Dyspnea in hospitalized advanced cancer patients: subjective and physiologic correlates

Dyspnea-Related Dimensions And Self-Efficacy: Associations With Well-Being in Advanced Lung Cancer

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.

Common and distinct risk factors that influence more severe and distressing shortness of breath profiles in oncology outpatients

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.

The role of corticosteroids in the palliation of dyspnea in cancer patients: an evidence-based review

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.

Higher Lifetime Stress and Symptom Burden Contribute to the Occurrence of Shortness of Breath

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.

Effect of Dexmedetomidine for Palliative Sedation for Refractory Dyspnoea in Patients with Terminal-Stage Cancer

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.

Systematic review of the literature on the occurrence and characteristics of dyspnea in oncology patients

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.

Effect of dexamethasone on dyspnoea in patients with cancer (ABCD): a parallel-group, double-blind, randomised, controlled trial

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.

Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life

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.

Research policy in supportive care and palliative care for cancer dyspnea

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.

Management of Dyspnea in Advanced Cancer: ASCO Guideline

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 .

Nonpharmacological Interventions for Managing Breathlessness in Patients With Advanced Cancer: A Systematic Review

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.

Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer

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.

Developing and Assessing the Effectiveness of a Nurse-Led Home-Based Educational Programme for Managing Breathlessness in Lung Cancer Patients. A Feasibility Study

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.

Management of dyspnea in palliative care

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.

The Bereaved Families' Preferences for Individualized Goals of Care for Terminal Dyspnea: What Is an Acceptable Balance between Dyspnea Intensity and Communication Capacity?

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.

Intensive Care Nurses' Perceptions of Routine Dyspnea Assessment

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.

Prophylactic Fentanyl Sublingual Spray for Episodic Exertional Dyspnea in Cancer Patients: A Pilot Double-Blind Randomized Controlled Trial

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.

Decomposition feature selection with applications in detecting correlated biomarkers of bipolar disorders

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.

Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults

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.

The minimal clinically important difference of the Richmond Agitation-Sedation Scale in patients with cancer with agitated delirium

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.

Effect of Prophylactic Fentanyl Buccal Tablet on Episodic Exertional Dyspnea: A Pilot Double-Blind Randomized Controlled Trial

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.

Impact of dyspnea on advanced cancer patients referred to a palliative radiotherapy clinic

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.

Routine dyspnea assessment and documentation: Nurses' experience yields wide acceptance

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.

Impact of Prophylactic Fentanyl Pectin Nasal Spray on Exercise-Induced Episodic Dyspnea in Cancer Patients: A Double-Blind, Randomized Controlled Trial

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.

Hospital without dyspnea: rationale and design of a multidisciplinary intervention

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.

The last days of life: symptom burden and impact on nutrition and hydration in cancer patients

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.

Prevalence of Sudden Death in Palliative Care: Data From the Australian Palliative Care Outcomes Collaboration

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.

Symptom prevalence in patients with advanced skin cancer

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.

Dexamethasone for Dyspnea in Cancer Patients: A Pilot Double-Blind, Randomized, Controlled Trial

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.

Breathlessness During the Last Week of Life in Palliative Care: An Australian Prospective, Longitudinal Study

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.

Symptom Clusters in Advanced Cancer Patients: An Empirical Comparison of Statistical Methods and the Impact on Quality of Life

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.

Pulmonary Rehabilitation and Palliative Care for the Lung Cancer Patient

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.

Symptom Expression in the Last Seven Days of Life Among Cancer Patients Admitted to Acute Palliative Care Units

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.

Intensity cut-points for the Respiratory Distress Observation Scale

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.

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

Dyspnea is a symptom that severely affects the quality of life of terminally ill patients. Its frequency differs considerably between studies. We aimed to characterize the frequency of dyspnea in a palliative care hospital (PCH) and to identify factors predisposing to dyspnea, particularly during the very last days of life, as a function of the underlying disease. Episodes of dyspnea were identified by the computerized extraction of prospectively collected data from the reports of care assistants or from medical observations recorded in the medical files for all stays at our PCH during the last 6 years. There were 6455 hospital stays, 88% ending in the death of the patient; 13,282 episodes of dyspnea were recorded during 2608 hospital stays (40%). Dyspnea was more frequently observed in cases of cancer than in other conditions (RR = 1.30; 95% CI: 1.14–1.48). Pulmonary metastasis increased the risk of dyspnea from 37% to 51% (RR = 1.37; 95% CI: 1.29–1.46). Dyspnea frequency varied with the primary cancer site, from 24% (brain cancer) to 60% (esophageal cancer). The data for cancer patients staying for more than 6 days who subsequently died indicated that 8% of patients experienced dyspnea exclusively during the last 4 days of the life, independently of the site of the primary cancer. Dyspnea during the last few days of life requires systematic assessment. Exclusively terminal dyspnea should be distinguished from more precocious dyspnea, as the pathophysiological mechanisms and treatments of these two forms are probably different.

Effects of prophylactic subcutaneous fentanyl on exercise-induced breakthrough dyspnea in cancer patients: a preliminary double-blind, randomized, controlled trial

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).