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Affiliation(s)
- Catherine Sweeney
- Department of Palliative Care and Rehabilitation Medicine, University of Texas M.D. Anderson Cancer Center, Houston, Texas, U.S.A
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, University of Texas M.D. Anderson Cancer Center, Houston, Texas, U.S.A
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Affiliation(s)
- Eric E. Prommer
- Division of Hematology/Oncology, Veterans Integrated Palliative Care Program, Veterans Integrated Palliative Care, David Geffen School of Medicine, University of California, Los Angeles, California
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Varani S, Dall'Olio FG, Messana R, Tanneberger S, Pannuti R, Pannuti F, Biasco G. Clinical and demographic factors associated to the place of death in advanced cancer patients assisted at home in Italy. PROGRESS IN PALLIATIVE CARE 2014. [DOI: 10.1179/1743291x14y.0000000094] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Cardoso F, Bese N, Distelhorst SR, Bevilacqua JLB, Ginsburg O, Grunberg SM, Gralla RJ, Steyn A, Pagani O, Partridge AH, Knaul FM, Aapro MS, Andersen BL, Thompson B, Gralow JR, Anderson BO. Supportive care during treatment for breast cancer: resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement. Breast 2013; 22:593-605. [PMID: 24001709 PMCID: PMC7442957 DOI: 10.1016/j.breast.2013.07.050] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 07/23/2013] [Indexed: 12/20/2022] Open
Abstract
Breast cancer patients may have unmet supportive care needs during treatment, including symptom management of treatment-related toxicities, and educational, psychosocial, and spiritual needs. Delivery of supportive care is often a low priority in low- and middle-income settings, and is also dependent on resources available. This consensus statement describes twelve key recommendations for supportive care during treatment in low- and middle-income countries, identified by an expert international panel as part of the 5th Breast Health Global Initiative (BHGI) Global Summit for Supportive Care, which was held in October 2012, in Vienna, Austria. Panel recommendations are presented in a 4-tier resource-stratified table to illustrate how health systems can provide supportive care services during treatment to breast cancer patients, starting at a basic level of resource allocation and incrementally adding program resources as they become available. These recommendations include: health professional and patient and family education; management of treatment related toxicities, management of treatment-related symptoms of fatigue, insomnia and non-specific pain, and management of psychosocial and spiritual issues related to breast cancer treatment. Establishing supportive care during breast cancer treatment will help ensure that breast cancer patients receive comprehensive care that can help 1) improve adherence to treatment recommendations, 2) manage treatment-related toxicities and other treatment related symptoms, and 3) address the psychosocial and spiritual aspects of breast cancer and breast cancer treatments.
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Affiliation(s)
| | - Nuran Bese
- Acibadem Maslak Hospital Breast Health, Istanbul, Turkey
| | | | | | - Ophira Ginsburg
- Women’s College Research Institute, Faculty of Medicine, Dalla Lana School of Public Health, University of Toronto, Canada
| | - Steven M. Grunberg
- Multinational Association of Supportive Care in Cancer, Shelburne, Vermont, USA
| | | | - Ann Steyn
- Reach to Recovery International; Reach to Recovery South Africa, Cape Town. South Africa
| | - Olivia Pagani
- European School of Oncology and Institute of Oncology of Southern Switzerland, Viganello, Switzerland
| | | | - Felicia Marie Knaul
- Harvard Global Equity Initiative, Boston, Massachusetts, USA; Tómatelo a Pecho A.C., Mexico City, Mexico
| | | | | | - Beti Thompson
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Julie R. Gralow
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Seattle Cancer Care Alliance, University of Washington, Seattle, Washington, USA
| | - Benjamin O. Anderson
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Seattle Cancer Care Alliance, University of Washington, Seattle, Washington, USA
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Roy S, Ninkovic J, Banerjee S, Charboneau RG, Das S, Dutta R, Kirchner VA, Koodie L, Ma J, Meng J, Barke RA. Opioid drug abuse and modulation of immune function: consequences in the susceptibility to opportunistic infections. J Neuroimmune Pharmacol 2011; 6:442-65. [PMID: 21789507 DOI: 10.1007/s11481-011-9292-5] [Citation(s) in RCA: 217] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 06/27/2011] [Indexed: 12/13/2022]
Abstract
Infection rate among intravenous drug users (IDU) is higher than the general public, and is the major cause of morbidity and hospitalization in the IDU population. Epidemiologic studies provide data on increased prevalence of opportunistic bacterial infections such as TB and pneumonia, and viral infections such as HIV-1 and hepatitis in the IDU population. An important component in the intravenous drug abuse population and in patients receiving medically indicated chronic opioid treatment is opioid withdrawal. Data on bacterial virulence in the context of opioid withdrawal suggest that mice undergoing withdrawal had shortened survival and increased bacterial load in response to Salmonella infection. As the body of evidence in support of opioid dependency and its immunosuppressive effects is growing, it is imperative to understand the mechanisms by which opioids exert these effects and identify the populations at risk that would benefit the most from the interventions to counteract opioid immunosuppressive effects. Thus, it is important to refine the existing animal model to closely match human conditions and to cross-validate these findings through carefully controlled human studies. Better understanding of the mechanisms will facilitate the search for new therapeutic modalities to counteract adverse effects including increased infection rates. This review will summarize the effects of morphine on innate and adaptive immunity, identify the role of the mu opioid receptor in these functions and the signal transduction activated in the process. The role of opioid withdrawal in immunosuppression and the clinical relevance of these findings will also be discussed.
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Affiliation(s)
- Sabita Roy
- Department of Surgery, University of Minnesota, Minneapolis, MN 55455, USA.
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Transforming the mortality review conference to assess palliative care in the acute care setting: a feasibility study. Palliat Support Care 2010; 8:421-6. [PMID: 20875205 DOI: 10.1017/s1478951510000283] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE This project sought to evaluate the impact of a hospital-based Palliative Care Consultation (PCC) service utilizing a common practice: the resident mortality review conference. METHOD Internal Medicine residents used a revised chart audit tool during the mortality review conference, which included domains described in the Clinical Practice Guidelines for Quality Palliative Care (2004). This study attempted to transform the common practice into a methodology for collecting data that could be used as a platform to assess the quality of hospital care near the end of life. In this review, the residents were asked not only "what care was delivered appropriately?" but "what could we have done?" to relieve the patient's and family's suffering. RESULTS The results showed that the mortality review process could be used to assess care at the end of life. It also showed that those patients who received a PCC received better care. Symptoms were addressed at a significantly higher rate for those patients who received a PCC than for those who did not. Specifically, these were symptoms of pain (75% vs. 51%, p < .0001), dyspnea (75% vs. 59%, p < 0.0001), nausea (28% vs. 18%, p < 0.0001), and agitation (53% vs. 33%, p < 0.0001). SIGNIFICANCE OF RESULTS The mortality review process was found to be valuable in assessing care delivery for patients near the end of life. The tool yielded results that were consistent with findings of other studies looking at pain and symptom management, advance care planning, and the rate of palliative care consults across major diagnostic categories, supporting the face validity of the mortality review process.
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Ben-Aharon I, Gafter-Gvili A, Paul M, Leibovici L, Stemmer SM. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol 2008; 26:2396-404. [PMID: 18467732 DOI: 10.1200/jco.2007.15.5796] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Dyspnea is one of the most distressing symptoms experienced by terminally ill cancer patients. This study aimed to evaluate the role of interventions for the palliation of dyspnea. METHODS We conducted a systematic review of randomized controlled trials assessing all pharmacologic and nonpharmacologic interventions for dyspnea palliation in cancer patients, and searched the Cochrane Library, MEDLINE, conference proceedings, and references. Two reviewers independently appraised the quality of trials and extracted data. RESULTS Our search yielded 18 trials. Fourteen evaluated pharmacologic interventions: seven assessing opioids (a total of 256 patients), five assessing oxygen (137 patients), one assessing helium-enriched air, and one assessing furosemide. Four trials evaluated nonpharmacologic interventions (403 patients). The administration of subcutaneous morphine resulted in a significant reduction in dyspnea Visual Analog Scale (VAS) compared with placebo. No difference was observed in dyspnea VAS score when nebulized morphine was compared with subcutaneous morphine, although patients preferred the nebulized route. The addition of benzodiazepines to morphine was significantly more effective than morphine alone, without additional adverse effects. Oxygen was not superior to air for alleviating dyspnea, except for patients with hypoxemia. Nursing-led interventions improved breathlessness. Acupuncture was not beneficial. CONCLUSION Our review supports the use of opioids for dyspnea relief in cancer patients. The use of supplemental oxygen to alleviate dyspnea can be recommended only in patients with hypoxemia. Nursing-led nonpharmacologic interventions seem valuable. Only a few studies addressing this question were performed. Thus, further studies evaluating interventions for alleviating dyspnea are warranted.
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Affiliation(s)
- Irit Ben-Aharon
- Institute of Oncology, Davidoff Center, Rabin Medical Center Campus, 49100 Petah-Tiqva, Israel.
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Castel LD, Saville BR, Depuy V, Godley PA, Hartmann KE, Abernethy AP. Racial differences in pain during 1 year among women with metastatic breast cancer: a hazards analysis of interval-censored data. Cancer 2008; 112:162-70. [PMID: 18040997 DOI: 10.1002/cncr.23133] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Longitudinal tumor-specific studies of cancer pain across the disease trajectory provide insight into the course of pain. Information on pain predictors refines our understanding of patients with greatest distress and need. METHODS The authors studied 1124 women with metastatic breast cancer and bone metastases, all of whom received standard treatment in an international clinical trial conducted from October 1998 to January 2001. The Brief Pain Inventory (BPI) was administered repeatedly during the course of 1 year. Hazard models were fitted to identify baseline and time-dependent covariates as predictors of pain worsening within cumulative 80-day intervals during the year. RESULTS Increased severe pain hazards were associated with non-Caucasian race (hazard ratio [HR] = 2.52; 95% CI, 1.69-3.76), restricted performance status (HR = 1.73; 95% CI, 1.13-2.64), and radiation therapy in a previous interval (HR = 2.86; 95% CI, 1.61-5.09). Estimated cumulative rates for not yet reaching a BPI score of 7 or above ranged from 0.79 (0.72-0.85) in the first interval to 0.64 (0.55-0.74) in the last interval for non-Caucasian women, whereas these rates ranged from 0.91 (0.89-0.93) to 0.84 (0.81-0.87) for Caucasian women. CONCLUSIONS By using a time-to-event hazards analysis for cancer symptom data, the authors demonstrated that non-Caucasian race predicted poorer pain control among women with metastatic breast cancer. Disparity findings from cross-sectional studies were confirmed. Pain management strategies should take race into account as a risk factor for worsening pain outcomes, and further investigation should seek to uncover and resolve the reasons for this obvious disparity.
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Affiliation(s)
- Liana D Castel
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
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Resnizky S, Bentur N. Can family caregivers of terminally ill patients be a reliable source of information about the severity of patient symptoms? Am J Hosp Palliat Care 2007; 23:447-56. [PMID: 17210998 DOI: 10.1177/1049909106294825] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study examines the reliability of family caregivers' assessments of a terminally ill patient's symptoms and identifies patient and caregiver characteristics that affect the reliability of caregiver reports. It compares the reports of 143 patients in home hospice units with those of their family caregiver about patient symptoms during the 3 days preceding the interview (Edmonton scale). Correlation coefficients between the patients' and proxies' reports were 0.5 to 0.8, indicating moderate-to-high agreement. Characteristics that had an independent effect on identical reporting were the patient being fully disabled, the care-giver being a woman in good health, the caregiver living with the patient, and the caregiver providing assistance with activities of daily living and medical care. These results suggest that primary caregivers can be a good source of information about a patient's symptoms, although their reports should be used with caution.
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Affiliation(s)
- Shirli Resnizky
- Aging Research Unit, Myers-JDC-Brookdale Institute, Jerusalem, Israel
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McLean LM, Jones JM. A review of distress and its management in couples facing end-of-life cancer. Psychooncology 2007; 16:603-16. [PMID: 17458836 DOI: 10.1002/pon.1196] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The aim of this review paper is to (1) provide an overview of the impact of cancer on the couple, (2) to identify potential outcomes for couple's interventions targeted specifically when one spouse is facing end of life, (3) to review and critique the empirical literature on psychosocial interventions for couple's facing end of life to date, and (4) to provide direction for research in this area. Based on our review, we found that there is clear evidence of significant distress arising from the impact of terminal illness on the marital relationship, which can result in greater suffering in the last months and weeks of life. Currently, there is a very small body of evidence on the effectiveness of couple interventions for those where one is in palliative care. Future randomized controlled trials are needed to examine the impact of couple therapy adapted for couples facing the end of life, and to guide in providing information on the number of sessions and format required for this population. Outcomes, such as more effective communication, reduction in the experience of hopelessness, uncertainty, isolation, depression, anxiety, and more adaptive coping strategies should be considered.
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Affiliation(s)
- Linda M McLean
- Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network, Canada.
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Penrod JD, Deb P, Luhrs C, Dellenbaugh C, Zhu CW, Hochman T, Maciejewski ML, Granieri E, Morrison RS. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med 2006; 9:855-60. [PMID: 16910799 DOI: 10.1089/jpm.2006.9.855] [Citation(s) in RCA: 207] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare per diem total direct, ancillary (laboratory and radiology) and pharmacy costs of palliative care (PC) compared to usual care (UC) patients during a terminal hospitalization; to examine the association between PC and ICU admission. DESIGN Retrospective, observational cost analysis using a VA (payer) perspective. SETTING Two urban VA medical centers. MEASUREMENTS Demographic and health characteristics of 314 veterans admitted during two years were obtained from VA administrative data. Hospital costs came from the VA cost accounting system. ANALYSIS Generalized linear models (GLM) were estimated for total direct, ancillary and pharmacy costs. Predictors included patient age, principal diagnosis, comorbidity, whether patient stay was medical or surgical, site and whether the patient was seen by the palliative care consultation team. A probit regression was used to analyze probability of ICU admission. Propensity score matching was used to improve balance in observed covariates. RESULTS PC patients were 42 percentage points (95% CI, -56% [corrected] to -31%) less likely to be admitted to ICU. Total direct costs per day were $239 (95% CI, -387 to -122) lower and ancillary costs were $98 (95% CI, -133 to -57) lower than costs for UC patients. There was no difference in pharmacy costs. The results were similar using propensity score matching. CONCLUSION PC was associated with significantly lower likelihood of ICU use and lower inpatient costs compared to UC. Our findings coupled with those indicating better patient and family outcomes with PC suggest both a cost and quality incentive for hospitals to develop PC programs.
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Affiliation(s)
- Joan D Penrod
- Program of Research in Serious Physical and Mental Illness, James J. Peters VA Medical Center, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Abstract
Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life-threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care may be delivered simultaneously with all appropriate curative and life-prolonging interventions. In practice, palliative care practitioners provide assessment and treatment of pain and other symptom distress; employ communication skills with patients, families, and colleagues; support complex medical decision making and goal setting based on identifying and respecting patient wishes and goals; and promote medically informed care coordination, continuity, and practical support for patients, family caregivers, and professional colleagues across healthcare settings and through the trajectory of an illness. The field of hospital palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life-threatening illness. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relation of hospital-based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.
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Affiliation(s)
- Diane E Meier
- Hertzberg Palliative Care Institute, Center to Advance Palliative Care, Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Rustøen T, Fosså SD, Skarstein J, Moum T. The impact of demographic and disease-specific variables on pain in cancer patients. J Pain Symptom Manage 2003; 26:696-704. [PMID: 12906954 DOI: 10.1016/s0885-3924(03)00239-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to examine to what extent demographic and disease-specific variables affected pain in cancer patients. Two to three weeks after their last hospitalization, 1,453 cancer patients completed questionnaires measuring demographic variables, quality of life, and pain (EORTC-QLQ C-30). Response rate was 72.1%. Data on type of cancer and the severity of the disease were also compiled. Sixty percent of the sample reported some pain. Type of cancer, presence of metastases, and time until death were significant predictors of experienced pain. The patients' experience of pain was mainly associated with disease-specific variables. Sex, age, level of education, and co-habitation were not related to pain, but employment status was. The patients on disability pensions had significantly more pain than the patients who were working or studying. Special attention should be given to patients with advanced prostate cancer with a short time to live, as they reported the most pain.
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Affiliation(s)
- Tone Rustøen
- Oslo University College Faculty of Nursing, Oslo, Norway
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Bruera E, Russell N, Sweeney C, Fisch M, Palmer JL. Place of death and its predictors for local patients registered at a comprehensive cancer center. J Clin Oncol 2002; 20:2127-33. [PMID: 11956274 DOI: 10.1200/jco.2002.08.138] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To help with planning of a palliative care program, we reviewed the place of death of patients who were registered at our comprehensive cancer center and explored factors that predicted death in the hospital versus death at home. PATIENTS AND METHODS A retrospective study was undertaken of local patients who were registered at the University of Texas M.D. Anderson Cancer Center and died during the 1997/1998 fiscal year. Data from the institutional tumor registry and from the State of Texas Bureau of Vital Statistics file were collected and analyzed. The main outcome measures were place of death, patient characteristics associated with place of death, and time from registration at the institution to death. RESULTS Of 1,793 local patients, 251 (14%) died at M.D. Anderson Cancer Center; the remaining 86% died elsewhere. A total of 617 (34%) died at home, and 929 (52%) died in an acute hospital setting (including M.D. Anderson). A total of 1,040 (58%) died within 2 years of registration. The risk of hospital death versus home death increased for patients with cancer at a hematologic site (odds ratio [OR], 4.4; 95% confidence interval [CI], 2.8 to 6.8) and black ethnicity (OR, 1.9; 95% CI, 1.4 to 2.6) and decreased for patients who paid with Medicare (OR, 0.71; 95% CI, 0.57 to 0.90). CONCLUSION Most patients died in an acute care hospital setting and within 2 years of registration. Our data show some predictors of hospital death for cancer patients and suggest that better hospital palliative care services and integrated palliative care systems that bridge community and acute hospitals are needed.
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Affiliation(s)
- Eduardo Bruera
- Department of Symptom Control and Palliative Care, the University of Texas M.D. Anderson Cancer Center, Houston, TX 77030-0049, USA.
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Abstract
Approximately 50% of patients diagnosed with cancer die because of progressive disease. Psychotropic drugs are frequently used for the management of physical and psychosocial symptoms in these patients. Thalidomide, cannabinoids and melatonin are emerging agents for the management of cachexia. Psychostimulants have a defined role in the management of opioid-induced sedation. Haloperidol, tricyclic anti-depressants and newer anti-depressants also have an established role in the management of neuropsychiatric symptoms such as delirium or depression. Cancer patients present unique challenges for successful psychotropic therapy including older age, malnutrition, autonomic failure, borderline cognition, opioid and psychotropic therapy. A practical clinical approach which defines a specific target symptom, an outcome latency period, expected side effects, and reviews possible drug interactions, and frequent monitoring is outlined. Continued research is needed to further define the role of psychotropics in the management of the different physical and psychosocial symptoms in advanced cancer patients.
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Affiliation(s)
- E Bruera
- Palliative Care Program, Grey Nuns Community Hospital and Health Center, Edmonton, AB, Canada
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