewed. The most common cancer is female breast (27.4%) followed by head and neck (15.3%). Majority of patients (67%) were new to PC clinic. Patients had 5.1 nonpain symptoms on average, with most common symptoms being tiredness (79.8%), loss of appetite (71.8%), dry mouth (69.4%), anxiety (60.5%), and depression (50.8%). The least common symptoms were confusion and nausea (22.6% each). The median scores of severity were highest for tiredness, loss of appetite, dry mouth, and insomnia (5 points each). Symptoms were fewer among patients with good performance status (P = 0.002), whereas age, gender, cancer type, and encounter type were not associated with difference in symptom prevalence. Younger patients, females and those with poor performance status have shown a tendency toward higher severity scores for several symptoms.

CONCLUSION

The significant prevalence and severity of nonpain symptoms among new and follow-up cancer patients seen in a PC outpatient clinic emphasizes the need for comprehensive assessment and routinely audited symptom management plans.