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Lo SB, Ruprecht AL, Post KE, Eche-Ugwu IJ, Cooley ME, Temel JS, Greer JA. Dyspnea-Related Dimensions And Self-Efficacy: Associations With Well-Being in Advanced Lung Cancer. J Pain Symptom Manage 2024; 67:366-374.e1. [PMID: 38307373 PMCID: PMC11032235 DOI: 10.1016/j.jpainsymman.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
CONTEXT Dyspnea is a complex, multidimensional symptom comprising sensory-perceptual, affective, and functional domains that commonly persists in patients with lung cancer and impairs mental health and quality of life (QOL). However, data are lacking on how dyspnea's dimensions or self-efficacy to manage dyspnea are associated with patient outcomes. OBJECTIVES To assess the associations of dyspnea dimensions (dyspnea-related sensory-perceptual experience, affective distress, and functional impact) and dyspnea self-efficacy with depression, anxiety, and QOL in patients with advanced lung cancer reporting dyspnea. METHODS We conducted a secondary analysis of baseline clinical trial data testing a supportive care intervention for dyspnea. Patients with advanced lung cancer reporting at least moderate dyspnea (≥2 on the Modified Medical Research Council Dyspnea Scale) self-reported dyspnea and patient outcome measures. Hierarchical regressions tested the associations of the dyspnea dimensions with depressive and anxiety symptoms (Hospital Anxiety and Depression Scale) and QOL (Functional Assessment of Cancer Therapy-Lung) while adjusting for variables known to affect these outcomes. RESULTS The sensory-perceptual experience of dyspnea (effort) was associated with worse depressive symptoms (b = 0.21, P < 0.01) and QOL (b = -0.53, P = 0.01). Dyspnea self-efficacy was associated with improved depressive (b = -1.26, P < 0.01) and anxiety symptoms (b = -1.72, P < 0.01) and QOL (b = 3.66, P < 0.01). The affective and functional dimensions of dyspnea were not associated with the patient outcomes in the final models. CONCLUSIONS Dyspnea-related sensory-perceptual experience and self-efficacy were associated with mental health and QOL outcomes in patients with lung cancer. Examining the individual contributions of dyspnea's multiple dimensions provides a nuanced understanding of its patient impact.
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Affiliation(s)
- Stephen B Lo
- Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital, Boston, MA, USA.
| | - Anna L Ruprecht
- Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital, Boston, MA, USA
| | - Kathryn E Post
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ijeoma Julie Eche-Ugwu
- Phyllis F. Cantor Center Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mary E Cooley
- Phyllis F. Cantor Center Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer S Temel
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph A Greer
- Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital, Boston, MA, USA
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Shin J, Hammer M, Cooley ME, Cooper BA, Paul SM, Cartwright F, Kober KM, Conley YP, Levine JD, Miaskowski C. Common and distinct risk factors that influence more severe and distressing shortness of breath profiles in oncology outpatients. Cancer Med 2024; 13:e7013. [PMID: 38400684 PMCID: PMC10891479 DOI: 10.1002/cam4.7013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/05/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Shortness of breath occurs in 10%-70% of oncology patients. Very little is known about interindividual variability in its severity and distress and associated risk factors. Using latent profile analyses (LPAs), purpose was to identify subgroups of patients with distinct severity and distress profiles for shortness of breath as single symptom dimensions. In addition, a joint LPA was done using patients' severity AND distress ratings. For each of the three LPAs, differences among the shortness of breath classes in demographic, clinical, symptom, stress, and resilience characteristics were evaluated. METHODS Patients completed ratings of severity and distress from shortness of breath a total of six times over two cycles of chemotherapy. All of the other measures were completed at enrollment (i.e., prior to the second or third cycle of chemotherapy). Separate LPAs were done using ratings of severity and distress, as well as a joint analysis using severity AND distress ratings. Differences among the latent classes were evaluated using parametric and nonparametric tests. RESULTS For severity, two classes were identified (Slight to Moderate [91.6%] and Moderate to Severe [8.4%]). For distress, two classes were identified (A Little Bit to Somewhat [83.9%] and Somewhat to Quite a Bit [16.1%]). For the joint LPA, two classes were identified (Lower Severity and Distress [79.9%] and Higher Severity and Distress [20.1%]). While distinct risk factors were associated with each of the LPAs, across the three LPAs, the common risk factors associated with membership in the worse class included: a past or current history of smoking, poorer functional status, and higher comorbidity burden. In addition, these patients had a higher symptom burden and higher levels of cancer-specific stress. CONCLUSIONS Clinicians can use the information provided in this study to identify high-risk patients and develop individualized interventions.
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Affiliation(s)
- Joosun Shin
- Dana‐Farber Cancer InstituteBostonMassachusettsUSA
| | | | | | - Bruce A. Cooper
- School of NursingUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Steven M. Paul
- School of NursingUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | | | - Kord M. Kober
- School of NursingUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Yvette P. Conley
- School of NursingUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Jon D. Levine
- School of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Christine Miaskowski
- School of NursingUniversity of CaliforniaSan FranciscoCaliforniaUSA
- School of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
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Kindred M, Isha S, Hanson A, Satashia P, Thompson A, Mielke C, Sanghavi D. Letter to the Editor: Improvement in Palliative Care Utilization and Provider Confidence With Respiratory Distress Observation Scale: A Single-Center Experience. J Palliat Med 2023; 26:1602-1603. [PMID: 38060318 DOI: 10.1089/jpm.2023.0498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Affiliation(s)
- Mary Kindred
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Abby Hanson
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Parthkumar Satashia
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Ashley Thompson
- Department of Nursing, University of Florida, Gainesville, Florida, USA
| | - Cathy Mielke
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
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Hui D, Yennurajalingam S. The role of corticosteroids in the palliation of dyspnea in cancer patients: an evidence-based review. Curr Opin Support Palliat Care 2023; 17:270-276. [PMID: 37773042 DOI: 10.1097/spc.0000000000000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
PURPOSE OF REVIEW To provide an evidence-based review on the use of corticosteroids for dyspnea in cancer patients. RECENT FINDINGS Corticosteroids are commonly used for palliation of dyspnea; however, there is wide variation in how they are prescribed due to the paucity of high-quality evidence. Some clinicians would offer corticosteroids routinely regardless of the causes of dyspnea, while others would only prescribe corticosteroids selectively for specific indications, such as lymphangitic carcinomatosis, upper airway obstruction, superior vena cava obstruction, and cancer treatment-induced pneumonitis. Few mechanistic studies have been conducted to support the use of corticosteroids in cancer patients. Two double-blind, placebo-controlled randomized trials have examined the routine use of high-dose dexamethasone for dyspnea in cancer patients. A pilot study suggested some benefits, but the larger confirmatory trial revealed no improvement compared to the placebo and significantly more adverse events. The selective use of corticosteroids use is only based on observational studies such as case series. SUMMARY The unfavorable risk:benefit ratio of high-dose dexamethasone suggests that it should not be routinely prescribed for dyspnea in cancer patients. More research is needed to assess the selective use of corticosteroids and identify patients most likely be benefit from corticosteroid use.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Shin J, Kober K, Yates P, Wong ML, Cooper BA, Paul SM, Hammer M, Conley Y, Levine JD, Wright F, Miaskowski C. Higher Lifetime Stress and Symptom Burden Contribute to the Occurrence of Shortness of Breath. Semin Oncol Nurs 2023; 39:151471. [PMID: 37500312 DOI: 10.1016/j.soncn.2023.151471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/10/2023] [Accepted: 06/21/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVES Among four classes of patients with distinct shortness of breath profiles, evaluate for differences in levels of global, cancer-specific, and cumulative life stress, as well as resilience; evaluate for differences in the occurrence rates for various stressful life events, and evaluate for differences in the severity of common co-occurring symptoms. DATA SOURCES Outpatients (N = 1338) completed questionnaires six times over two cycles of chemotherapy. The occurrence of shortness of breath was assessed using the Memorial Symptom Assessment Scale. Latent class analysis was used to identify subgroups of patients with distinct shortness of breath profiles. Differences among the classes were evaluated using parametric and nonparametric tests. CONCLUSION Shortness of breath classes were labeled based on their distinct occurrence trajectories: None (70.5%), Decreasing (8.2%), Increasing (7.8%), and High (13.5%). Compared to None class, Decreasing and High classes had higher global and cancer-specific stress scores. The High class reported higher occurrence rates for several adverse childhood experiences. Compared to None class, Decreasing and High classes had higher depression, anxiety, and morning fatigue scores and lower morning energy and cognitive function scores. IMPLICATIONS FOR NURSING PRACTICE Given the additive or synergistic relationships between stress, co-occurring symptoms, and shortness of breath, multimodal interventions that include stress management, exercise training, and/or symptom management may decrease shortness of breath in oncology patients.
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Affiliation(s)
- Joosun Shin
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California
| | - Kord Kober
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California
| | - Patsy Yates
- Cancer & Palliative Outcomes Centre, Centre for Health Transformation, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Melisa L Wong
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Bruce A Cooper
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California
| | - Steven M Paul
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California
| | - Marilyn Hammer
- The Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Yvette Conley
- Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jon D Levine
- Department of Medicine, School of Medicine, University of California, San Francisco, California
| | - Fay Wright
- Rory Meyers College of Nursing, New York University, New York, New York
| | - Christine Miaskowski
- Departments of Physiological Nursing and Anesthesia, School of Nursing and School of Medicine, University of California, San Francisco, California.
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6
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Li N, Cui M, Wang Y. Effect of Dexmedetomidine for Palliative Sedation for Refractory Dyspnoea in Patients with Terminal-Stage Cancer. Cancer Manag Res 2023; 15:291-299. [PMID: 36987523 PMCID: PMC10040164 DOI: 10.2147/cmar.s404934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/14/2023] [Indexed: 03/30/2023] Open
Abstract
Background Dyspnoea affects a considerable percentage of patients with terminal-stage cancer, and clinical guidelines recommend palliative sedation for patients with refractory dyspnoea. Midazolam is currently the most commonly used sedative; however, it can cause serious adverse reactions, such as respiratory/circulatory depression. Hence, there is a need for an alternative sedative. Dexmedetomidine (DEX) is a promising alternative as its "awake sedation" effect; however, little is known regarding its use in patients with end-stage dyspnoea. Therefore, the aim of this study was to determine the safety and usefulness of DEX for palliative sedation of patients with refractory dyspnoea. Methods This retrospective study included patients with terminal-stage cancer who received DEX for palliative sedation owing to refractory dyspnoea in the hospice ward from January 2018 to October 2022. We analysed their general data, dyspnoea conditions, sedation details, sedative treatment effect, dyspnoea relief, and changes in vital signs before and after sedation, via paired t-tests. Results We included 17 patients with terminal-stage cancer who received DEX palliative sedation at a dose of 0.2-0.9 µg/kg·h for refractory dyspnoea, among whom 6 (35%) received a loading dose of 1 µg/kg in 10 min. After 1 h of sedation and at the maximum sedation dose, the Respiratory Distress Observation Scale and Richmond Agitation-Sedation Scale scores decreased significantly compared with those before sedation (all P<0.001), as did the respiratory rate (P=0.024 and P=0.008, respectively). The heart rate and blood oxygen saturation did not significantly change, whereas the systolic and diastolic blood pressure after 1 h of sedation were significantly lower than those before sedation (both P=0.015). Conclusion DEX is a promising palliative sedative for patients with terminal-stage cancer, as it safely relieved the symptoms of refractory dyspnoea without inducing serious adverse reactions. Therefore, DEX may greatly enhance the quality of life for patients with terminal-stage cancer.
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Affiliation(s)
- Na Li
- Department of Hospice Care, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
| | - Meng Cui
- Department of Hospice Care, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
- Correspondence: Meng Cui; Yumei Wang, Department of Hospice Care, Shengjing Hospital of China Medical University, No. 39 Huaxiang Road, Tiexi District, Shenyang, Liaoning, People’s Republic of China, Tel +86 18940254587; +86 18940251490, Email ;
| | - Yumei Wang
- Department of Hospice Care, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China
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Shin J, Kober K, Wong ML, Yates P, Miaskowski C. Systematic review of the literature on the occurrence and characteristics of dyspnea in oncology patients. Crit Rev Oncol Hematol 2023; 181:103870. [PMID: 36375635 DOI: 10.1016/j.critrevonc.2022.103870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/31/2022] [Accepted: 11/10/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Dyspnea is a common and distressing symptom for oncology patients.However, dyspnea is not well-characterized and often underestimated by clinicians. This systematic review summarizes the prevalence, intensity, distress, and impact of dyspnea in oncology patients and identifies research gaps. METHODS A search of all of the relevant databases was done from 2009 to May 2022. A qualitative synthesis of the extant literature was performed using established guidelines. RESULTS One hundred-seventeen studies met inclusion criteria. Weighted grand mean prevalence of dyspnea in patients with advanced cancer was 58.0%. Intensity of dyspnea was most common dimension evaluated, followed by the impact and distress. Depression and anxiety were the most common symptoms that co-occurred with dyspnea. CONCLUSION Numerous methodologic challenges were evident across studies. Future studies need to use valid and reliable measures; evaluate the impact of dyspnea; and determine biomarkers for dyspnea.
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Affiliation(s)
- Joosun Shin
- School of Nursing, University of California, San Francisco, CA, USA.
| | - Kord Kober
- School of Nursing, University of California, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Melisa L Wong
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA; Division of Hematology/Oncology, Division of Geriatrics, University of California, San Francisco, CA, USA
| | - Patsy Yates
- Cancer & Palliative Outcomes Centre, Centre for Health Transformation, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia; School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Christine Miaskowski
- School of Nursing, University of California, San Francisco, CA, USA; School of Medicine, University of California, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
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8
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Hui D, Puac V, Shelal Z, Dev R, Hanneman SK, Jennings K, Ma H, Urbauer DL, Shete S, Fossella F, Liao Z, Blumenschein G, Chang JY, O'Reilly M, Gandhi SJ, Tsao A, Mahler DA, Bruera E. Effect of dexamethasone on dyspnoea in patients with cancer (ABCD): a parallel-group, double-blind, randomised, controlled trial. Lancet Oncol 2022; 23:1321-1331. [PMID: 36087590 PMCID: PMC10618956 DOI: 10.1016/s1470-2045(22)00508-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Systemic corticosteroids are commonly prescribed for palliation of dyspnoea in patients with cancer, despite scarce evidence to support their use. We aimed to assess the effect of high-dose dexamethasone versus placebo on cancer-related dyspnoea. METHODS The parallel-group, double-blind, randomised, controlled ABCD (Alleviating Breathlessness in Cancer Patients with Dexamethasone) trial was done at the at the University of Texas MD Anderson Cancer Center and the general oncology clinic at Lyndon B Johnson General Hospital (both in Houston, TX, USA). Ambulatory patients with cancer, aged 18 years or older, and with an average dyspnoea intensity score on an 11-point numerical rating scale (NRS; 0=none, 10=worst) over the past week of 4 or higher were randomly assigned (2:1) to receive dexamethasone 8 mg orally every 12 h for 7 days followed by 4 mg orally every 12 h for 7 days, or matching placebo capsules for 14 days. Pharmacists did permuted block randomisation with a block size of six, and patients were stratified by baseline dyspnoea score (4-6 vs 7-10) and study site. Patients, research staff, and clinicians were masked to group assignment. The primary outcome was change in dyspnoea NRS intensity over the past 24 h from baseline to day 7 (±2 days). Analyses were done by modified intention-to-treat (ie, including all patients who were randomly assigned and started the study treatment, regardless of whether they completed the study). Enrolment was stopped after the second preplanned interim analysis, when the futility criterion was met. This study is registered with ClinicalTrials.gov (NCT03367156) and is now completed. FINDINGS Between Jan 11, 2018, and April 23, 2021, we screened 2867 patients, enrolled 149 patients, and randomly assigned 128 to dexamethasone (n=85) or placebo (n=43). The mean change in dyspnoea NRS intensity from baseline to day 7 (±2 days) was -1·6 (95% CI -2·0 to -1·2) in the dexamethasone group and -1·6 (-2·3 to -0·9) in the placebo group, with no significant between-group difference (mean 0 [95% CI -0·8 to 0·7]; p=0·48). The most common all-cause grade 3-4 adverse events were infections (nine [11%] of 85 patients in the dexamethasone group vs three [7%] of 43 in the placebo group), insomnia (seven [8%] vs one [2%]), and neuropsychiatric symptoms (three [4%] vs none [0%]). Serious adverse events, all resulting in hospital admissions, were reported in 24 (28%) of 85 patients in the dexamethasone group and in three (7%) of 43 patients in the placebo group. No treatment-related deaths occurred in either group. INTERPRETATION High-dose dexamethasone did not improve dyspnoea in patients with cancer more effectively than placebo and was associated with a higher frequency of adverse events. These data suggest that dexamethasone should not be routinely given to unselected patients with cancer for palliation of dyspnoea. FUNDING US National Cancer Institute.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Veronica Puac
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeena Shelal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rony Dev
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sandra K Hanneman
- Cizik School of Nursing at UTHealth, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kristofer Jennings
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hilary Ma
- Department of General Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana L Urbauer
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanjay Shete
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Frank Fossella
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhongxing Liao
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George Blumenschein
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joe Y Chang
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael O'Reilly
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Saumil J Gandhi
- Department of Thoracic Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne Tsao
- Department of Thoracic Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA; Respiratory Services, Valley Regional Hospital, Claremont, NH, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Azhar A, Hui D. Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life. Cancer Res Treat 2022; 54:661-670. [PMID: 35790195 PMCID: PMC9296923 DOI: 10.4143/crt.2022.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.
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Matsuda Y, Yamaguchi T, Matsumoto Y, Ishiki H, Usui Y, Kako J, Suzuki K, Matsunuma R, Mori M, Watanabe H, Zenda S. Research policy in supportive care and palliative care for cancer dyspnea. Jpn J Clin Oncol 2021; 52:260-265. [PMID: 34894136 PMCID: PMC8894919 DOI: 10.1093/jjco/hyab193] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dyspnea is a common and distressing symptom in patients with cancer. To improve its management, multicenter confirmatory studies are necessary. Research policy would be useful in conducting these studies. Here, we propose a new research policy for the management of dyspnea in patients with cancer. METHODS The first draft was developed by a policy working group of 11 specialists in the field of supportive care or palliative care for dyspnea. Then, a provisional draft was developed after review by a research support group (the Japanese Supportive, Palliative and Psychosocial Care Study Group) and five Japanese scientific societies (Japanese Association of Supportive Care in Cancer, Japanese Society of Medical Oncology, Japanese Society of Palliative Medicine, Japanese Association of Rehabilitation Medicine and Japanese Society of Clinical Oncology), and receipt of public comments. RESULTS The policy includes the following components of research policy on dyspnea: (i) definition of dyspnea, (ii) scale for assessment of dyspnea, (iii) reason for dyspnea or factors associated with dyspnea and (iv) treatment effectiveness outcomes/adverse events. The final policy (Ver1.0) was completed on 1 March 2021. CONCLUSIONS This policy could help researchers plan and conduct studies on the management of cancer dyspnea.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Medical Center, Kobe, Japan.,Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroto Ishiki
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Usui
- Division of Palliative Therapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Ryo Matsunuma
- Division of Palliative Care, Department of Medicine, Konan Medical Center, Kobe, Japan.,Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masanori Mori
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | | | - Sadamoto Zenda
- Department of Radiation Oncology, National Cancer Center Hospital East, Kashiwa, Japan
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11
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Hui D, Bohlke K, Bao T, Campbell TC, Coyne PJ, Currow DC, Gupta A, Leiser AL, Mori M, Nava S, Reinke LF, Roeland EJ, Seigel C, Walsh D, Campbell ML. Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol 2021; 39:1389-1411. [DOI: 10.1200/jco.20.03465] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer. METHODS ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020. RESULTS The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea. RECOMMENDATIONS A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .
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Affiliation(s)
- David Hui
- MD Anderson Cancer Center, Houston, TX
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Ting Bao
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Arjun Gupta
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Aliza L. Leiser
- Rutgers RWJ Cancer Institute of New Jersey, New Brunswick, NJ
| | - Masanori Mori
- Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Stefano Nava
- IRCCS Azienda Ospedaliera University of Bologna, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy
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12
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Gupta A, Sedhom R, Sharma R, Zhang A, Waldfogel JM, Feliciano JL, Day J, Gersten RA, Davidson PM, Bass EB, Dy SM. Nonpharmacological Interventions for Managing Breathlessness in Patients With Advanced Cancer: A Systematic Review. JAMA Oncol 2021; 7:290-298. [PMID: 33211072 DOI: 10.1001/jamaoncol.2020.5184] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Breathlessness is a frequent and debilitating symptom in patients with advanced cancer. Often, in the context of breathlessness, aggressive cancer treatment is not beneficial, feasible, or aligned with goals of care. Targeted symptom-focused interventions may be helpful in this scenario. Objective To evaluate the advantages and harms of nonpharmacological interventions for managing breathlessness in adults with advanced cancer. Evidence Review PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception through May 2020 for published randomized clinical trials (RCTs), nonrandomized controlled trials, and observational studies of the advantages and/or harms of nonpharmacological interventions on alleviating breathlessness in adults with advanced cancer. Only English-language studies were screened for eligibility, titles, abstracts, and full text. Risk of bias and strength of evidence (SOE) were independently assessed. The key outcomes reported in studies were breathlessness, anxiety, exercise capacity, health-related quality of life, and harms. Data were analyzed from October 1, 2019, to June 30, 2020. Findings A total of 29 RCTs (2423 participants) were included. These RCTs evaluated various types of interventions, such as respiratory (9 RCTs), activity and rehabilitation (7 RCTs), behavioral and psychoeducational (3 RCTs), integrative medicine (4 RCTs), and multicomponent (6 RCTs). Several nonpharmacological interventions were associated with improved breathlessness, including fan therapy (standardized mean difference [SMD], -2.09; 95% CI, -3.81 to -0.37; I2 = 94.3%; P for heterogeneity = .02; moderate SOE) and bilevel ventilation (estimated slope difference, -0.58; 95% CI, -0.92 to -0.23; low SOE), lasting for a few minutes to hours, in the inpatient setting. In the outpatient setting, nonpharmacological interventions associated with improved breathlessness were acupressure and reflexology (integrative medicine) (low SOE) and multicomponent interventions (combined activity and rehabilitation, behavioral and psychoeducational, and integrative medicine) (low SOE) lasting for a few weeks to months. Five of the 29 RCTs (17%) reported adverse events, although adverse events and study dropouts were uncommon. Conclusions and Relevance Findings of this review include the safety and association with improved breathlessness of several nonpharmacological interventions for adults with advanced cancer. Guidelines and clinical practice should evolve to incorporate nonpharmacological interventions as first-line treatment for adults with advanced cancer and breathlessness.
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Affiliation(s)
- Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Ritu Sharma
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Allen Zhang
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Julie M Waldfogel
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Josephine L Feliciano
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Jeff Day
- Department of Art as Applied to Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca A Gersten
- Division of Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Eric B Bass
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sydney M Dy
- Johns Hopkins Evidence-Based Practice Center, Johns Hopkins School of Public Health, Baltimore, Maryland.,Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Hui D, Maddocks M, Johnson MJ, Ekström M, Simon ST, Ogliari AC, Booth S, Ripamonti C. Management of breathlessness in patients with cancer: ESMO Clinical Practice Guidelines †. ESMO Open 2020; 5:e001038. [PMID: 33303485 PMCID: PMC7733213 DOI: 10.1136/esmoopen-2020-001038] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/19/2020] [Accepted: 10/24/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Magnus Ekström
- Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
| | - Steffen T Simon
- Department of Palliative Medicine and Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Anna C Ogliari
- Pulmonary Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sara Booth
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, London, UK; Cambridge Breathlessness Intervention Service, Cambridge University Hospitals NHS Foundation Trust, University of Cambridge, Cambridge, UK
| | - CarlaI Ripamonti
- Oncology-Supportive Care in Cancer Unit, Department Onco-Haematology, Fondazione IRCCS Istituto Nazionale dei Tumori Milano, Milan, Italy
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14
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Mori M, Yamaguchi T, Matsuda Y, Suzuki K, Watanabe H, Matsunuma R, Kako J, Imai K, Usui Y, Matsumoto Y, Hui D, Currow D, Morita T. Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer. ESMO Open 2020; 5 Suppl 1:e000603. [PMID: 33558034 PMCID: PMC7046422 DOI: 10.1136/esmoopen-2019-000603] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/01/2019] [Accepted: 02/04/2020] [Indexed: 12/14/2022] Open
Abstract
Breathlessness is among the most common and deteriorating symptoms in patients with advanced cancer, which may worsen towards the end of life. Breathlessness in patients with estimated life expectancy of weeks to days has unique clinical features: it tends to worsen rapidly over days to hours as death approaches often despite current symptom control measures. Breathlessness in patients during the last weeks to days of life can be called ‘terminal breathlessness’. While evidence has accumulated for the management of breathlessness in patients with cancer who are not dying, such evidence may not be fully applied to terminal breathlessness. Only a few studies have investigated the best practice of terminal breathlessness in patients with cancer. In this paper, we summarise the current evidence for the management of terminal breathlessness, and propose future directions of clinical research.
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Affiliation(s)
- Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan.
| | | | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jun Kako
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yuko Usui
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - David Currow
- Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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15
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Choratas A, Papastavrou E, Charalambous A, Kouta C. Developing and Assessing the Effectiveness of a Nurse-Led Home-Based Educational Programme for Managing Breathlessness in Lung Cancer Patients. A Feasibility Study. Front Oncol 2020; 10:1366. [PMID: 32983967 PMCID: PMC7492635 DOI: 10.3389/fonc.2020.01366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 06/29/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Breathlessness is the most common and refractory symptom in lung cancer patients. Even though various educational programmes have been developed, only a few were intended for implementation in the home setting for its management. Aim: Feasibility of a study for implementing a nurse-led educational programme for breathlessness management of lung cancer patients at home. Method: A randomized feasibility study was undertaken between February 2017 and October 2018. Patients were recruited through referral from oncologists from two oncology centers in Cyprus under certain inclusion and exclusion criteria. Patients were randomized in the intervention or control group via a computer programme, and their named family caregivers (f.c.) were allocated in the same group. Participants were not blinded to group assignment. The intervention consisted of a PowerPoint presentation and implementation of three non-pharmacological interventions. The control group received usual care. Patients were assessed for breathlessness, anxiety, and depression levels, whereas f.c. were assessed for anxiety, depression, and burden levels. F.c. also assessed patients' dyspnea level. The duration of the study process for both the intervention and control group was over a period of 4 weeks. Results: Twenty-four patients and their f.c. (n = 24) were allocated equally in the intervention and control group. Five patients withdrew, and the final sample entered analysis was 19 patients and 19 family caregivers. In the intervention group n = 11 + 11, and in the control group n = 8 + 8. In the intervention group patients' breathlessness and anxiety levels showed improvement and their f.c.s in the anxiety and burden levels. Major consideration was the sample size and the recruitment of the patients by the referring oncologists. Attrition was minor during the study process. No harm was recorded by the participants of the study. Conclusions: The study provided evidence of the feasibility of the implementation of the educational programme. For the future definitive study major consideration should be patients' recruitment method in order to achieve adequate sample size. Moreover, qualitative data should be collected in relation to the intervention and the involvement of f.c. The feasibility study was registered to the Cyprus Bioethics Committee with the registration number 2016/16. There was no funding of the study.
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Affiliation(s)
- Aristides Choratas
- Nursing Department, Cyprus University of Technology, Limassol, Cyprus
- *Correspondence: Aristides Choratas
| | | | - Andreas Charalambous
- Nursing Department, Cyprus University of Technology, Limassol, Cyprus
- Nursing Department, University of Turku, Turku, Finland
| | - Christiana Kouta
- Nursing Department, Cyprus University of Technology, Limassol, Cyprus
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16
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Abstract
Dyspnea is a symptom commonly experienced by cancer patients that causes significant suffering, worsens throughout a patient's disease trajectory, and can be more difficult to manage than other symptoms. Assessment of dyspnea is best accomplished by a subjective description; physiologic measures are only weakly correlated with the patient's experience. It is important to consider a wide range of possible malignant and nonmalignant causes of dyspnea in cancer patients and to correct underlying causes where possible. For patients with refractory dyspnea, opioids are a safe and effective treatment. Benzodiazepines can be considered, but the evidence for their use is weak. Supplemental oxygen is beneficial if patients are hypoxemic, or if they have concurrent chronic obstructive pulmonary disease. Nonpharmacologic strategies such as fan therapy, exercise programs, and pulmonary rehabilitation can also be beneficial. One important diagnosis to consider in all cancer patients is venous thromboembolism. Prompt evaluation and treatment are vital to improving symptoms and outcomes for patients. Although dyspnea is common and potentially debilitating in cancer patients, it can be effectively managed with a structured approach to rule out reversible causes while concurrently treating the patient using appropriate therapeutic strategies.
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Affiliation(s)
- A M Crombeen
- Department of Family Medicine, Western University, London, ON
| | - E J Lilly
- Department of Family Medicine, Western University, London, ON
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17
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Mori M, Morita T, Imai K, Yokomichi N, Yamaguchi T, Masukawa K, Kizawa Y, Tsuneto S, Shima Y, Miyashita M. The Bereaved Families' Preferences for Individualized Goals of Care for Terminal Dyspnea: What Is an Acceptable Balance between Dyspnea Intensity and Communication Capacity? Palliat Med Rep 2020; 1:42-49. [PMID: 34223455 PMCID: PMC8241337 DOI: 10.1089/pmr.2020.0035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Toward the individualized care of terminally ill patients with dyspnea (“terminal dyspnea”), it is essential to identify individualized goals of care (GOC) to achieve an acceptable balance between dyspnea intensity and communication capacity. Objective: To explore preferences for individualized GOC for terminal dyspnea, and factors associated with the preferences. Design: A nationwide cross-sectional survey. Setting/Subjects: In total, 1055 bereaved families of cancer patients admitted to 167 inpatient hospices in Japan. Measurements: Preferences for individualized GOC for terminal dyspnea to achieve an acceptable balance between dyspnea intensity and communication capacity, should individuals experience continuous moderate or severe/overwhelming dyspnea despite optimal palliative care, and perceptions about a good death. Results: Among 548 participants (response rate = 52%), we analyzed responses of 477 families whose loved one suffered dyspnea in the last week of life. In total, 167 (45%; 95% confidence interval [CI] = 40%–50%) and 272 (80%; 95% CI = 75%–84%) participants would prioritize dyspnea relief over communication capacity, should they continuously suffer moderate or severe/overwhelming dyspnea, respectively. In multivariate analyses, the determinants of the prioritization of dyspnea relief were perceiving physical comfort as important for a good death (odds ratio [OR] = 1.389; 95% CI = 1.062–1.818; p = 0.017) in moderate dyspnea, and perceiving physical comfort (OR = 2.505; 95% CI = 1.718–3.651; p < 0.001) and not perceiving mental awareness (OR = 0.695; 95% CI = 0.529–0.913; p = 0.009) as important in severe/overwhelming dyspnea. Conclusions: Preferences for individualized GOC for terminal dyspnea can vary among individuals and with different symptom intensity, and may be influenced by perceptions about a good death. Outcome measurements incorporating an acceptable balance between dyspnea intensity and communication capacity should be developed.
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Affiliation(s)
- Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | | | - Kento Masukawa
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
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18
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Baker KM, Vragovic NS, Banzett RB. Intensive Care Nurses' Perceptions of Routine Dyspnea Assessment. Am J Crit Care 2020; 29:132-139. [PMID: 32114611 DOI: 10.4037/ajcc2020711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Dyspnea (breathing discomfort) is commonly experienced by critically ill patients and at this time is not routinely assessed and documented. Intensive care unit nurses at the study institution recently instituted routine assessment and documentation of dyspnea in all patients able to report using a numeric scale ranging from 0 to 10. OBJECTIVE To assess nurses' perceptions of the utility of routine dyspnea measurement, patients' comprehension of assessment questions, and the impact on nursing practice and to gather nurses' suggestions for improvement. METHODS Data were obtained from interviews with intensive care unit nurses in small focus groups and an anonymous online survey randomly distributed to nurses representing all intensive care units. RESULTS Intensive care unit nurses affirmed the importance of routine dyspnea assessment and documentation. Before implementing the measurement tool, nurses often assessed for breathing discomfort in patients by using observed signs. Most nurses agreed that routine assessment can be used to predict patients' outcomes and improve patient-centered care. Nurses found the assessment tool easy to use and reported that it did not interfere with workflow. Nurses felt that patients were able to provide meaningful ratings of dyspnea, similar to ratings of pain, and often used patients' ratings in conjunction with observed physical signs to optimize patient care. CONCLUSION Our study shows that nurses understand the importance of routine dyspnea assessment and that the addition of a simple patient report scale can improve care delivery and does not add to the burden of work-flow.
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Affiliation(s)
| | - Natalia Sullivan Vragovic
- Natalia Sullivan Vragovic is a nurse practitioner in the bone marrow transplant unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Robert B. Banzett
- Robert B. Banzett is an associate professor, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Hui D, Hernandez F, Larsson L, Liu D, Kilgore K, Naberhuis J, Virgilio A, Reddy S, Reddy A, Dalal S, Haider A, Driver L, Azhar A, Dev R, Bruera E. Prophylactic Fentanyl Sublingual Spray for Episodic Exertional Dyspnea in Cancer Patients: A Pilot Double-Blind Randomized Controlled Trial. J Pain Symptom Manage 2019; 58:605-613. [PMID: 31276809 PMCID: PMC6754768 DOI: 10.1016/j.jpainsymman.2019.06.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/22/2022]
Abstract
CONTEXT The optimal dose of fentanyl sublingual spray (FSS) for exertional dyspnea has not been determined. OBJECTIVES We examined the effect of two doses of prophylactic FSS on exertional dyspnea. METHODS In this parallel, dose-finding, double-blind randomized clinical trial, opioid-tolerant cancer patients completed a shuttle walk test at baseline. Patients completed a second shuttle walk test 10 minutes after a single dose of FSS equivalent to either 35%-45% (high dose) or 15%-25% (low dose) of the total daily opioid dose. The primary outcome was change in modified dyspnea Borg scale (0-10) between the first and second shuttle walk tests. Secondary outcomes included adverse events as well as changes in walk distance, vital signs, and neurocognitive function. RESULTS Thirty of the 50 enrolled patients completed the study. High-dose FSS (n = 13) resulted in significantly lower dyspnea (mean change -1.42; 95% CI -2.37, -0.48; P = 0.007) and greater walk distance (mean change 44 m; P = 0.001) compared to baseline. Low-dose FSS (n = 17) resulted in a nonsignificant reduction in dyspnea (mean change -0.47; 95% CI -1.26, 0.32; P = 0.24) and significant increase in walk distance (mean change 24 m; P = 0.01) compared to baseline. Global evaluation showed high-dose group was more likely to report at least somewhat better improvement (64% vs. 24%; P = 0.06). No significant adverse events or detriment to vital signs or neurocognitive function was detected. CONCLUSION Prophylactic FSS was well tolerated and demonstrated a dose-response relationship in improving both dyspnea and walk distance. High-dose FSS should be tested in confirmatory trials.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.
| | - Farley Hernandez
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Liliana Larsson
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelly Kilgore
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jane Naberhuis
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Avery Virgilio
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Suresh Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Akhila Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Haider
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Larry Driver
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ahsan Azhar
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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Huang H, Li Y, Liang H, Wu CO. Decomposition feature selection with applications in detecting correlated biomarkers of bipolar disorders. Stat Med 2019; 38:4574-4582. [PMID: 31304613 DOI: 10.1002/sim.8317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/24/2019] [Accepted: 06/14/2019] [Indexed: 12/16/2022]
Abstract
Feature selection is an important initial step of exploratory analysis in biomedical studies. Its main objective is to eliminate the covariates that are uncorrelated with the outcome. For highly correlated covariates, traditional feature selection methods, such as the Lasso, tend to select one of them and eliminate the others, although some of the eliminated ones are still scientifically valuable. To alleviate this drawback, we propose a feature selection method based on covariate space decomposition, referred herein as the "Decomposition Feature Selection" (DFS), and show that this method can lead to scientifically meaningful results in studies with correlated high dimensional data. The DFS consists of two steps: (i) decomposing the covariate space into disjoint subsets such that each of the subsets contains only uncorrelated covariates and (ii) identifying significant predictors by traditional feature selection within each covariate subset. We demonstrate through simulation studies that the DFS has superior practical performance over the Lasso type methods when multiple highly correlated covariates need to be retained. Application of the DFS is demonstrated through a study of bipolar disorders with correlated biomarkers.
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Affiliation(s)
- Hailin Huang
- Department of Statistics, The George Washington University, Washington, District of Columbia
| | - Yuanzhang Li
- Division of Preventive Medicine, Walter Reed Army Institute of Research, Washington, District of Columbia
| | - Hua Liang
- Department of Statistics, The George Washington University, Washington, District of Columbia
| | - Colin O Wu
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
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21
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Goto H, Kiyohara Y, Shindo M, Yamamoto O. Symptoms of and Palliative Treatment for Unresectable Skin Cancer. Curr Treat Options Oncol 2019; 20:34. [DOI: 10.1007/s11864-019-0626-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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22
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Haywood A, Duc J, Good P, Khan S, Rickett K, Vayne-Bossert P, Hardy JR. Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. Cochrane Database Syst Rev 2019; 2:CD012704. [PMID: 30784058 PMCID: PMC6381295 DOI: 10.1002/14651858.cd012704.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Dyspnoea is a common symptom in advanced cancer, with a prevalence of up to 70% among patients at end of life. The cause of dyspnoea is often multifactorial, and may cause considerable psychological distress and suffering. Dyspnoea is often undertreated and good symptom control is less frequently achieved in people with dyspnoea than in people with other symptoms of advanced cancer, such as pain and nausea. The exact mechanism of action of corticosteroids in managing dyspnoea is unclear, yet corticosteroids are commonly used in palliative care for a variety of non-specific indications, including pain, nausea, anorexia, fatigue and low mood, despite being associated with a wide range of adverse effects. In view of their widespread use, it is important to seek evidence of the effects of corticosteroids for the management of cancer-related dyspnoea. OBJECTIVES To assess the effects of systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Science Citation Index Web of Science, Latin America and Caribbean Health Sciences (LILACS) and clinical trial registries, from inception to 25 January 2018. SELECTION CRITERIA We included randomised controlled trials that included adults aged 18 years and above. We included participants with cancer-related dyspnoea when randomised to systemic corticosteroids (at any dose) administered for the relief of cancer-related dyspnoea or any other indication, compared to placebo, standard or alternative treatment. DATA COLLECTION AND ANALYSIS Five review authors independently assessed trial quality and three extracted data. We used means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). We assessed the risk of bias and quality of evidence using GRADE. We extracted primary outcomes of sensory-perceptual experience of dyspnoea (intensity of dyspnoea), affective distress (quality of dyspnoea) and symptom impact (burden of dyspnoea or impact on function) and secondary outcomes of serious adverse events, participant satisfaction with treatment and participant withdrawal from trial. MAIN RESULTS Two studies met the inclusion criteria, enrolling 157 participants (37 participants in one study and 120 in the other study), of whom 114 were included in the analyses. The studies compared oral dexamethasone to placebo, followed by an open-label phase in one study. One study lasted seven days, and the duration of the other study was 15 days.We were unable to conduct many of our predetermined analyses due to different agents, dosages, comparators and outcome measures, routes of drug delivery, measurement scales and time points. Subgroup analysis according to type of cancer was not possible.Primary outcomesWe included two studies (114 participants) with data at one week in the meta-analysis for change in dyspnoea intensity/dyspnoea relief from baseline. Corticosteroid therapy with dexamethasone resulted in an MD of lower dyspnoea intensity compared to placebo at one week (MD -0.85 lower dyspnoea (scale 0-10; lower score = less breathlessness), 95% CI -1.73 to 0.03; very low-quality evidence), although we were uncertain as to whether corticosteroids had an important effect on dyspnoea as results were imprecise. We downgraded the quality of evidence by three levels from high to very low due to very serious study limitations and imprecision.One study measured affective distress (quality of dyspnoea) and results were similar between groups (29 participants; very low-quality evidence). We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Both studies assessed symptom impact (burden of dyspnoea or impact on function) (113 participants; very low-quality evidence). In one study, it was unclear whether dexamethasone had an effect on dyspnoea as results were imprecise. The second study showed more improvement for physical well-being scores at days eight and 15 in the dexamethasone group compared with the control group, but there was no evidence of a difference for FACIT social/family, emotional or functional scales. We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Secondary outcomesDue to the lack of homogenous outcome measures and inconsistency in reporting, we could not perform quantitative analysis for any secondary outcomes. In both studies, the frequency of adverse events was similar between groups, and corticosteroids were generally well tolerated. The withdrawal rates for the two studies were 15% and 36%. Reasons for withdrawal included lost to follow-up, participant or carer (or both) refusal, and death due to disease progression. We downgraded the quality of evidence for these secondary outcomes by three levels from high to very low due to serious study limitations, inconsistency and imprecision.Neither study examined participant satisfaction with treatment. AUTHORS' CONCLUSIONS There are few studies assessing the effects of systemic corticosteroids on cancer-related dyspnoea in adults with cancer. We judged the evidence to be of very low quality that neither supported nor refuted corticosteroid use in this population. Further high-quality studies are needed to determine if corticosteroids are efficacious in this setting.
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Affiliation(s)
- Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
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Hui D, Hess K, Dibaj SS, Arthur J, Dev R, Dalal S, Reddy S, Bruera E. The minimal clinically important difference of the Richmond Agitation-Sedation Scale in patients with cancer with agitated delirium. Cancer 2018; 124:2246-2252. [PMID: 29469951 DOI: 10.1002/cncr.31312] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/12/2018] [Accepted: 02/03/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND The Richmond Agitation-Sedation Scale (RASS) is commonly used to assess psychomotor activity; however, to the authors' knowledge, its minimal clinically important difference (MCID) has not been determined to date. The objective of the current study was to identify the MCID for RASS using 2 anchor-based approaches. METHODS The current study was a secondary analysis of a randomized controlled trial to compare the effect of lorazepam versus placebo as an adjuvant to haloperidol for persistent agitation in patients with delirium. The primary outcome was change in RASS (10-point numeric rating scale ranging from -5 [unarousable] to +4 [combative]) from baseline to 8 hours after treatment administration. The sensitivity-specificity and within-patient change methods were used to identify the MCID, with the anchor being patient comfort after the study intervention as perceived by caregivers and nurses. RESULTS A total of 90 patients were randomized and 58 (64%) received the study medication for restlessness/agitation (mean baseline RASS, 1.6). A total of 23 caregivers (61%) and 23 nurses (55%) perceived that the patient was more comfortable after treatment. Using the sensitivity-specificity method, the optimal RASS reduction was ≥4 points according to both caregivers (sensitivity of 61% and specificity of 80%; area under the curve, 0.71) and nurses (sensitivity of 73% and specificity of 84%; area under the curve, 0.78). The RASS cutoff value based on the within-patient change method was similar (-4.2 for caregivers and -4.0 for nurses). CONCLUSIONS For patients with persistent restlessness/agitation, a reduction of ≥4 points in RASS was considered to be the MCID for both nurses and caregivers. These preliminary findings may have implications for sample size calculation and the interpretation of treatment effect in future delirium trials. Cancer 2018;124:2246-52. © 2018 American Cancer Society.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of General Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Seyedeh S Dibaj
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph Arthur
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rony Dev
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shalini Dalal
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Suresh Reddy
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Hui D, Kilgore K, Frisbee-Hume S, Park M, Liu D, Balachandran DD, Bruera E. Effect of Prophylactic Fentanyl Buccal Tablet on Episodic Exertional Dyspnea: A Pilot Double-Blind Randomized Controlled Trial. J Pain Symptom Manage 2017; 54:798-805. [PMID: 28803087 PMCID: PMC5705410 DOI: 10.1016/j.jpainsymman.2017.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/31/2017] [Accepted: 08/03/2017] [Indexed: 01/21/2023]
Abstract
CONTEXT Episodic dyspnea is one of the most common, debilitating, and difficult-to-treat symptoms. OBJECTIVE We conducted a pilot study to examine the effect of prophylactic fentanyl buccal tablet (FBT) on exercise-induced dyspnea. METHODS In this parallel, double-blind randomized placebo-controlled trial, opioid-tolerant patients were asked to complete a six-minute walk test (6MWT) at baseline and then a second 6MWT 30 minutes after a single dose of FBT (equivalent to 20-50% of their total opioid dose) or matching placebo. We compared dyspnea Numeric Rating Scale (NRS, 0-10, primary outcome), walk distance, vital signs, neurocognitive function, and adverse events between the two 6MWTs. RESULTS Among 22 patients enrolled, 20 (91%) completed the study. FBT was associated with a significant within-arm reduction in dyspnea NRS between 0 and six minutes (mean change -2.4, 95% CI -3.5, -1.3) and respiratory rate (mean change -2.6, 95% CI -4.7, -0.4). Placebo was also associated with a nonstatistically significant decrease in dyspnea (mean change -1.1). Between-arm comparison of dyspnea scores in the second 6MWT favored FBT, albeit not statistically significant (estimate -0.25, P = 0.068). Global impression revealed more patients in the FBT group than placebo group reporting their dyspnea was at least "somewhat better" in the second 6MWT (4 of 9 vs. 0 of 11, P = 0.03). The other secondary outcomes did not differ significantly between arms. CONCLUSIONS This study supports that prophylactic FBT was associated with a reduction of exertional dyspnea and was well tolerated. Our findings support the need for larger trials to confirm the therapeutic potential of rapid-onset opioids.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.
| | - Kelly Kilgore
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan Frisbee-Hume
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
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Haywood A, Duc J, Good P, Khan S, Rickett K, Vayne-Bossert P, Hardy JR. Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. Hippokratia 2017. [DOI: 10.1002/14651858.cd012704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Alison Haywood
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University; Gold Coast Australia
- Mater Research Institute - The University of Queensland; Brisbane Australia
| | - Jacqueline Duc
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
- Faculty of Medicine; University of Brisbane Brisbane Australia
- Children's Health Queensland; Paediatric Palliative Care Service; Brisbane Australia
| | - Phillip Good
- Mater Research Institute - The University of Queensland; Brisbane Australia
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
- St Vincent's Private Hospital; Department of Palliative Care; 411 Main Street Kangaroo Point Brisbane Queensland Australia 4169
| | - Sohil Khan
- School of Pharmacy, Menzies Health Institute Queensland, Griffith University; Gold Coast Australia
- Mater Research Institute - The University of Queensland; Brisbane Australia
| | - Kirsty Rickett
- UQ/Mater McAuley Library; The University of Queensland Library; Raymond Terrace Brisbane Queensland Australia 4101
| | - Petra Vayne-Bossert
- University Hospitals of Geneva; Department of Readaptation and Palliative Medicine; 11 chemin de la Savonnière Collonge-Bellerive Geneva Switzerland 1245
| | - Janet R Hardy
- Mater Research Institute - The University of Queensland; Brisbane Australia
- Mater Health Services; Department of Palliative and Supportive Care; Brisbane Australia
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Impact of dyspnea on advanced cancer patients referred to a palliative radiotherapy clinic. Support Care Cancer 2017; 25:2691-2696. [PMID: 28341970 DOI: 10.1007/s00520-017-3677-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/15/2017] [Indexed: 01/04/2023]
Abstract
PURPOSE Dyspnea is a debilitating symptom commonly experienced by advanced cancer patients that can lead to negative effects on function and quality of life (QOL). The present study aims to determine the relationship between dyspnea and other Edmonton Symptom Assessment System (ESAS) symptoms in palliative cancer patients referred to a radiotherapy clinic. METHODS The presence and severity of dyspnea was measured using the ESAS. All patients that visited a palliative radiotherapy clinic between 1999 to 2002 and 2006 to 2009 and completed the ESAS were included. ESAS scores and other demographic and clinical information were extracted from a prospectively collected database. Statistical tests including chi-squared tests, Spearman correlations, and multivariate analysis were conducted to explore the relationship between dyspnea, other ESAS items, and other demographic factors. Kaplan-Meier overall survival curves were generated based on dyspnea severity. RESULTS One thousand three hundred forty-four patients were included in the dyspnea analysis; reported moderate or severe dyspnea. Dyspnea severity was significantly associated with eight other ESAS interference severities (p < 0.001). Upon multivariate analysis, greater severity of dyspnea was significantly related to higher ESAS scores for tiredness, nausea, depression, anxious, drowsiness, and poor appetite (p < 0.05). The actuarial median survival time was 6.57 months (95% CI 5.91-7.29 months). There were highly significant differences in overall survival between those with none, mild, and moderate dyspnea (p < 0.0001). CONCLUSION Cancer patients often experience dyspnea along with a multitude of other symptoms. Moderate and severe dyspnea should be assessed and optimally managed to reduce functional and QOL debilitations. As presence of increased dyspnea severity is associated with worse overall survival, interventions should occur at the end of life to reduce symptom burden in palliative patients.
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Baker KM, DeSanto-Madeya S, Banzett RB. Routine dyspnea assessment and documentation: Nurses' experience yields wide acceptance. BMC Nurs 2017; 16:3. [PMID: 28100958 PMCID: PMC5237543 DOI: 10.1186/s12912-016-0196-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 12/12/2016] [Indexed: 01/27/2023] Open
Abstract
Background Dyspnea (breathing discomfort) is a common and distressing symptom. Routine assessment and documentation can improve management and relieve suffering. A major barrier to routine dyspnea documentation is the concern that it will have a deleterious effect on nursing workflow and that it will not be readily accepted by nurses. Nurses at our institution recently began to assess and document dyspnea on all medical-surgical patients upon admission and once per shift throughout their hospitalization. A year after dyspnea measurement was implemented we explored nurses’ approach to dyspnea assessment, their perception of patient response, and their perception of the utility and burden of dyspnea measurement. Methods We obtained feedback from nurses using a three-part assessment of practice: 1) a series of recorded focus group interviews with nurses, 2) a time-motion observation of nurses performing routine dyspnea and pain assessment, and 3) a randomized, anonymous on-line survey based, in part, on issues raised in focus groups. Results Ninety-four percent of the nurses surveyed reported administering the dyspnea assessment is “easy” or “very easy”. None of the nurses reported that assessing dyspnea negatively impacted workflow and many reported that it positively improved their practice by increasing their awareness. Our time-motion data showed dyspnea assessment and documentation takes well less than a minute. Nurses endorsed the importance of routine measurement and agreed that most patients were able to provide a meaningful rating of their dyspnea. Nurses found the patient report very useful, and used it in conjunction with observed signs to respond to changes in a patient’s condition. Conclusions In this study, we have demonstrated that routine dyspnea assessment and documentation was widely accepted by the nurses at our institution. Our nurses fully incorporated routine dyspnea assessment and documentation into their practice and felt that it improved patient-centered care. Electronic supplementary material The online version of this article (doi:10.1186/s12912-016-0196-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kathy M Baker
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, 330 Brookline Avenue Reisman 1113, Boston, MA 02215 USA
| | - Susan DeSanto-Madeya
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, 330 Brookline Avenue Reisman 1113, Boston, MA 02215 USA ; Connell School of Nursing, Boston College, Chestnut Hill, MA USA
| | - Robert B Banzett
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA ; Harvard Medical School, Boston, MA USA
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Hui D, Kilgore K, Park M, Williams J, Liu D, Bruera E. Impact of Prophylactic Fentanyl Pectin Nasal Spray on Exercise-Induced Episodic Dyspnea in Cancer Patients: A Double-Blind, Randomized Controlled Trial. J Pain Symptom Manage 2016; 52:459-468.e1. [PMID: 27401508 PMCID: PMC5075501 DOI: 10.1016/j.jpainsymman.2016.05.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 12/19/2022]
Abstract
CONTEXT Episodic breathlessness is common and debilitating in cancer patients. OBJECTIVES In this pilot study, we examined the effect of prophylactic fentanyl pectin nasal spray (FPNS) on exercise-induced dyspnea, physiologic function, and adverse events. METHODS In this parallel, double-blind randomized placebo-controlled trial, opioid-tolerant patients performed three six-minute walk tests (6MWTs) to induce dyspnea. They were randomized to receive either FPNS (15%-25% of total daily opioid dose each time) or placebo 20 minutes before the second and third 6MWTs. We compared dyspnea Numeric Rating Scale (NRS, 0-10, primary outcome), walk distance, vital signs, neurocognitive function, and adverse events between the first and second 6MWTs (T2-T1) and between the first and third 6MWTs (T3-T1). RESULTS Twenty-four patients enrolled, with 96% completion. FPNS was associated with significant within-arm reduction in dyspnea NRS at rest (T2-T1: -0.9 [95% CI -1.7, -0.1]; T3-T1: -1.3 [95% CI -2.0, -0.5]) and at the end of a 6MWT (T2-T1: -2.0 [95% CI -3.5, -0.6]; T3-T1: -2.3 [95% CI -4.0, -0.7]), and longer walk distance (T2-T1 +23.8 m [95% CI +1.3, +46.2 m]; T3-T1: +23.3 m [95% CI -1.7, +48.2]). In the placebo arm, we observed no significant change in walk distance nor dyspnea NRS at rest, but significant reduction in dyspnea NRS at six minutes (T2-T1: -1.7 [95% CI -3.3, -0.1]; T3-T1: -2.5 [95% CI -4.2, -0.9]). Vital signs, neurocognitive function, and adverse effects did not differ significantly. CONCLUSION FPNS was safe, reduced dyspnea at rest, and increased walk distance in before-after comparison. The placebo effect was substantial, which needs to be factored in future study designs. TRIAL REGISTRATION ClinicalTrials.govNCT01832402.
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Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - Kelly Kilgore
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Janet Williams
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Diane Liu
- Department of Biostatistics, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
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Hospital without dyspnea: rationale and design of a multidisciplinary intervention. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:625-31. [PMID: 27605944 PMCID: PMC4996838 DOI: 10.11909/j.issn.1671-5411.2016.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Dyspnea is a common and disabling symptom of respiratory and heart diseases, which is growing in incidence. During hospital admission, breathlessness is under-diagnosed and under-treated, although there are treatments available for controlling the symptom. We have developed a tailored implementation strategy directed to medical staff to promote the application of these pharmacological and non-pharmacological tools in dealing with dyspnea. The primary aim is to decrease the rate of patients that do not receive an adequate relief of dyspnea. This is a four-stage quasi-experimental study. The intervention consists in two teaching talks that will be taught in Cardiology and Respiratory Medicine Departments. The contents will be prepared by Palliative Care specialists, based on available tools for management of dyspnea and patients' needs. A cross-sectional study of dyspnea in hospitalized patients will be performed before and after the intervention to ascertain an improvement in dyspnea intensity due to changes in medical practices. The last phase consists in the creation of consensus protocols for dyspnea management based in our experience. The results of this study are expected to be of great value and may change clinical practice in the near future and promote a changing for the better of dyspnea care.
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The last days of life: symptom burden and impact on nutrition and hydration in cancer patients. Curr Opin Support Palliat Care 2016; 9:346-54. [PMID: 26509860 DOI: 10.1097/spc.0000000000000171] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW To examine the symptom burden in cancer patients during the last days of life, its impact on nutrition and hydration, and the role of artificial nutrition and hydration in the final days. RECENT FINDINGS During the last days of life, cancer patients often experience progressive functional decline and worsening symptom burden. Many symptoms such as anorexia-cachexia, dysphagia, and delirium could impair oral intake. These, coupled with refractory cachexia, contribute to persistent weight loss and decreased quality of life. Furthermore, the inability to eat/drink and body image changes can result in emotional distress for patients and caregivers. Clinicians caring for these individuals need to ensure longitudinal communication about goals of care, education about the natural process of dying, optimization of symptom management, and provide appropriate emotional support for patients and caregivers. There is a lack of evidence to support that artificial nutrition and hydration can improve outcomes during the last days of life. Artificial nutrition is not recommended because of its invasive nature, whereas artificial hydration may be considered on a case-by-case basis. SUMMARY This review highlights the need to conduct further research on symptom burden, nutrition, and hydration during the last days of life.
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Ekström M, Vergo MT, Ahmadi Z, Currow DC. Prevalence of Sudden Death in Palliative Care: Data From the Australian Palliative Care Outcomes Collaboration. J Pain Symptom Manage 2016; 52:221-7. [PMID: 27220950 DOI: 10.1016/j.jpainsymman.2016.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/20/2016] [Accepted: 02/13/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Advanced, life-limiting illnesses are likely to have a predictable functional decline through a terminal phase to death, but some patients may also die suddenly. To date, empirical evidence characterizing "sudden death" in hospice/palliative care is lacking. OBJECTIVES The aim of this study was to determine prevalence and clinicodemographic predictors of sudden death in hospice/palliative care. METHODS This is a longitudinal consecutive cohort study of prospectively collected national data in 104 specialist palliative care services from the Australian Palliative Care Outcomes Collaboration. Patients who died between July 1, 2013, and June 30, 2014, with one or more measurement of Australian-modified Karnofsky Performance Status (AKPS) in the last 30 days of life were included. "Sudden death" was defined as a lowest AKPS score of 50 or more in the last seven days of life and excluded anyone with "terminal phase" as their last phase before death. Predictors were defined using logistic regression. RESULTS In total, 13,966 patients were included, mean age 73.6 (SD 13.6) years, 46% women, and 77% had cancer. During the seven days before death, there were 20,992 AKPS measurements; median 1 (interquartile range 1-2) per patient. Four percent of deaths (one of 25) were sudden, predicted independently by having lung cancer (odds ratio [OR] 2.64), cardiovascular disease (OR 1.94), other cancers (OR 1.63), being male (OR 1.23), younger, worse fatigue, and worse breathlessness. Sudden death was associated with higher rates of death at home (OR 3.2; 95% CI 2.9 to 3.6). CONCLUSION This study quantifies rates of sudden death in hospice/palliative care and has implications for conversations about prognosis between clinicians, patients, and their families.
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Affiliation(s)
- Magnus Ekström
- Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden; Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia.
| | - Maxwell T Vergo
- Palliative Medicine and Hospice Care, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Zainab Ahmadi
- Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia; Palliative Medicine and Hospice Care, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Goto H, Yoshikawa S, Otsuka M, Omodaka T, Yoshimi K, Yoshida Y, Yamamoto O, Kiyohara Y. Symptom prevalence in patients with advanced skin cancer. J Dermatol 2016; 44:123-126. [PMID: 27451253 DOI: 10.1111/1346-8138.13527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 06/19/2016] [Indexed: 01/04/2023]
Abstract
Knowledge of the prevalence of symptoms in patients with incurable cancer in the terminal stage is important for clinicians. However, there has been no report on the prevalence of symptoms in patients with incurable skin cancer. We analyzed the prevalence of symptoms in 224 patients who died due to skin cancer in our center. These data were obtained from medical records compiled by a miscellaneous population of medical staff retrospectively. We evaluated the symptoms at 3 months, 1 month, 2 weeks, 1 week and 3 days before the patients died. Data for symptoms included Eastern Cooperative Oncology Group performance status and the presence or absence of the following 13 symptoms: (i) bleeding or exudate; (ii) pain or necessity for an analgesic; (iii) fatigue; (iv) anorexia; (v) nausea; (vi) dyspnea or need for oxygen administration; (vii) bloating; (viii) insomnia; (ix) delirium; (x) drowsiness; (xi) anemia; (xii) spasm; and (xiii) paralysis. The average performance status gradually progressed. Pain and anorexia were the most common symptoms in patients with advanced skin cancer. Dyspnea, anemia and drowsiness also tended to be frequent as death approached despite the fact that the frequencies of these symptoms were not high 3 months before death. We considered that frequencies of prevalence of pain and dyspnea were due to bone and lung metastases. Bleeding or exudate from lesions is a characteristic symptom in patients with skin cancer. Our results regarding the prevalence of symptoms in patients with advanced skin cancer will be helpful for medical professionals to assess patients' conditions and to plan treatment.
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Affiliation(s)
- Hiroyuki Goto
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan.,Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Tottori, Japan
| | | | - Masaki Otsuka
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Kosuke Yoshimi
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yuichi Yoshida
- Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Osamu Yamamoto
- Division of Dermatology, Department of Medicine of Sensory and Motor Organs, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Yoshio Kiyohara
- Department of Dermatology, Shizuoka Cancer Center, Shizuoka, Japan
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Hui D, Kilgore K, Frisbee-Hume S, Park M, Tsao A, Delgado Guay M, Lu C, William W, Pisters K, Eapen G, Fossella F, Amin S, Bruera E. Dexamethasone for Dyspnea in Cancer Patients: A Pilot Double-Blind, Randomized, Controlled Trial. J Pain Symptom Manage 2016; 52:8-16.e1. [PMID: 27330023 PMCID: PMC4958556 DOI: 10.1016/j.jpainsymman.2015.10.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT Dexamethasone is often used to treat dyspnea in cancer patients, but evidence is lacking. OBJECTIVES We determined the feasibility of conducting a randomized trial of dexamethasone in cancer patients and estimated the efficacy of dexamethasone in the treatment of dyspnea. METHODS In this double-blind, randomized, controlled trial, patients with dyspnea ≥4 were randomized to receive either dexamethasone 8 mg twice daily × four days then 4 mg twice daily × three days or placebo for seven days, followed by an open-label phase for seven days. We documented the changes in dyspnea (0-10 numeric rating scale), spirometry measures, quality of life, and toxicities. RESULTS A total of 41 patients were randomized and 35 (85%) completed the blinded phase. Dexamethasone was associated with a significant reduction in dyspnea numeric rating scale of -1.9 (95% CI -3.3 to -0.5, P = 0.01) by Day 4 and -1.8 (95% CI -3.2 to -0.3, P = 0.02) by Day 7. In contrast, placebo was associated with a reduction of -0.7 (95% CI -2.1 to 0.6, P = 0.38) by Day 4 and -1.3 (95% CI -2.4 to -0.2, P = 0.03) by Day 7. The between-arm difference was not statistically significant. Drowsiness improved with dexamethasone. Dexamethasone was well tolerated with no significant toxicities. CONCLUSION A double-blind, randomized, controlled trial of dexamethasone was feasible with a low attrition rate. Our preliminary data suggest that dexamethasone may be associated with rapid improvement in dyspnea and was well tolerated. Further studies are needed to confirm our findings. TRIAL REGISTRATION ClinicalTrials.govNCT01670097.
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Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - Kelly Kilgore
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Susan Frisbee-Hume
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Minjeong Park
- Department of Biostatistics, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Anne Tsao
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Marvin Delgado Guay
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Charles Lu
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - William William
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Pisters
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - George Eapen
- Department of Pulmonary Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Frank Fossella
- Department of Thoracic Medical Oncology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Sapna Amin
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
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Ekström M, Allingham SF, Eagar K, Yates P, Johnson C, Currow DC. Breathlessness During the Last Week of Life in Palliative Care: An Australian Prospective, Longitudinal Study. J Pain Symptom Manage 2016; 51:816-23. [PMID: 26802626 DOI: 10.1016/j.jpainsymman.2015.12.311] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 11/20/2022]
Abstract
CONTEXT Breathlessness is a major cause of suffering and distress, and little is known about the trajectory of breathlessness near death. OBJECTIVES To determine the trajectory and clinical-demographic factors associated with breathlessness in the last week of life in patients receiving specialist palliative care. METHODS This was a prospective, longitudinal cohort study using national data on specialist palliative care from the Australian Palliative Care Outcomes Collaboration. We included patients in the Australian Palliative Care Outcomes Collaboration who died between July 1, 2013 and June 30, 2014 with at least one measurement of breathlessness on a 0-10 numerical rating scale in the week before death. The trajectory and factors associated with breathlessness were analyzed using multivariate random-effects linear regression. RESULTS A total 12,778 patients from 87 services (33,404 data points) were analyzed. The average observed breathlessness was 2.1 points and remained constant over time. Thirty-five percent reported moderate to severe distress (numerical rating scale ≥4) at some time in their last week. Factors associated with higher breathlessness were younger age, male gender, cardiopulmonary involvement, concurrent fatigue, nausea, pain, sleeping problems, higher Australia-modified Karnofsky Performance Status, and clinical instability in the multivariate analysis. Respiratory failure showed the largest association (mean adjusted difference 3.1 points; 95% confidence interval, 2.8-3.4). CONCLUSION Although breathlessness has been reported to worsen in the last months, the mean severity remained stable in the final week of life. In specialized palliative care, one in three people experienced significant breathlessness especially in respiratory disease.
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Affiliation(s)
- Magnus Ekström
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; Division of Respiratory Medicine & Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden.
| | - Samuel F Allingham
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kathy Eagar
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Patsy Yates
- School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Claire Johnson
- The Cancer and Palliative Care Research and Evaluation Unit, School of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
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Dong ST, Costa DSJ, Butow PN, Lovell MR, Agar M, Velikova G, Teckle P, Tong A, Tebbutt NC, Clarke SJ, van der Hoek K, King MT, Fayers PM. Symptom Clusters in Advanced Cancer Patients: An Empirical Comparison of Statistical Methods and the Impact on Quality of Life. J Pain Symptom Manage 2016; 51:88-98. [PMID: 26300025 DOI: 10.1016/j.jpainsymman.2015.07.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/11/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022]
Abstract
CONTEXT Symptom clusters in advanced cancer can influence patient outcomes. There is large heterogeneity in the methods used to identify symptom clusters. OBJECTIVES To investigate the consistency of symptom cluster composition in advanced cancer patients using different statistical methodologies for all patients across five primary cancer sites, and to examine which clusters predict functional status, a global assessment of health and global quality of life. METHODS Principal component analysis and exploratory factor analysis (with different rotation and factor selection methods) and hierarchical cluster analysis (with different linkage and similarity measures) were used on a data set of 1562 advanced cancer patients who completed the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. RESULTS Four clusters consistently formed for many of the methods and cancer sites: tense-worry-irritable-depressed (emotional cluster), fatigue-pain, nausea-vomiting, and concentration-memory (cognitive cluster). The emotional cluster was a stronger predictor of overall quality of life than the other clusters. Fatigue-pain was a stronger predictor of overall health than the other clusters. The cognitive cluster and fatigue-pain predicted physical functioning, role functioning, and social functioning. CONCLUSIONS The four identified symptom clusters were consistent across statistical methods and cancer types, although there were some noteworthy differences. Statistical derivation of symptom clusters is in need of greater methodological guidance. A psychosocial pathway in the management of symptom clusters may improve quality of life. Biological mechanisms underpinning symptom clusters need to be delineated by future research. A framework for evidence-based screening, assessment, treatment, and follow-up of symptom clusters in advanced cancer is essential.
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Affiliation(s)
- Skye T Dong
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia; University of Aberdeen, Aberdeen, UK.
| | - Daniel S J Costa
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, New South Wales, Australia; University of Aberdeen, Aberdeen, UK
| | - Phyllis N Butow
- Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; University of Aberdeen, Aberdeen, UK
| | - Melanie R Lovell
- Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia; HammondCare, Greenwich Hospital, Sydney, New South Wales, Australia; University of Aberdeen, Aberdeen, UK
| | - Meera Agar
- The University of Sydney Medical School, Sydney, New South Wales, Australia; University of NSW, South West Sydney Clinical School, Sydney, New South Wales, Australia; Discipline of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; University of Aberdeen, Aberdeen, UK
| | - Galina Velikova
- St James's Hospital, Leeds, UK; University of Aberdeen, Aberdeen, UK
| | - Paulos Teckle
- Canadian Centre for Applied Research in Cancer Control, BC Cancer Research Centre, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Canada; University of Aberdeen, Aberdeen, UK
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia; University of Aberdeen, Aberdeen, UK
| | - Niall C Tebbutt
- Olivia Newton-John Cancer and Wellness Centre, Austin Health, Melbourne, Victoria, Australia; University of Aberdeen, Aberdeen, UK
| | - Stephen J Clarke
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, New South Wales, Australia; University of Aberdeen, Aberdeen, UK
| | - Kim van der Hoek
- Canadian Centre for Applied Research in Cancer Control, BC Cancer Research Centre, Vancouver, Canada; University of Aberdeen, Aberdeen, UK
| | - Madeleine T King
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, New South Wales, Australia; Central Clinical School, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; University of Aberdeen, Aberdeen, UK
| | - Peter M Fayers
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway; University of Aberdeen, Aberdeen, UK
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Abstract
Pulmonary rehabilitation, as a quality of life intervention, has a role to play in palliative care for lung cancer patients. Combining the art and skills of clinical care, physiological, and behavioral tools, pulmonary rehabilitation can serve to rebuild the functional capacity of patients limited by breathlessness and deconditioning. Exercise programs are the primary tool used to restore and rebuild the patient's endurance by challenging the entire pathway of oxygen transport and improving gas exchange. Other tools of pulmonary rehabilitation include breathing retraining, self-management skills, airway clearance techniques, bronchodilitation, smoking cessation and oxygen therapy. Pulmonary rehabilitation is now becoming a part of supportive care for patients undergoing chemotherapy and radiation therapy. The ability to be more active without suffering the consequences of dyspnea on exertion boosts the patient's self-efficacy and allows for an improved quality of life, so that lung cancer patients can participate in their family lives during this therapeutic challenge.
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Hui D, dos Santos R, Chisholm GB, Bruera E. Symptom Expression in the Last Seven Days of Life Among Cancer Patients Admitted to Acute Palliative Care Units. J Pain Symptom Manage 2015; 50:488-94. [PMID: 25242021 PMCID: PMC4366352 DOI: 10.1016/j.jpainsymman.2014.09.003] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 08/28/2014] [Accepted: 09/12/2014] [Indexed: 11/26/2022]
Abstract
CONTEXT The symptom burden in the last week of life of patients with advanced cancer has not been well characterized. OBJECTIVES To examine the frequency, intensity, and predictors for symptoms in the last seven days of life among patients who were able to communicate and died in an acute palliative care unit (APCU). METHODS We systematically documented the Edmonton Symptom Assessment System (ESAS) daily and 15 symptoms twice daily on consecutive advanced cancer patients admitted to APCUs at MD Anderson Cancer Center (U.S.) and Barretos Cancer Hospital (Brazil) from admission to death or discharge in 2010/2011. We examined the frequency and intensity of the symptoms from death backward. RESULTS A total of 203 of 357 patients died. The proportion of patients able to communicate decreased from 80% to 39% over the last seven days of life. ESAS anorexia (P = 0.001 in longitudinal analyses), drowsiness (P < 0.0001), fatigue (P < 0.0001), poor well-being (P = 0.01), and dyspnea (P < 0.0001) increased in intensity closer to death. In contrast, ESAS depression (P = 0.008) decreased over time. Dysphagia to solids (P = 0.01) and liquids (P = 0.005) as well as urinary incontinence (P = 0.0002) also were present in an increasing proportion of patients in the last few days of life. In multivariate analyses, female sex, non-Hispanic race, and lung cancer were significantly associated with higher ESAS symptom expression (odds ratio > 1). CONCLUSION Despite intensive management in APCUs, some cancer patients continue to experience high symptom burden as they approached death.
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Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - Renata dos Santos
- Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil
| | - Gary B Chisholm
- Department of Biostatistics, M. D. Anderson Cancer Center, Houston, Texas, USA; Division of Bioinformatics and Computational Biology, M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA
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Abstract
BACKGROUND The Respiratory Distress Observation Scale(©) is an innovative solution to assessment when a dyspnea report cannot be elicited. The Respiratory Distress Observation Scale has acceptable reliability and validity psychometrics. AIM To identify distress-intensity cut-points of the Respiratory Distress Observation Scale. DESIGN Receiver operating characteristic curve analysis was conducted with inpatients stratified by four levels of respiratory distress-none, mild, moderate, or severe. Patients provided three self-report measures of dyspnea: dichotomous (yes/no); a ranking of none, mild, moderate, or severe; and a numerical rating scale. Respiratory distress was assessed using the Respiratory Distress Observation Scale instrument. SETTING/PARTICIPANTS Participants were 136 adult inpatients, mean age 61.8 years (standard deviation = 13.18 years), 89.7% African American, and 56.6% female, who were recruited from an urban, tertiary care hospital in the Midwest of the United States. RESULTS In all, 47% (n = 64) self-reported dyspnea (yes/no). Ranking was distributed as follows: none = 36, mild = 35, moderate = 40, and severe = 25. Numerical rating scale scores ranged from 0 to 10, mean = 4.99 (standard deviation = 2.9). Respiratory Distress Observation Scale scores ranged from 0 to 7, median (interquartile range) = 2 (1-3). Receiver operating characteristic curve analysis-determined Respiratory Distress Observation Scale score of 0-2 suggests little or no respiratory distress; score ≥3 signified moderate to severe distress. CONCLUSION A Respiratory Distress Observation Scale score ≥3 signifies a patient's need for palliation of respiratory distress. An end-point for identifying responsiveness to treatment, in other words, respiratory comfort, is Respiratory Distress Observation Scale <3. Because patients with imminent respiratory failure, as typified by dying patients, were not represented yielding lower than expected Respiratory Distress Observation Scale scores, further substantiation is needed to determine moderate or severe cut-points.
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Guirimand F, Sahut d'izarn M, Laporte L, Francillard M, Richard JF, Aegerter P. Sequential occurrence of dyspnea at the end of life in palliative care, according to the underlying cancer. Cancer Med 2015; 4:532-9. [PMID: 25644607 PMCID: PMC4402068 DOI: 10.1002/cam4.419] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/22/2014] [Accepted: 12/28/2014] [Indexed: 12/15/2022] Open
Abstract
Dyspnea is a symptom that severely affects the quality of life of terminally ill patients. Its frequency differs considerably between studies. We aimed to characterize the frequency of dyspnea in a palliative care hospital (PCH) and to identify factors predisposing to dyspnea, particularly during the very last days of life, as a function of the underlying disease. Episodes of dyspnea were identified by the computerized extraction of prospectively collected data from the reports of care assistants or from medical observations recorded in the medical files for all stays at our PCH during the last 6 years. There were 6455 hospital stays, 88% ending in the death of the patient; 13,282 episodes of dyspnea were recorded during 2608 hospital stays (40%). Dyspnea was more frequently observed in cases of cancer than in other conditions (RR = 1.30; 95% CI: 1.14–1.48). Pulmonary metastasis increased the risk of dyspnea from 37% to 51% (RR = 1.37; 95% CI: 1.29–1.46). Dyspnea frequency varied with the primary cancer site, from 24% (brain cancer) to 60% (esophageal cancer). The data for cancer patients staying for more than 6 days who subsequently died indicated that 8% of patients experienced dyspnea exclusively during the last 4 days of the life, independently of the site of the primary cancer. Dyspnea during the last few days of life requires systematic assessment. Exclusively terminal dyspnea should be distinguished from more precocious dyspnea, as the pathophysiological mechanisms and treatments of these two forms are probably different.
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Affiliation(s)
- Frédéric Guirimand
- Pôle Recherche SPES ("Soins Palliatifs En Société"), Maison Médicale Jeanne Garnier, Paris, 75015, France
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Hui D, Xu A, Frisbee-Hume S, Chisholm G, Morgado M, Reddy S, Bruera E. Effects of prophylactic subcutaneous fentanyl on exercise-induced breakthrough dyspnea in cancer patients: a preliminary double-blind, randomized, controlled trial. J Pain Symptom Manage 2014; 47:209-17. [PMID: 23830530 PMCID: PMC3808512 DOI: 10.1016/j.jpainsymman.2013.03.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 03/19/2013] [Accepted: 03/24/2013] [Indexed: 01/22/2023]
Abstract
CONTEXT Dyspnea is one of the most distressing symptoms in patients with cancer, and often worsens with breakthrough episodes on exertion. We hypothesized that fentanyl given prophylactically may alleviate breakthrough dyspnea. OBJECTIVES To determine the feasibility of conducting a randomized trial of subcutaneous fentanyl in patients with cancer, and examine the effects of fentanyl on dyspnea, walk distance, vital signs, and adverse events. METHODS In this double-blind, randomized, controlled trial, we asked ambulatory patients with breakthrough dyspnea to perform a baseline six minute walk test (6MWT), and then assigned them to either subcutaneous fentanyl or placebo 15 minutes before a second 6MWT. We documented the change in dyspnea Numeric Rating Scale (NRS) score, walk distance, vital signs, and adverse events between the first and second 6MWT. RESULTS A total of 20 patients were enrolled (1:1 ratio) without attrition. Comparison between baseline and second walk showed that fentanyl was associated with significant improvements in dyspnea NRS score at the end of the 6MWT (mean [95% CI] -1.8 [-3.2, -0.4]), dyspnea NRS score at rest of 15 minutes after drug administration (-0.9 [-1.8, -0.04]), Borg Scale fatigue score at the end of the 6MWT (-1.3 [-2.4, -0.2]), 6MWT distance (+37.2m [5.8, 68.6]), and respiratory rate (-2.4 [-4.5, -0.3]). Nonstatistically significant improvements also were observed in the placebo arm, with no difference between the two study arms. No significant adverse effects were observed. CONCLUSION Prophylactic fentanyl was safe and improved dyspnea, fatigue, walk distance, and respiratory rate. We also observed a large placebo effect. Our results justify larger randomized controlled trials with higher fentanyl doses (clinicaltrials.gov registration: NCT01515566).
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Affiliation(s)
- David Hui
- Department of Palliative Care and Rehabilitation Medicine, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
| | - Angela Xu
- Department of Palliative Care and Rehabilitation Medicine, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Susan Frisbee-Hume
- Department of Palliative Care and Rehabilitation Medicine, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Gary Chisholm
- Department of Biostatistics, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Margarita Morgado
- Department of Palliative Care and Rehabilitation Medicine, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Suresh Reddy
- Department of Palliative Care and Rehabilitation Medicine, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Currow DC, Ekstrom M, Abernethy AP. Opioids for Chronic Refractory Breathlessness: Right Patient, Right Route? Drugs 2013; 74:1-6. [DOI: 10.1007/s40265-013-0162-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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