Physicians’ attitude toward recurrent hypercalcemia in terminally ill cancer patients

Treatment of Hypercalcemia of Malignancy in Adults: An Endocrine Society Clinical Practice Guideline

BACKGROUND

Hypercalcemia of malignancy (HCM) is the most common metabolic complication of malignancies, but its incidence may be declining due to potent chemotherapeutic agents. The high mortality associated with HCM has declined markedly due to the introduction of increasingly effective chemotherapeutic drugs. Despite the widespread availability of efficacious medications to treat HCM, evidence-based recommendations to manage this debilitating condition are lacking.

OBJECTIVE

To develop guidelines for the treatment of adults with HCM.

METHODS

A multidisciplinary panel of clinical experts, together with experts in systematic literature review, identified and prioritized 8 clinical questions related to the treatment of HCM in adult patients. The systematic reviews (SRs) queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. An independent SR was conducted in parallel to assess patients' and physicians' values and preferences, costs, resources needed, acceptability, feasibility, equity, and other domains relevant to the Evidence-to-Decision framework as well as to enable judgements and recommendations.

RESULTS

The panel recommends (strong recommendation) in adults with HCM treatment with denosumab (Dmab) or an intravenous (IV) bisphosphonate (BP). The following recommendations were based on low certainty of the evidence. The panel suggests (conditional recommendation) (1) in adults with HCM, the use of Dmab rather than an IV BP; (2) in adults with severe HCM, a combination of calcitonin and an IV BP or Dmab therapy as initial treatment; and (3) in adults with refractory/recurrent HCM despite treatment with BP, the use of Dmab. The panel suggests (conditional recommendation) the addition of an IV BP or Dmab in adult patients with hypercalcemia due to tumors associated with high calcitriol levels who are already receiving glucocorticoid therapy but continue to have severe or symptomatic HCM. The panel suggests (conditional recommendation) in adult patients with hypercalcemia due to parathyroid carcinoma, treatment with either a calcimimetic or an antiresorptive (IV BP or Dmab). The panel judges the treatments as probably accessible and feasible for most recommendations but noted variability in costs, resources required, and their impact on equity.

CONCLUSIONS

The panel's recommendations are based on currently available evidence considering the most important outcomes in HCM to patients and key stakeholders. Treatment of the primary malignancy is instrumental for controlling hypercalcemia and preventing its recurrence. The recommendations provide a framework for the medical management of adults with HCM and incorporate important decisional and contextual factors. The guidelines underscore current knowledge gaps that can be used to establish future research agendas.

Patient and Physician Decisional Factors Regarding Hypercalcemia of Malignancy Treatment: A Novel Mixed-Methods Study

BACKGROUND

Integrating shared decision making between patients and physicians and incorporating their values and preferences in the development of clinical practice guidelines (CPGs) is of critical importance to optimize CPG implementation and treatment adherence. This applies to many debilitating diseases, including hypercalcemia of malignancy (HCM).

OBJECTIVE

Evaluate patient and physician values, preferences, and attitudes to better inform CPGs to treat HCM in adults.

METHODS

We followed a mixed-methods approach. We conducted a systematic review using 5 databases to identify studies reporting on patient and physician values, costs and resources, feasibility, acceptability, and equity regarding HCM treatment. We also gathered data from different countries on the cost of multiple treatment modalities. We collected data on outcome prioritization from the CPG Working Group. Similarly, we collected data from patients with HCM regarding outcome prioritization and administered a questionnaire to evaluate their attitudes and perceptions toward treatment as well as treatment acceptability and feasibility.

RESULTS

In the systematic review, we included 2 cross-sectional surveys conducted on the same population of physicians who agreed that treating HCM alleviates symptoms and improves quality of life; however, harms and benefits should be thoroughly considered when deciding on the duration of treatment. We also included 2 studies on cost showing that intravenous (IV) bisphosphonate is more cost-effective than a combination of IV bisphosphonate and calcitonin and administration of IV zoledronic acid at home is more cost-effective than other IV bisphosphonates. The cost of zoledronic acid, denosumab, and cinacalcet varied widely among countries and types (brand vs generic). Both the CPG Working Group and patients with HCM agreed that the most important outcomes when deciding on treatment were survival and resolution of HCM, but there was some variability in the ratings for other outcomes.

CONCLUSION

Using mixed methods, CPG developers can obtain meaningful information regarding evidence to decision criteria. In the case of HCM CPGs, this approach has provided the required contextual information and supported the development of evidence-based recommendations.

Determinants of Physicians' Attitudes Toward the Management of Infectious Diseases in Terminally Ill Patients With Cancer

OBJECTIVES

Antimicrobials are frequently prescribed to terminally ill patients with cancer; however, physicians' practice patterns regarding antimicrobial use vary widely. This study aimed to systematically identify factors that determine physicians' attitudes toward the management of infectious diseases in terminally ill patients with cancer.

METHODS

A nationwide cross-sectional survey involving 600 oncologists, 600 infectious diseases physicians, 600 palliative care physicians, and 220 home care physicians was conducted between November 2017 and January 2018. The primary endpoint was physicians' attitudes toward the management of infectious diseases in terminally ill patients with cancer with a few weeks of prognosis. Physicians' beliefs regarding management of infectious diseases as well as physician-perceived "good death" were also assessed (1 = strongly disagree to 6 = strongly agree).

RESULTS

There were 895 (44.3%) analyzable response, and average scores of physicians' attitudes ranged between 2.69 and 4.32. In total, 241 (27%; 95% CI = 24-30) to 691 (78%; 95% CI = 75-81) respondents showed proactive attitudes toward various infectious diseases management. In linear regression analysis, determinants of proactive attitudes included the following: physicians' belief that examination and treatment will improve quality of life and prognosis and reduce suffering (β = 0.32, t = 9.99, P = 0.00); greater physician-perceived importance on receiving enough treatment (β = 0.09, t = 2.88, P = 0.00) and less importance on dying a natural death (β = -0.07, t = -2.14, P = 0.03) for a "good death"; working at a tertiary care hospital (β = 0.16, t = 4.40, P = 0.00); and not being a home care physician (β = -0.20, t = -5.51, P = 0.00) or palliative care physician (β = -0.12, t = -3.64, P = 0.00).

CONCLUSIONS

Physicians have divergent attitudes toward the management of infectious diseases in terminally ill patients with cancer. Reflection by physicians on their own beliefs and perceptions regarding infectious disease management and a "good death" may help provide the best end-of-life care.

Mechanical Thrombectomy for Trousseau Syndrome in a Terminally Ill Cancer Patient

Trousseau syndrome was first described by Armand Trousseau in 1865 and is characterized by hypercoagulation resulting from malignant tumors. This complication can markedly impact quality of life (QOL). This is the first report of a terminally ill patient who developed large-vessel occlusion stroke from Trousseau syndrome and underwent mechanical thrombectomy. A 75-year-old woman presented with Stage IV ovarian cancer. Goals of care were transitioned to palliative care. The patient was hospitalized with vertebral compression fracture and suddenly developed right hemiparesis and total aphasia during admission. Magnetic resonance imaging and angiography showed occlusion of Segment 1 of the left middle cerebral artery. We administered tissue-plasminogen activator, but symptoms remained unimproved. We performed mechanical thrombectomy based on medical indications and with the consent of her family. Thrombectomy improved symptoms dramatically. She was able to walk and talk with her family at discharge. She eventually died of respiratory failure on postoperative Day 98, but QOL remained high for those 98 days. Mechanical thrombectomy has the potential to markedly improve QOL in terminally ill patients with large-vessel occlusion associated with Trousseau syndrome.

The Management of Nausea at the End of Life

The evaluation and management of nausea in patients near the end of life can be more challenging than that of nausea in patients undergoing antineoplastic therapies. Unlike in the oncology setting in which nausea is primarily managed using antiemetic regimens that have been developed with the neuropharmacology and emetogenic potentials of chemotherapy agents in mind, many patients receiving end-of-life care have nausea of multifactorial etiology. Patients also may be older with reduced physiologic ability to metabolize and clear drugs. Therefore, typical antiemetics in regimens initially selected for oncology patients may be ineffective. In this article, the prevalence, manifestation, and pathophysiology of nausea experienced by patients near and at the end of life will be reviewed, with a focus on pharmacological and nonpharmacological interventions that have been found to effectively manage this symptom in this patient population.

A National Survey to Systematically Identify Factors Associated With Oncologists' Attitudes Toward End-of-Life Discussions: What Determines Timing of End-of-Life Discussions?

BACKGROUND

End-of-life discussions (EOLds) occur infrequently until cancer patients become terminally ill.

METHODS

To identify factors associated with the timing of EOLds, we conducted a nationwide survey of 864 medical oncologists. We surveyed the timing of EOLds held with advanced cancer patients regarding prognosis, hospice, site of death, and do-not-resuscitate (DNR) status; and we surveyed physicians' experience of EOLds, perceptions of a good death, and beliefs regarding these issues. Multivariate analyses identified determinants of early discussions.

RESULTS

Among 490 physicians (response rate: 57%), 165 (34%), 65 (14%), 47 (9.8%), and 20 (4.2%) would discuss prognosis, hospice, site of death, and DNR status, respectively, "now" (i.e., at diagnosis) with a hypothetical patient with newly diagnosed metastatic cancer. In multivariate analyses, determinants of discussing prognosis "now" included the physician perceiving greater importance of autonomy in experiencing a good death (odds ratio [OR]: 1.34; p = .014), less perceived difficulty estimating the prognosis (OR: 0.77; p = .012), and being a hematologist (OR: 1.68; p = .016). Determinants of discussing hospice "now" included the physician perceiving greater importance of life completion in experiencing a good death (OR: 1.58; p = .018), less discomfort talking about death (OR: 0.67; p = .002), and no responsibility as treating physician at end of life (OR: 1.94; p = .031). Determinants of discussing site of death "now" included the physician perceiving greater importance of life completion in experiencing a good death (OR: 1.83; p = .008) and less discomfort talking about death (OR: 0.74; p = .034). The determinant of discussing DNR status "now" was less discomfort talking about death (OR: 0.49; p = .003).

CONCLUSION

Reflection by oncologists on their own values regarding a good death, knowledge about validated prognostic measures, and learning skills to manage discomfort talking about death is helpful for oncologists to perform appropriate EOLds.

IMPLICATIONS FOR PRACTICE

Oncologists' own perceptions about what is important for a "good death," perceived difficulty in estimating the prognosis, and discomfort in talking about death influence their attitudes toward end-of-life discussions. Reflection on their own values regarding a good death, knowledge about validated prognostic measures, and learning skills to manage discomfort talking about death are important for improving oncologists' skills in facilitating end-of-life discussions.