Corticosteroids in terminal cancer--a prospective analysis of current practice

Development of Care Pathway for Assessment and Treatment of Fatigue in Palliative Care

Objectives

Fatigue is a frequent and burdensome symptom in patients with advanced disease in palliative care. However, it is under-assessed and undertreated in clinical practice, even though many treatment options have been identified in systematic reviews. Care pathways with defined and standardised steps have been recommended for effective management in the clinical setting. This paper describes a care pathway for managing fatigue in palliative care patients. This study aims to develop a care pathway with detailed guidance for screening, assessment, diagnosis, and treatment of fatigue in palliative care patients.

Material and methods

A collaborative effort of multidisciplinary clinicians participated in constructing the care pathway. The care pathway was developed using the following steps: (a) Developing an intervention; (b) piloting and feasibility; (c) evaluating the intervention; (d) reporting; and (e) implementation. This paper covers the first step, which includes the evidence base identification, theory identification/development, and process/outcomes modeling. A literature search was conducted to understand the extent of the fatigue problem in the palliative care setting and identify existing guidelines and strategies for managing fatigue. Consistent recommendations emanating from the included papers were then contributed to a care pathway. Patient representatives and palliative care professionals provided feedback on the draft.

Results

The care pathway address the following care processes: (1) Screening for the presence of fatigue; (2) assessment to evaluate the severity of fatigue; (3) diagnostic procedure, including history, physical examination, and laboratory finding; (4) therapeutic management pathway for clinical decision-making; and (5) valuation of treatment effect, using questionnaires, diaries and physical activity monitoring with body-worn sensors.

Conclusion

The development of a care pathway will help to implement regular and structured assessment, diagnosis, and treatment of fatigue for healthcare professionals treating palliative care patients. Reviewing the pathway with a multidisciplinary expert group and field testing the pathway will be the next steps toward implementation.

A narrative review of the principal glucocorticoids employed in cancer

Glucocorticoids (GCs) are a pharmacological class of drugs widely used in oncology in both supportive and palliative settings. GCs differentially impact organs with immediate and long-term effects; with suppressive effect on the immune system anchoring their use to manage the toxicities of immune checkpoint inhibitors (ICIs). In addition, GCs are often used in the management of symptoms related to cancer or chemotherapy and as adjuvants in the treatment of pain in the management of other. In the palliative setting, GCs, especially administered subcutaneously can be to assist in the control of nausea, dyspnea, asthenia, and anorexia-cachexia syndrome. In this narrative review, we aim to summarize the role of GCs in the different settings (curative, supportive, and palliative) to help clinicians use these important drugs in their daily clinical practice with cancer patients.

Combination Therapy of Physical Activity and Dexamethasone for Cancer-Related Fatigue: A Phase II Randomized Double-Blind Controlled Trial

BACKGROUND

Despite the high frequency of cancer-related fatigue (CRF) and its debilitating effects on the quality of life of patients with advanced cancer, there are limited treatment options available. Treatments including physical activity (PA) or dexamethasone (Dex) improve CRF; however, they have lower adherence rates (PA) or long-term adverse effects (Dex). The aim of this study was to determine the feasibility of and preliminary results for the combination of PA and Dex in improving CRF.

METHODS

In this phase II randomized controlled trial, patients with advanced cancer and CRF scores of ≥4/10 on the Edmonton Symptom Assessment Scale were eligible. Patients were randomized to standardized PA for 4 weeks with either 4 mg of Dex (LoDex arm) or 8 mg of Dex (HiDex arm) twice a day for 7 days. Feasibility and change in the Functional Assessment of Cancer Illness Therapy-Fatigue subscale (FACIT-F) from baseline to day 8 and day 29 (primary outcome) were assessed. Secondary outcomes included changes in fatigue dimensions (FACIT-General, Patient-Reported Outcomes Measurement Information System [PROMIS]-Fatigue).

RESULTS

A total of 60 of 67 (90%) patients were evaluable. All patients were adherent to study medication. We found that 84% and 65% of patients in the LoDex arm and 96% and 68% of patients in the HiDex arm were adherent to aerobic and resistance exercise, respectively. The FACIT-F effect size in the LoDex arm was 0.90 (P<.001) and 0.92 (P<.001) and the effect size in the HiDex arm was 0.86 and 1.03 (P<.001 for both) at days 8 and 29, respectively. We found significant improvements in the Functional Assessment of Cancer Therapy-Physical (P≤.013) and the PROMIS-Fatigue (P≤.003) at days 8 and 29 in both arms. Mixed-model analysis showed a significant improvement in the FACIT-F scores at day 8 (P<.001), day 15 (P<.001), and day 29 (P=.002). Changes in the FACIT-F scores were not significantly different between patients in the 2 arms (P=.86).

CONCLUSIONS

Our study found that the combination therapy of PA with Dex was feasible and resulted in the improvement of CRF. The improvement was seen for up to 3 weeks after the discontinuation of Dex. Further larger studies are justified.

CLINICALTRIALS

gov identifier: NCT02491632.

Effects of exercise in patients with connective tissue disease receiving high-dose glucocorticoids: A pilot prospective cohort study

PURPOSE

High doses of glucocorticoids induce skeletal muscle weakness. The aim of this study was to evaluate the effects of exercise therapy on skeletal muscle strength, mass, and exercise capacity in patients with connective tissue disease treated with high doses of glucocorticoids.

METHODS

This prospective, observational, single-center, cohort study included 35 patients aged ≥ 15 years diagnosed with connective tissue disease who received high-dose glucocorticoids and physical training. Exercise therapy, including moderate aerobic and strength training, was performed five times a week. Knee extension strength, skeletal muscle mass, anaerobic threshold, and peak oxygen consumption were measured at the beginning of exercise therapy and at discharge.

RESULTS

After 6 weeks of aerobic and strength exercises, skeletal muscle mass significantly decreased by 5.5%, right knee extension decreased by 11.6%, and left knee extension decreased by 9.7%. The anaerobic threshold and peak oxygen consumption significantly increased by 13.0% and 9.0%, respectively. The increase in glucocorticoid dose was inversely correlated with changes in knee extension strength.

CONCLUSION

In patients with connective tissue disease being treated with high-dose glucocorticoids, exercise therapy might attenuate the decrease in skeletal muscle mass and strength and increase the anaerobic threshold and peak oxygen consumption, thus moderating the side effects of high-dose glucocorticoid treatment. Trial registration The trial is registered with UMIN (University Hospital Medical Information Network), ID number UMIN000038836.

Practice review: Evidence-based quality use of corticosteroids in the palliative care of patients with advanced cancer

BACKGROUND

It would be unusual for a patient with advanced cancer not to be prescribed corticosteroids at some stage of their disease course for a variety of specific and non-specific indications.

AIM

The aim of this practice review was to provide a pragmatic overview of the evidence supporting current practice and to identify areas in which further research is indicated.

DESIGN

A 'state-of-the-art' review approach was used to examine the evidence supporting the use of corticosteroids for the management of cancer-related complications and in symptom control, in the context of known risks and harms to inform quality use of this medicine. We developed 'Do', 'Do not', and 'Don't know' recommendations based on current literature and identified areas for future investigation and research.

DATA SOURCES

We searched MEDLINE, EMBASE and the Cochrane library from inception to 14th October 2020. Our initial search limited to reviews, reviews of reviews, randomised controlled trials (RCTs) and controlled trials was supplemented by supporting literature as appropriate.

RESULTS

Evidence to support common practice in the use of corticosteroids is lacking for most indications. This is in the context of strong evidence for the potential for significant toxicity and poor quality use of medicine.

CONCLUSION

Guidelines recommending the widespread use of corticosteroids should acknowledge the poor evidence base supporting much current dogma. Quality research is essential not only to define the role of corticosteroids in this context but to ensure good prescribing practice.

Predictors of the Usefulness of Corticosteroids for Cancer-Related Fatigue in End-of-Life Patients

BACKGROUND AND OBJECTIVES

Although some studies have examined the use of corticosteroids, their effectiveness in treating cancer-related fatigue (CRF) has yet to be established. Therefore, this retrospective study attempted to identify factors that would predict the usefulness of corticosteroids in treating CRF.

METHODS

We examined 87 hospitalized end-of-life cancer patients who were given betamethasone for relief of CRF at our hospital between January 2008 and January 2014. We evaluated the effect of betamethasone at 3 days after administration and performed a multivariate logistic regression analysis designed to identify predictive factors for the usefulness of corticosteroids. Threshold measurements were examined using a receiver operating characteristic (ROC) curve.

RESULTS

This analysis identified the initial daily dose of betamethasone [odds ratio (OR) = 1.662], days from the start date of betamethasone administration to the date of death (OR = 1.05), administration of fentanyl (OR = 0.206) and age (OR = 1.055) as significant factors related to the effect of betamethasone. ROC curve analysis of the effect of the betamethasone showed that the threshold for the initial daily dose of betamethasone was above 4 mg, the threshold for the days from the start date of the betamethasone administration to the date of death was above 16 days and the threshold for age was above 60 years old.

CONCLUSION

The initial daily dose of betamethasone, days from the start date of the betamethasone administration to the date of death, non-administration of fentanyl and advanced age were shown to be predictive factors for the usefulness of corticosteroids for CRF in end-of-life patients.

A Prospective Observational Study on Effect of Short-Term Periodic Steroid Premedication on Bone Metabolism in Gastrointestinal Cancer (ESPRESSO-01)

BACKGROUND

A multicenter prospective observational study evaluated the effect of gastrointestinal cancer chemotherapy with short-term periodic steroid premedication on bone metabolism.

PATIENTS AND METHODS

Seventy-four patients undergoing chemotherapy for gastrointestinal cancer were studied. The primary endpoints were changes in bone mineral densities (BMDs) and metabolic bone turnover 16 weeks after initiation of chemotherapy. BMDs, measured by dual-energy x-ray absorptiometry, and serum cross-linked N-telopeptides of type I collagen (sNTX), and bone alkaline phosphatase (sBAP) were assessed for evaluation of bone resorption and formation, respectively.

RESULTS

In 74.3% (55/74) of the patients, BMDs were significantly reduced at 16 weeks relative to baseline. The percent changes of BMD were -1.89% (95% confidence interval [CI], -2.67% to -1.11%: p < .0001) in the lumbar spine, -2.24% (95% CI, -3.59% to -0.89%: p = .002) in the total hip, and -2.05% (95% CI, -3.11% to -0.99%: p < .0001) in the femoral neck. Although there was no significant difference in sNTX levels during 16 weeks (p = .136), there was a significant increase in sBAP levels (p = .010). Decreased BMD was significantly linked to number of chemotherapy cycles (p = .02). There were no significant correlations between changes in BMDs and the primary site of malignancy, chemotherapy regimens, total cumulative steroid dose, steroid dose intensity, and additive steroid usage.

CONCLUSION

Gastrointestinal cancer chemotherapy with periodic glucocorticoid premedication was associated with reduced BMD and increased sBAP levels, which were linked to number of chemotherapy cycles but independent of primary site, chemotherapy regimen, duration, and additive steroid usage. The Oncologist 2017;22:592-600 IMPLICATIONS FOR PRACTICE: Bone health and the management of treatment-related bone loss are important for cancer care. The present study showed that a significant decrease in bone mineral density (BMD) and an increase in serum bone alkaline phosphatase levels occurred in gastrointestinal cancer patients receiving chemotherapy, which were linked to number of chemotherapy cycles but were independent of primary site, chemotherapy regimen, total steroid dose, and steroid dose intensity. Surprisingly, it seems that the decreasing BMD levels after only 16 weeks of chemotherapy for gastrointestinal cancer were comparable to that of 12-month adjuvant aromatase inhibitor therapy for early-stage breast cancer patients.

Predictors of Delirium in Corticosteroid-Treated Patients with Advanced Cancer: An Exploratory, Multicenter, Prospective, Observational Study

BACKGROUND

Corticosteroids are often used to treat fatigue and anorexia, but occasionally produce delirium. Information on the predictors of delirium in corticosteroid-treated cancer patients remains limited.

OBJECTIVE

To identify potential factors predicting the development of delirium in corticosteroid-treated cancer patients.

DESIGN

An exploratory, multicenter, prospective, observational study.

SETTING/SUBJECTS

Inclusion criteria for this study were patients who had metastatic or locally advanced cancer and a fatigue or anorexia intensity score of 4 or more on a 0-10 Numerical Rating Scale.

MEASUREMENT

Univariate and multivariable analyses were performed to identify the predictors of delirium diagnosed by the Confusion Assessment Method (CAM) within three days of initiation of corticosteroids.

RESULTS

Among 207 patients administered corticosteroids, 35 (17%; 95% confidence interval [CI] 12%-23%) developed at least one episode of delirium diagnosed by the CAM. Factors predictive of the development of delirium were as follows: Palliative Performance Scale ≤20, Eastern Cooperative Oncology Group Performance Status (ECOG PS) = 4, the Support Team Assessment Schedule (STAS) score of drowsiness >1, concurrent opioid use, parenteral hydration volume ≤500 mL, and the absence of lung metastasis. A multivariable analysis identified the independent factors predicting responses as ECOG PS = 4 (odds ratio [OR] 4.0; 95% CI 1.7-9.3), STAS score of drowsiness >1 (OR 3.4; 95% CI 1.4-8.2), and concurrent opioid use (OR 3.7; 95% CI 1.0-13).

CONCLUSION

Delirium in corticosteroid-treated advanced cancer patients may be predicted by PS, drowsiness, and concurrent opioid use. Larger prospective studies are needed to confirm these results.

Management of Chronic Postthoracotomy Pain

Postthoracotomy pain management is essential imme diately after surgery and crucial for the patient suffering from this problem for a long duration. Understanding the causative and pathophysiological basis for this condition requires frequent assessment and a multidi mensional approach. Inadequate pain control has detri mental effects on the routine activities of patients as well as on their physical and emotional well-being. During the last 2 decades, the understanding of various pain-related issues has been strengthened resulting in early intervention and pain management. Various phar macological modalities including the role of nonopiates, opiates, and adjuvant drugs are helpful in combating postthoracotomy pain. A selective group of patients will benefit from interventional techniques. The treat ment decision requires a clear understanding of the disease and its impact on the patient. There must also be an understanding of risk and benefits as well as cost and benefits for various drugs and techniques before selecting the appropriate therapy.

A little help from steroids in oncology

Steroids are widely used in oncology and have been demonstrated to possess an anticancer effect or antiswelling effect. They are considered to improve refractory symptoms such as dyspnea or gastrointestinal (GI) obstruction. However, their roles in nonspecific indications are not well proved. Clinical practice and several studies suggest that corticosteroids may be effective in the treatment of bone and neuropathic pain, when administered along with opioids and with other adjuvant analgesics. The decrease in pain intensity is probably connected with both anti-inflammatory and antiswelling effects as well as modulation of neuroimmune interactions and an inhibition of angiogenesis.

Investigation of Optimal Time for Starting Betamethasone Using Fatigue Scores and Prognostic Nutritional Index in Terminally Ill Patients With Cancer-Related Fatigue

BACKGROUND

Corticosteroids are frequently used to treat cancer-related fatigue (CRF), but it is yet to be established as standard care, and few reports have defined the appropriate time to start treatment.

OBJECTIVES

We investigated the optimal time for starting betamethasone and evaluated the clinical validity of using the prognostic nutritional index (PNI) for this purpose.

METHODS

Data were retrospectively collected for patients with terminal cancer receiving betamethasone for palliative care. Fatigue strength was evaluated by the daily occurrence of fatigue, using proportion of adequate fatigue, AF(%), defined as the average of the daily score for all treatment days, AF(%)_all, the initial 5 days, AF(%)_initi5, or the last 5 days, AF(%)_last5. We examined (1) the relationship between survival time and adequate fatigue for CRF and (2) the correlation between survival time and PNI (based on serum albumin and lymphocytes).

RESULTS

Data from 24 patients were included. The AF(%)_all was approximately 50% at 42 days before death and gradually decreased as the survival time shortened ( R² =.41, P <.001). There was a clear positive correlation between AF(%)_all and AF(%)_initi5 ( R² =.84, P <.001). At 42 days before death, PNI was approximately 30 and significantly correlated with the survival time ( R² = .873, P <.001).

CONCLUSION

The adequate fatigue appears to be dependent on survival time, and PNI might be useful for identifying patients that will benefit from betamethasone use. It is hoped that these results will contribute to individualized pharmacotherapy of terminally ill patients with CRF.

Opportunities for targeting the fatigue-anorexia-cachexia symptom cluster

Cancer patients experience multiple symptoms throughout their illness trajectory. Symptoms consistently occurring together, known as symptom clusters, share common pathophysiologic mechanisms. Understanding and targeting such symptom clusters may allow for more effective and efficient use of treatments for a variety of symptoms. Fatigue-anorexia-cachexia is one of the most prevalent symptom clusters and significantly impairs quality of life. In this review, we explore the fatigue-anorexia-cachexia symptom cluster and focus on current and emerging therapies with an emphasis on pharmacologic management.

Corticosteroids in palliative care - perspectives of clinicians involved in prescribing: a qualitative study

Background

Corticosteroids are commonly prescribed in palliative care for alleviation of both specific and non-specific symptoms, but relatively little is known of the perspectives of clinicians and what influences their prescribing in this context. The aim of this study was to explore the experiences and perspectives of those involved in the prescribing of corticosteroids in palliative care.

Methods

Semi-structured interviews were undertaken with 12 medical practitioners and six senior nurses from a sample of six New Zealand hospices to identify their experiences and attitudes regarding the prescribing of corticosteroids. A general inductive approach was used to thematically analyse data.

Results

Five broad themes were identified: the role of corticosteroids in palliative care; indications for corticosteroids; influences on prescribing; use of guidelines; and perceptions of previous study data on prescribing patterns for their hospice. Interviewees regarded these agents as having an important place in in palliative care but expressed a degree of uncertainty about certain aspects of their use. They were concerned about issues such as prescribing for non-specific indications, methods of stopping, and lack of monitoring and reviewing. Guidelines were used routinely by only one of the sample hospices. Corticosteroids tended to be prescribed experientially or by habit, rather than based on evidence-based guidelines.

Conclusions

This study has highlighted differences in the understanding of the place of corticosteroids in palliative care by the clinicians interviewed in this study and different practices, particularly in the treatment of non-specific symptoms and in the use of guidelines. These findings suggest a need for further research and discussion about the role of corticosteroids in palliative care and the development of evidence-based guidelines to assist prescribers.

Corticosteroid prescribing in palliative care settings: a retrospective analysis in New Zealand

BACKGROUND

Corticosteroids are a potent group of medicines, with many adverse effects, that are widely prescribed in palliative care for both specific and non-specific indications. The aim of this study was to document current patterns of corticosteroid prescribing in New Zealand palliative care settings and to reflect on whether they were in line with international experience.

METHODS

A retrospective review of inpatient use of corticosteroids was undertaken in a sample of six New Zealand hospices. Data were collected on numbers of patients prescribed corticosteroids, indications for use, choice of agent, doses and dosage changes, duration of course, incidence of adverse effects, method of stopping, use of guidelines, and processes for monitoring and review.

RESULTS

The case notes of 1179 inpatients were reviewed and 768 patients (65.1%) had received at least one course of corticosteroids. There was a marked consistency in the proportion of patients prescribed corticosteroids among the sample hospices (61-69%). Detailed information was recorded for a sample of 260 patients. Corticosteroids were prescribed most commonly for non-specific reasons (40.4% of prescribing events), followed by neurological (25.3%) and soft tissue infiltration symptoms (14.4%). The agent of choice was dexamethasone with a dose range of 1 mg to 40 mg and a median dose of 8 mg. The median course duration for all corticosteroid prescribing events was 29 days. Abrupt stopping occurred in 72 (23.2%) cases, of these 35 (49%) had been on a course of corticosteroids for more than three weeks. Guidelines were only available in one hospice. Monitoring and review was documented in 135 (52%) of cases, and adverse effects were recorded in 82 (32%); these are likely to be underestimates due to a high level of non-recording.

CONCLUSIONS

This New Zealand study showed that corticosteroids are widely prescribed in palliative care, most commonly for non-specific indications. These findings are consistent with the international literature in this area and this large, multi-site study adds weight to the findings and the need for ongoing discussion about the place of these drugs in palliative care.

Reduction of cancer-related fatigue with dexamethasone: a double-blind, randomized, placebo-controlled trial in patients with advanced cancer

PURPOSE

Cancer-related fatigue (CRF) is the most common symptom in patients with advanced cancer. The primary objective of this prospective, randomized, double-blind, placebo-controlled study was to compare the effect of dexamethasone and placebo on CRF.

PATIENTS AND METHODS

Patients with advanced cancer with ≥ three CRF-related symptoms (ie, fatigue, pain, nausea, loss of appetite, depression, anxiety, or sleep disturbance) ≥ 4 of 10 on the Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomly assigned to either dexamethasone 4 mg or placebo orally twice per day for 14 days. The primary end point was change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) subscale from baseline to day 15. Secondary outcomes included anorexia, anxiety, depression, and symptom distress scores.

RESULTS

A total of 84 patients were evaluable (dexamethasone, 43; placebo, 41). Mean (± standard deviation) improvement in the FACIT-F subscale at day 15 was significantly higher in the dexamethasone than in the placebo group (9 [± 10.3] v 3.1 [± 9.59]; P = .008). The improvement in FACIT-F total quality-of-life scores was also significantly better for the dexamethasone group at day 15 (P = .03). The mean differences in the ESAS physical distress scores at day 15 were significantly better for the dexamethasone group (P = .013, respectively). No differences were observed for ESAS overall symptom distress (P = .22) or psychological distress score (P = .76). Frequency of adverse effects was not significantly different between groups (41 of 62 v 44 of 58; P = .14).

CONCLUSION

Dexamethasone is more effective than placebo in improving CRF and quality of life in patients with advanced cancer.

Can you help me feel less exhausted all the time?

A 64-year-old woman with metastatic rectal cancer is admitted to the acute palliative care unit of our cancer center because of debilitating fatigue. She had been diagnosed with metastatic disease in 2009, when liver metastases were found 1 year after the primary treatment of her rectal cancer with preoperative radiotherapy and low anterior resection. Since then, she had been treated with resection of liver metastases in 2009 and 2010, palliative combination chemotherapy (oxaliplatin plus capecitabine) after the diagnosis of new liver and lung metastases in 2010, irinotecan in 2011, and then cetuximab until progression. She declined participation in a phase I clinical trial because she was afraid of experiencing adverse effects; she felt relatively well at the time. She had functioned without hindering symptoms until 2 weeks before admission. Her condition had deteriorated markedly since then. At admission, she is bedridden because of progressive fatigue. Furthermore, she complains of dyspnea and nausea and vomits approximately twice per day. She also suffers from pain in the upper abdomen, especially when rising from the bed. She is no longer able to care for her 84-year-old husband or her 40-year-old mentally disabled son, who lives with them. She is aware of her poor prognosis but is not able to share her sorrows with her family.

The role of corticosteroids in the treatment of pain in cancer patients

Pain is one of the most frequent and most distressing symptoms in the course of cancer. The management of pain in cancer patients is based on the concept of the World Health Organization (WHO) analgesic ladder and was recently updated with the EAPC (European Association for Palliative Care) recommendations. Cancer pain may be relieved effectively with opioids administered alone or in combination with adjuvant analgesics. Corticosteroids are commonly used adjuvant analgesics and play an important role in neuropathic and bone pain treatment. However, in spite of the common use of corticosteroids, there is limited scientific evidence demonstrating their efficacy in cancer patients with pain. The use of corticosteroids in spinal cord compression, superior vena cava obstruction, raised intracranial pressure, and bowel obstruction is better established than in other nonspecific indications. This review aims to present the role of steroids in pain and management of other symptoms in cancer patients according to the available data, and discusses practical aspects of steroid use.

Physician-reported corticosteroid therapy practices in certified palliative care units in Japan: a nationwide survey

BACKGROUND

Although corticosteroids are commonly used for symptom relief in the treatment of patients with advanced cancer, few studies have addressed nationwide physician-reported practices and attitudes toward corticosteroid therapy in palliative care settings.

DESIGN AND SUBJECTS

To clarify physician-reported practices and attitudes toward corticosteroid therapy for anorexia, fatigue, and dyspnea, a 15-item questionnaire was mailed to all 178 certified palliative care units in Japan.

RESULTS

In total, 124 physicians returned questionnaires (response rate of 70%). The median percentage receiving corticosteroids among all terminally ill cancer inpatients was 80% (fatigue, 80%; anorexia, 80%; dyspnea, 80%). Physicians reported varying methods and attitudes regarding corticosteroid use in palliative care settings. Regarding withdrawal when patient death was imminent, 46% of respondents usually abruptly ceased corticosteroid use, while 33% reduced but did not stop administration, and 21% neither stopped nor reduced corticosteroids. As for dosage, 47% of physicians selected a minimum daily dose for fatigue <2 mg, while 51% chose 2-4 mg. As for administration period, 50% started administering corticosteroids for dyspnea regardless of the prognosis, while 30% regarded a predicted survival of less than 3 months to be an indication for corticosteroid treatment. For side effect management, 48% did not principally prescribe corticosteroids for patients with hyperactive delirium, while 44% cautiously prescribed corticosteroids.

CONCLUSION

The use of corticosteroids is very common in Japanese palliative care units, but physicians reported varying practices and attitudes regarding administration protocols. Future studies are needed to determine the standard treatment protocol for corticosteroid use in the terminally ill.

Efficacy and undesirable effects of corticosteroid therapy experienced by palliative care specialists in Japan: a nationwide survey

BACKGROUND AND METHODS

Corticosteroids are commonly used for symptom relief in the treatment of patients with advanced cancer. Consistent efficacy of corticosteroid treatment in palliative care remains controversial. A cross-sectional anonymous survey was mailed to representative managing physicians in certified palliative care units in Japan to clarify the physician-perceived efficacy of steroid treatment on anorexia, fatigue, and dyspnea in terminal cancer patients, to clarify physicians' experience of side effects of corticosteroid use, and to determine the Japanese palliative care physician-reported predictive factors for efficacy and lack of efficacy.

RESULTS AND CONCLUSIONS

Many Japanese palliative care specialists perceived that corticosteroids are effective for each of the symptoms, are aware of the prevalence and importance of serious adverse effects, and predict the effectiveness of steroid therapy by etiological factors.

The emotional consequences of corticosteroid use in hematology: preliminary findings

This article presents the findings from a pilot study conducted as a first step in understanding the myriad psychological and psychiatric sequelae stemming from the use of steroids for hematology patients. Descriptions of the side effects experienced by 10 hematology patients undergoing steroid treatment are documented and discussed. Steroid usage can have a range of physical and emotional side effects on patients, including hematology patients. The insights are a serious reminder to all who care for hematology patients that the psychological and psychiatric side effects of steroids need to be taken seriously.

Can observational studies provide a realistic alternative to randomized controlled trials in palliative care?

Evidence-based medicine demands 'gold standard' randomized controlled trials (RCTs). If strict criteria of quality, validity, and size are met, observational studies give the same result. Given the dearth of RCTs in palliative care, our aim was to identify good observational studies using PubMed searches and e-mail letters to experts in palliative care. The prior intention was provide the most comprehensive description possible to date of observational studies in palliative care, rather than to perform any statistical analyses. Three hundred and forty abstracts of study reports were identified, of which 27% (91) included > or = 200 subjects and 8% (27) > or = 1000 subjects. In reports with > or = 200 subjects, 51% included only cancer patients, and 42% included heterogeneous 'palliative care' patients. Prospective and retrospective studies accounted for 38% and 32% of all reports with > or = 200 subjects. In reports with > or = 1000 subjects, 59% were retrospective and 19% prospective. Patients had some input in 26% of studies with > or = 200 subjects, and 15% with > or = 1000 subjects. Only 12 prospective reports had one specific intervention. We found that palliative care is deficient not only in RCTs, but also good quality observational studies. Those that exist are extremely heterogeneous in subject, design, outcome reporting, and intervention.

The use of corticosteroids in Swedish palliative care

Corticosteroids are commonly used in patients with advanced cancer on both specific and non-specific indications. They are potent drugs with potentially serious adverse side effects. We have in two separate surveys collected answers from 302 physicians and data from 1292 patients on corticosteroid prescription attitudes and clinical practice in Swedish palliative care. Corticosteroids were used in more than 50% of the cancer patients and with high response rates when treating appetite loss, nausea, fatigue or poor wellbeing. The positive response came within the first week of treatment and persisted beyond four weeks. Patients with prostate cancer had a significantly better treatment response of corticosteroids on fatigue as compared to patients with lung cancer. Few physicians had guidelines on the use of corticosteroids in advanced cancer and there were differences in the attitudes between different medical specialties. Guidelines based on prospective clinical trials are needed.

Symptom management in the older adult

Palliative care begins at the time of diagnosis of a life-threatening illness and continues beyond the time of death. Defined in the broadest sense, the goal of palliative care is to provide aggressive symptom management and address the psychological and spiritual needs of the patient and the family. This article reviews the management of some symptoms commonly observed in older patients, highlighting treatment considerations specific to the older population. Ultimately the approach to symptoms must be individualized, and treatment decisions must reflect the patient's goals of care. Although symptom management in older patients may be challenging, it is possible to provide care that significantly enhances quality of life throughout the course of illness.

Medical decompressive therapy for primary and metastatic intracranial tumours

Medical decompressive therapy (MDT) with corticosteroids and mannitol is often used in patients with primary or metastatic brain tumours. This review highlights the lack of sound evidence regarding the indications and dosage schedule of steroids, prolonged use of which may cause debilitating complications. The available evidence supports the short-term use of MDT for raised intracranial pressure or progressive neurological deficits, but in the absence of these symptoms, MDT is not recommended for stable focal deficits, abnormal higher mental functions, seizures, or as prophylaxis during cranial irradiation. A practical stepladder guideline (based on symptom severity) is proposed with a starting daily dexamethasone dose of 6 mg for non-severe headache and or vomiting; 12 mg for progressive focal neurological deficit with or without non-severe headache or vomiting; and 24 mg dexamethasone with mannitol for severe headache, vomiting, or altered consciousness. Depending on the clinical response, dose can be increased to the next step(s) or tapered every 48 h (more slowly in patients who are dependent on steroids). A scheme for the assessment of efficacy and toxicity prevention is also proposed. The proposed guidelines may be used as a template for further clinical research.

Supportive therapy of elderly cancer patients

Elderly cancer patients often require supportive care due to the physiologic decline of organs and apparatus linked with the aging process per se, and for the effects of tumor or of anticancer treatments. Pain and nutritional deficits are some clinical aspects requiring supportive care. Lack of studies on these latter topics does not allow an in depth analysis of the problem. The present review deals with literature concerning pain and nutritional problems in the general cancer population with emphasis on aspects typical for elderly cancer subjects. Physiologic and cancer-related changes in body composition, physical function and cognitive capacity of the elderly are presented and, when appropriate, linked with pathogenetic factors of pain and malnutrition, as well as their treatment. Pain demographic data, pain intensity evaluation and currently available techniques to provide pain relief such as etiologic treatment, analgesic pharmacotherapy and invasive analgesic procedures, are extensively discussed. Causes and assessment of malnutrition as well as available nutritional approaches such as oral, enteral and parenteral nutrition are also debated.

Modern management of the cancer anorexia-cachexia syndrome

The cancer anorexia-cachexia syndrome is common, occurring in 80% of patients with advanced-stage cancer, and it is one of the most frequent causes of death in patients with cancer. It is a complex problem involving abnormalities in protein, carbohydrate, and fat metabolism. Tumors have both direct and indirect effects that result in anorexia and weight loss. The disease burden does not necessarily correlate with the degree of cachexia. In addition to the physical manifestations, the resulting abnormalities have a significant psychologic effect on patients and their families. Although there is no treatment to reverse the process, pharmacologic and nonpharmacologic measures can enhance food intake and improve quality of life.

Modern management of the cancer anorexia-cachexia syndrome

The cancer anorexia-cachexia syndrome is common, occurring in 80% of patients with advanced-stage cancer, and it is one of the most frequent causes of death in patients with cancer. It is a complex problem involving abnormalities in protein, carbohydrate, and fat metabolism. Tumors have both direct and indirect effects that result in anorexia and weight loss. The disease burden does not necessarily correlate with the degree of cachexia. In addition to the physical manifestations, the resulting abnormalities have a significant psychologic effect on patients and their families. Although there is no treatment to reverse the process, pharmacologic and nonpharmacologic measures can enhance food intake and improve quality of life.

Corticosteroids in the management of bowel obstruction on a gynecological oncology unit

The development of gastrointestinal obstruction commonly occurs as a complication of advanced gynecological cancer. While surgery remains the mainstay of treatment for these patients, it is not always feasible, and when it is performed, it does not always resolve the obstruction. In this prospective study of patients presenting to a gynecologic oncology unit, 13 patients were administered 8 mg of dexamethasone subcutaneously or intravenously for a minimum of 3 days to manage the symptoms of bowel obstruction. Nine patients (69%) had a response to this therapy with decreased pain, nausea, and vomiting and improved oral intake. This response was maintained for a median of 31 days, with 7 of the 9 patients maintaining this symptomatic response until death. Mean survival of those responding was 39 days, including a subgroup of patients with extremely limited prognosis who, at their request, were discharged from the hospital in order to die at home. This subgroup had a mean survival of 20 days. The mean survival for nonresponders was 54 days. In patients for whom surgery is not contemplated, corticosteroids may provide a palliative treatment for bowel obstruction secondary to malignancy, provided there are no contraindications.

The palliation of dyspnea in terminal disease

Dyspnea is a complex subjective experience that is common in terminal illness. Patients may present at any time during the course of their illness, although prevalence increases with disease progression. Dyspnea has physical, psychological, social and spiritual components; without recognizing how each of these contributes to the total suffering of dyspnea, management is unlikely to be successful. The management of dyspnea involves both pharmacological and non-pharmacological treatment. The main pharmacological palliative treatments are oxygen, opioids, and benzodiazepines, but the evidence to support these treatments is limited. More research is urgently needed to establish the efficacy of current treatments and to identify new ones.

A review of the drug treatment of cachexia associated with cancer

In the past 20 years, cachexia in cancer patients has attracted increasing interest from both clinicians and basic researchers. It is now clear that the cachexia is secondary to major metabolic abnormalities due to tumour by-products and cytokine release. These metabolic abnormalities produce numerous symptoms such as cachexia, anorexia and asthenia. There are now effective drugs such as corticosteroids and progestational drugs that have been shown to improve appetite, food intake and sensation of well-being, and which elicit bodyweight gain. While hydrazine (hydrazine sulfate) has received much attention, unfortunately it has been shown to be ineffective in improving the symptoms of the patient with cancer cachexia. A new group of drugs, such as thalidomide and melatonin because of their effects on tumour necrosis factor-alpha, and beta 2-adrenoceptor agonists because of their effects on muscle metabolism, and other agents, is presently reaching the clinical trial stage. There is now the possibility of addressing this fascinating syndrome at a different level and an opportunity for combined therapy to try to improve the quality of life of these patients.

Anorexia in older persons: epidemiology and optimal treatment

Anorexia and weight loss are common findings in older persons. Over a life-time, normal persons decrease their food intake to counterbalance the decrease in physical activity and resting metabolic rate that occurs with aging. This physiological anorexia of aging increases the propensity to develop pathological anorexia and weight loss when an older person develops either a medical or psychological illness. The physiological anorexia of aging is due to a decreased opioid (dynorphin) feeding drive and an increase in the satiating effect of the gastrointestinal hormone, cholecystokinin. Nitric oxide deficiency may play a role in the early satiation commonly seen in older persons. A variety of social, psychological and medical conditions can lead to pathological anorexia. Depression is the most common cause of weight loss and anorexia in older persons. A number of conditions such as cancer and rheumatoid arthritis produce their anorectic and wasting effects by releasing cytokines. An idiopathic pathological senile anorexia has been characterised which also appears to be a cytokine-dependent syndrome. Early screening for malnutrition is a cornerstone of the management of anorexia; the Mini Nutritional Assessment is a well validated screening tool available for this purpose. Aggressive use of caloric supplements, enteral tube feeding and peripheral parenteral nutrition all have a role in the early management of anorexia. Numerous drugs (growth hormone, megestrol, cyproheptadine, tetrahydrocannabinol, anabolic steroids, prokinetic agents and antidepressants) have been utilised to treat the anorexia of aging with varying success.

Adjuvant analgesic agents

Adjuvant analgesics are usually considered when the patient with cancer pain fails to attain a satisfactory balance between analgesia and side effects during opioid therapy, or experiences a comorbid symptom or disorder that may be amenable to one of the adjuvant drugs. When pain is the primary indication, the use of adjuvant analgesics is one strategy that must be evaluated in comparison with other potentially analgesic approaches. The potential costs, inconvenience, and risks associated with polypharmacy must be balanced by demonstrable benefits. To offer the most informed recommendation, the clinician must have a strong working knowledge of the many drugs currently used as adjuvant analgesics and a detailed assessment of the patient and pain syndrome.

Anorexia, cachexia, and dysphagia: the symptom experience

OBJECTIVES

To review the symptoms of anorexia, cachexia, and dysphagia and to provide information on nutritional assessment and interventions.

DATA SOURCES

Published studies of anorexia, cachexia, and dysphagia, research abstracts, and review articles.

CONCLUSIONS

Anorexia, cachexia, and dysphagia can cause severe alterations in nutrition in cancer patients that may lead to irreversible nutritional compromise and death. Nursing research must focus on symptom management of these three symptoms, the needs of the patient and family, and the impact of dysphagia on quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Assessment, objective evaluation, pharmacological interventions, and nutritional counseling are important interventions for patients with anorexia and cachexia. Swallowing therapy, food intake adjustments, oral hygiene, and supportive care are important measures needed by the patient with dysphagia.

Pain Control Research in the Terminally ILL

The realities of clinical practice as well as the intricacies of basic science must be taken into account by future research into pain control for the terminally ill. Attention is also needed to the integration of various approaches to pain control in order to develop the best possible treatment plan for each individual. An encouraging development in this regard is the rapid growth of interdisciplinary pain clinics and hospice programs. A review of the research literature also suggests that the politics of pain control is another topic requiring closer attention. As a recent National Institutes of Health conference has found, pain control is often inadequate across all settings: acute pain, chronic non-malignant pain, and pediatric pain. It is necessary not only to make further strides in pain control per se, but also to identify those factors that facilitate or hinder the dissemination and implementation of improved techniques. The two main goals in care of the terminally ill are to optimize the quality of their remaining life and to alleviate the distress of their survivors. Pain control research has contributed significantly to meeting those goals, but continued progress is needed in both basic studies and the expanded application of new techniques.

Corticosteroids as adjuvant analgesics

Corticosteroids have multiple effects as adjuvant drugs in pain management. Their pharmacologic characteristics will be described. Studies documenting the efficacy of corticosteroids for different pain syndromes and other cancer-related symptoms will be reviewed. Practical guidelines will be given and directions for future research suggested.