Interventions for alleviating cancer-related dyspnea: a systematic review

Cancer and multiple sclerosis: 2023 recommendations from the French Multiple Sclerosis Society

BACKGROUND

Epidemiological data reveal that 45% of persons with multiple sclerosis (PwMS) in France are more than 50 years. This population more than 50 is more susceptible to cancer, and this risk may be increased by frequent use of immunosuppressive drugs. Consequently, concerns have arisen about the potential increased risk of cancer in PwMS and how patients should be screened and managed in terms of cancer risk.

OBJECTIVE

To develop evidence-based recommendations to manage the coexistence of cancer and multiple sclerosis (MS).

METHODS

The French Group for Recommendations in MS collected articles from PubMed and university databases covering the period January 1975 through June 2022. The RAND/UCLA method was employed to achieve formal consensus. MS experts comprehensively reviewed the full-text articles and developed the initial recommendations. A group of multidisciplinary health care specialists then validated the final proposal.

RESULTS

Five key questions were addressed, encompassing various topics such as cancer screening before or after initiating a disease-modifying therapy (DMT), appropriate management of MS in the context of cancer, recommended follow-up for cancer in patients receiving a DMT, and the potential reintroduction of a DMT after initial cancer treatment. A strong consensus was reached for all 31 recommendations.

CONCLUSION

These recommendations propose a strategic approach to managing cancer risk in PwMS.

[Comfort Terminal Care in the intensive care unit: recommendations for practice]

BACKGROUND AND OBJECTIVE

The Working Group on Ethics in Anesthesia and Intensive Care Medicine of the Austrian Society for Anesthesiology Resuscitation and Intensive Care Medicine (ÖGARI) already developed documentation tools for the adaption of therapeutic goals 10 years ago. Since then the practical implementation of Comfort Terminal Care in the daily routine in particular has raised numerous questions, which are discussed in this follow-up paper and answered in an evidence-based manner whenever possible.

RESULTS

The practical implementation of pain therapy and reduction of anxiety, stress and respiratory distress that are indicated in the context of Comfort Terminal Care are described in more detail. The measures that are not (or no longer) indicated, such as oxygen administration and ventilation as well as the administration of fluids and nutrition, are also commented on. Furthermore, recommendations are given regarding monitoring, (laboratory) findings and drug treatment and the importance of nursing actions in the context of Comfort Terminal Care is mentioned. Finally, the support for the next of kin and the procedure in the time after death are presented.

DISCUSSION

A change in treatment goals with a timely switch to Comfort Terminal Care enables good and humane care for seriously ill patients and their relatives at the end of life and the appreciation of their previous life with the possibility of positive experiences until the end.

Nursing interventions for dyspnoea management among inpatients with cancer in palliative care

BACKGROUND

Dyspnoea, a commonly reported symptom among patients with cancer, necessitates the need for appropriate non-pharmacological interventions for its management and suitable assessment scales.

AIMS

To explore the nursing interventions and assessment scales for managing dyspnoea in patients with cancer receiving palliative care.

METHODS

Systematic review. Five databases (CINAHL Complete, PubMed, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials) were searched, and seven studies were identified. Only studies that comprised randomised controlled trials (RCTs), non-randomised controlled trials or quasi-experimental settings were included.

FINDINGS

Nursing interventions, that support a patient's physical breathing and mental functioning, are effective in managing dyspnoea. It is crucial to use both subjective and physical assessment methods to accurately measure the outcomes of these interventions.

CONCLUSION

These interventions have been proven to be effective, with outcomes centred on changes in physiological measurements and patients' subjective expressions.

Noninvasive respiratory supports for the relief of terminal breathlessness

PURPOSE OF REVIEW

Breathlessness is a common symptom in patients with respiratory failure in the terminal phase of their illness. Noninvasive methods of oxygen delivery are frequently used in the palliative setting. We review the evidence supporting noninvasive respiratory supports for the relief of terminal breathlessness in those with life-limiting illnesses.

RECENT FINDINGS

There is limited evidence to support the use of supplemental oxygen for patients without hypoxia. It is unclear whether the symptomatic benefit of oxygen therapy relates to the oxygen delivery and/or airflow across the nasal mucosa. Early trials suggest that high-flow nasal cannula (HFNC) oxygen therapy improves breathlessness at rest and on exertion for patients with cancer. Noninvasive ventilation (NIV) also appears to improve breathlessness in the palliative setting; however, potential harms include facial pressure injuries, claustrophobia and anxiety. Goals of care should be explicitly discussed and frequently reviewed given that these interventions have the potential for harm and can be challenging to withdraw.

SUMMARY

HFNC oxygen therapy and NIV appear to reduce breathlessness in the palliative setting. Further high-quality trials are needed to confirm the symptomatic benefits of noninvasive respiratory supports on breathlessness for patients with cancer.

Impact of end-of-life respiratory modalities on quality of dying and death and symptom relief in patients with interstitial lung disease: a multicenter descriptive cross-sectional study

BACKGROUND

Respiratory modalities applied at the end of life may affect the burden of distressing symptoms and quality of dying and death (QODD) among patients with end-stage interstitial lung disease (ILD); however, there have been few studies into respiratory modalities applied to these patients near death. We hypothesized that high-flow nasal cannula (HFNC) might contribute to improved QODD and symptom relief in patients with end-stage ILD.

OBJECTIVES

This multicenter study examined the proportion of end-of-life respiratory modalities in a hospital setting and explored its impact on QODD and symptom relief among patients dying with ILD.

METHODS

Consecutive patients with ILD who died in four participating hospitals in Japan from 2015 to 2019 were identified and divided into four groups according to end-of-life respiratory modality: conventional oxygen therapy (COT), HFNC, non-invasive ventilation (NIV), and invasive mechanical ventilation (IMV). In addition, a mail survey was performed to quantify the QODD and symptom relief at their end of life from a bereaved family's perspective. QODD and symptom relief were quantified using the Good Death Inventory (GDI) for patients with a completed bereavement survey. The impact of end-of-life respiratory modalities on QODD and symptom relief was measured by multivariable linear regression using COT as a reference.

RESULTS

Among 177 patients analyzed for end-of-life respiratory modalities, 80 had a completed bereavement survey. The most common end-of-life respiratory modality was HFNC (n = 76, 42.9%), followed by COT (n = 62, 35.0%), NIV (n = 27, 15.3%), and IMV (n = 12, 6.8%). Regarding the place of death, 98.7% of patients treated with HFNC died outside the intensive care unit. Multivariable regression analyses revealed patients treated with HFNC had a higher GDI score for QODD [partial regression coefficient (B) = 0.46, 95% CI 0.07-0.86] and domain score related to symptom relief (B = 1.37, 95% CI 0.54-2.20) than those treated with COT.

CONCLUSION

HFNC was commonly used in patients with end-stage ILD who died in the hospital and was associated with higher bereaved family ratings of QODD and symptom relief. HFNC might contribute to improved QODD and symptom relief in these patients who die in a hospital setting.

Evaluation of diagnostic and treatment approaches to acute dyspnea in a palliative care setting among medical doctors with different educational levels

Background

Dyspnea is common in patients with advanced cancer. Diagnostic procedures in patients with dyspnea are mandatory but often time-consuming and hamper rapid treatment of the underlying refractory symptoms. Opioids are the first-line drugs for the treatment of refractory dyspnea in palliative care patients with advanced lung cancer.

Methods

To evaluate the knowledge levels of medical doctors with different educational levels on the diagnosis of and treatment options for dyspnea in patients with advanced lung cancer in a palliative care setting, a case report and survey were distributed to physicians at the University Hospital Krems, describing acute dyspnea in a 64-year-old stage IV lung cancer patient. A total of 18 diagnostic and 22 therapeutic options were included in the survey. The physicians were asked to suggest and rank in order of preference their diagnosis and treatment options. Statistical analyses of the data were performed, including comparison of the responses of the senior doctors and the physicians in training.

Results

A total of 106 surveys were completed. The respondents were 82 senior physicians and 24 physicians in training (response rates of 86% and 80%, respectively). Regarding diagnostic investigations, inspection and reading the patient’s chart were the most important diagnostic tools chosen by the respondents. The choices of performing blood gas analysis (p = 0.01) and measurement of oxygen saturation (p = 0.048) revealed a significant difference between the groups, both investigations performed more frequently by the physicians in training. As for non-pharmacological treatment options, providing psychological support was one of the most relevant options selected. A significant difference was seen in choosing the option of improving a patient’s position in relation to level of training (65.9% senior physicians vs. 30.4% physicians in training, p = 0.04). Regarding pharmacological treatment options, oxygen application was the most chosen approach. The second most frequent drug chosen was a ß-2 agonist. Only 9.8% of the senior physicians and 8.7% of the physicians in training suggested oral opioids as a treatment option, whereas intravenous opioids were suggested by 43.9% of the senior physicians and 21.7% of the physicians in training (p = 0.089). For subcutaneous application of opioids, the percentage of usage was significantly higher for the physicians in training than for the senior physicians (78.3% vs. 48.8%, p = 0.017, respectively).

Conclusion

The gold standard treatment for treating refractory dyspnea in patients with advanced lung cancer is opioids. Nevertheless, this pharmacological treatment option was not ranked as the most important. Discussing hypothetical cases of patients with advanced lung cancer and refractory dyspnea with experienced doctors as well as doctors at the beginning of their training may help improve symptom control for these patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-06996-6.

Glucocorticoid receptor regulates PD-L1 and MHC-I in pancreatic cancer cells to promote immune evasion and immunotherapy resistance

Despite unprecedented responses of some cancers to immune checkpoint blockade (ICB) therapies, the application of checkpoint inhibitors in pancreatic cancer has been unsuccessful. Glucocorticoids and glucocorticoid receptor (GR) signaling are long thought to suppress immunity by acting on immune cells. Here we demonstrate a previously undescribed tumor cell-intrinsic role for GR in activating PD-L1 expression and repressing the major histocompatibility complex class I (MHC-I) expression in pancreatic ductal adenocarcinoma (PDAC) cells through transcriptional regulation. In mouse models of PDAC, either tumor cell-specific depletion or pharmacologic inhibition of GR leads to PD-L1 downregulation and MHC-I upregulation in tumor cells, which in turn promotes the infiltration and activity of cytotoxic T cells, enhances anti-tumor immunity, and overcomes resistance to ICB therapy. In patients with PDAC, GR expression correlates with high PD-L1 expression, low MHC-I expression, and poor survival. Our results reveal GR signaling in cancer cells as a tumor-intrinsic mechanism of immunosuppression and suggest that therapeutic targeting of GR is a promising way to sensitize pancreatic cancer to immunotherapy.

Care Associated With Satisfaction of Bereaved Family Members of Terminally Ill Cancer Patients With Dyspnea: A Cross-sectional Nationwide Survey

CONTEXT

Terminal dyspnea in dying cancer patients is frequent and distressing, and the impact extends to their families. Families are often involved in providing care for terminal dyspnea.

OBJECTIVES

This study aimed to describe various care strategies for terminal dyspnea in cancer patients hospitalized in palliative care units (PCUs), evaluate families' satisfaction with care for terminal dyspnea, and explore determinants contributing to families' satisfaction.

METHODS

A nationwide, cross-sectional survey was conducted using a self-reported questionnaire among bereaved families of cancer patients who died in PCUs. The questionnaire consisted of questions on the perceptions of care offered to patients with terminal dyspnea and their families, satisfaction with care for terminal dyspnea, family-perceived intensity of terminal dyspnea, use of oxygen, and background data of patients and families.

RESULTS

In total, 533 participants (response rate = 54%) returned the completed questionnaires, and 231 reported that their loved one had experienced terminal dyspnea. Dedicated and compassionate care was perceived by 60%-89% of the participants as the strategy provided for patients. Care for family members was perceived by 58%-69% of the participants. Perception of dedicated and compassionate care for patients and that of care for family members were significantly associated with high satisfaction (odds ratio, 95% confidence interval: 8.64, 3.85-19.36 and 15.37, 5.00-47.25, respectively).

CONCLUSION

Dedicated and compassionate care may be the essential part of the care for terminal dyspnea. Dedicated and compassionate care for patients and care for family members have a potential of improving the care satisfaction among family caregivers.

Treatment of Dyspnea in Advanced Disease and at the End of Life

Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations, varies in intensity, and can only be known through the patient's report. Dyspnea is akin to suffocation and is one of the most distressing symptoms experienced by patients with advanced illness and at the end of life. Common approaches to dyspnea management, such as pulmonary rehabilitation, breathing strategies, or supplemental oxygen, have become accepted through pragmatic use or because studies do not include dyspnea as a measured outcome. Patients and clinicians urgently need evidence-based treatments to alleviate this frightening symptom. To fill this gap, a group of dyspnea researchers with expertise to conduct a literature review of evidence-based interventions for dyspnea in patients with serious illness produced these guidelines. We present the evidence from the strongest recommendations for practice to the weakest recommendations and include practical considerations for clinical nurses.

Immunotherapy Use in Patients With Lung Cancer and Comorbidities

Immune checkpoint inhibitor (ICI) therapy is now in widespread clinical use for the treatment of lung cancer. Although patients with autoimmune disease and other comorbidities were excluded from initial clinical trials, emerging real-world experience suggests that these promising treatments may be administered safely to individuals with inactive low-risk autoimmune disease such as rheumatoid arthritis or psoriasis, mild to moderate renal and hepatic dysfunction, and certain chronic viral infections. Considerations for ICI in autoimmune disease populations include exacerbations of the underlying autoimmune disease, increased risk of ICI-induced immune-related adverse events, and potential for compromised efficacy if patients are receiving chronic immunosuppression. Immune checkpoint inhibitor use in higher-risk autoimmune conditions, such as myasthenia gravis or multiple sclerosis, requires careful evaluation on a case-by-case basis. Immune checkpoint inhibitor use in individuals with solid organ transplant carries a substantial risk of organ rejection. Ongoing research into the prediction of ICI efficacy and toxicity may help in patient selection, treatment, and monitoring.

An Update on Survivorship Issues in Lung Cancer Patients

Recent advances in lung cancer therapeutics and screening have led to increased numbers of lung cancer survivors. Most survivors have undergone invasive treatment (surgery, radiation therapy, chemotherapy and/or immunotherapy) and carry a high comorbidity burden. Overall quality of life suffers during the evaluation, treatment and follow-up phase, with the potential for long-term decline. The issues faced by survivors include physical symptoms, emotional distress as well as socioeconomic instability. These issues may lead to poor compliance with recommended follow-up plan. This article provides an up-to-date literature review on the major issues faced by lung cancer survivors and identifies under-recognized problems such as stigma, financial toxicity and sexual dysfunction. Future collaborative efforts are needed to further elucidate the complex issues that affect overall well-being of lung cancer survivors and to develop appropriate interventions in this expanding survivor population.

Effect of Systemic Corticosteroid Therapy on the Efficacy and Safety of Nivolumab in the Treatment of Non-Small-Cell Lung Cancer

INTRODUCTION

Corticosteroids are used to treat immune-related adverse events (irAEs) associated with nivolumab. However, patients with non-small-cell lung cancer who are administered corticosteroids before the initiation of nivolumab treatment are commonly excluded from clinical trials. The appropriate timing for corticosteroid administration in relation to nivolumab treatment, effects of corticosteroids on the efficacy of nivolumab, and resulting adverse events are not clearly understood. In this study, the effects of differences in the timing of corticosteroid administration on nivolumab efficacy and the resulting adverse events were examined.

METHODS

A retrospective study was conducted with 109 patients who were treated with nivolumab at Sapporo Minami-Sanjo Hospital between December 2015 and March 2018.

RESULTS

Of the 109 patients treated with nivolumab, 12 patients were administered corticosteroids before the first cycle of nivolumab (pre-CS), and 33 patients were administered corticosteroids after the first cycle of nivolumab (post-CS). These 2 groups were compared with the control group comprising 64 patients who were not administered corticosteroids (non-CS). The objective response rate in the post-CS group was significantly higher than that in the non-CS group, and the disease control rate in the pre-CS group was significantly lower than that in the non-CS group. The overall survival time and progression-free survival time in the pre-CS group were significantly shorter than those observed in the non-CS group; however, these did not differ from those in the post-CS group.

CONCLUSIONS

These results suggest that corticosteroids administered to patients with non-small-cell lung cancer after initiation of nivolumab treatment did not affect the disease prognosis. Thus, corticosteroids can be administered immediately for rapid treatment of irAEs.

Challenges of Immunotherapy in Stage IV Non-Small-Cell Lung Cancer

Treatment for metastatic non-small-cell lung carcinoma has seen important advances in recent years with the introduction of targeted therapies and immunotherapy. Immune checkpoint inhibitors, which target the programmed death 1 receptor and programmed death ligand-1, alone or in combination with platinum-based chemotherapy, have become standard of care in the first-line setting for patients with advanced non-small-cell lung carcinoma without targetable driver mutations. However, several clinical questions have now since emerged. Physicians treating lung cancer lack guidance when treating patients who have a poor performance status, patients who are receiving corticosteroids, and those known for pre-existing autoimmune disorders. Furthermore, data are scarce on rechallenging a patient with immune checkpoint inhibitors after the occurrence of a significant immune-related adverse event. In this review, we aim to shed light on these topics.

A population-based analysis of spirometry use and the prevalence of chronic obstructive pulmonary disease in lung cancer

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and lung cancer are associated diseases. COPD is underdiagnosed and thus undertreated, but there is limited data on COPD diagnosis in the setting of lung cancer. We assessed the diagnosis of COPD with lung cancer in a large public healthcare system.

METHODS

Anonymous administrative data was acquired from ICES, which links demographics, hospital records, physician billing, and cancer registry data in Ontario, Canada. Individuals age 35 or older with COPD were identified through a validated, ICES-derived cohort and spirometry use was derived from physician billings. Statistical comparisons were made using Wilcoxon rank sum, Cochran-Armitage, and chi-square tests.

RESULTS

From 2002 to 2014, 756,786 individuals were diagnosed with COPD, with a 2014 prevalence of 9.3%. Of these, 51.9% never underwent spirometry. During the same period, 105,304 individuals were diagnosed with lung cancer, among whom COPD was previously diagnosed in 34.9%. Having COPD prior to lung cancer was associated with lower income, a rural dwelling, a lower Charlson morbidity score, and less frequent stage IV disease (48 vs 54%, p < 0.001). Spirometry was more commonly undertaken in early stage disease (90.6% in stage I-II vs. 54.4% in stage III-IV).

CONCLUSION

Over a third of individuals with lung cancer had a prior diagnosis of COPD. Among individuals with advanced lung cancer, greater use of spirometry and diagnosis of COPD may help to mitigate respiratory symptoms.

High-Flow Oxygen and High-Flow Air for Dyspnea in Hospitalized Patients with Cancer: A Pilot Crossover Randomized Clinical Trial

BACKGROUND

The effect of high-flow oxygen (HFOx) and high-flow air (HFAir) on dyspnea in nonhypoxemic patients is not known. We assessed the effect of HFOx, HFAir, low-flow oxygen (LFOx), and low-flow air (LFAir) on dyspnea.

SUBJECTS, MATERIALS, AND METHODS

This double-blind, 4×4 crossover clinical trial enrolled hospitalized patients with cancer who were dyspneic at rest and nonhypoxemic (oxygen saturation >90% on room air). Patients were randomized to 10 minutes of HFOx, HFAir, LFOx, and LFAir in different orders. The flow rate was titrated between 20-60 L/minute in the high-flow interventions and 2 L/minute in the low-flow interventions. The primary outcome was dyspnea numeric rating scale (NRS) "now" where 0 = none and 10 = worst.

RESULTS

Seventeen patients (mean age 51 years, 58% female) completed 55 interventions in a random order. The absolute change of dyspnea NRS between 0 and 10 minutes was -1.8 (SD 1.7) for HFOx, -1.8 (2.0) for HFAir, -0.5 (0.8) for LFOx, and - 0.6 (1.2) for LFAir. In mixed model analysis, HFOx provided greater dyspnea relief than LFOx (mean difference [95% confidence interval] -0.80 [-1.45, -0.15]; p = .02) and LFAir (-1.24 [-1.90, -0.57]; p < .001). HFAir also provided significantly greater dyspnea relief than LFOx (-0.95 [-1.61, -0.30]; p = .005) and LFAir (-1.39 [-2.05, -0.73]; p < .001). HFOx was well tolerated. Seven (54%) patients who tried all interventions blindly preferred HFOx and four (31%) preferred HFAir.

CONCLUSION

We found that HFOx and HFAir provided a rapid and clinically significant reduction of dyspnea at rest in hospitalized nonhypoxemic patients with cancer. Larger studies are needed to confirm these findings (Clinicaltrials.gov: NCT02932332).

IMPLICATIONS FOR PRACTICE

This double-blind, 4×4 crossover trial examined the effect of oxygen or air delivered at high- or low-flow rates on dyspnea in hospitalized nonhypoxemic patients with cancer. High-flow oxygen and high-flow air were significantly better at reducing dyspnea than low-flow oxygen/air, supporting a role for palliation beyond oxygenation.

Acupuncture as a Treatment Within Integrative Health for Palliative Care: A Brief Narrative Review of Evidence and Recommendations

Background: Acupuncture is one of the fastest developing evidence bases in Complementary Medicine and is one of the leading therapies included within integrative health care. This narrative review includes two separate parts: the first is about evaluation of the current evidence status in reviews on acupuncture and the second examines and gives examples of available recommendations on acupuncture in treatment guidelines from health care experts and public health organizations recommending acupuncture as a viable treatment in patients in palliative care. Methods: Electronic searches were performed in PubMed using the terms "acupuncture" + "palliative" and adding the term "safety" to find review articles documenting safety and evidence of effectiveness of acupuncture for treatment of symptoms in palliative care patients. Treatment guidelines that recommend use of acupuncture for symptom control in palliative care were found by searching through a database currently under construction by the lead author. Results: Acupuncture shows emerging evidence for 17 indications in palliative care. Examples were found and presented of publications recommending acupuncture for treatment of symptoms for patients in palliative care from Government, public health, oncology, and medical expert sources. The most publications are in oncology, but other conditions were found and a number were found in pediatric care. Conclusions: While the evidence for use of acupuncture to treat symptoms in palliative care patients is relatively weak, the evidence base is growing. Experts worldwide are also increasingly recommending acupuncture as a treatment for symptoms in palliative care. Since acupuncture is a safe, nonpharmacological treatment but with small, clinically significant effects, these recommended uses appear as pragmatic efforts to bridge the gap of treatment options available to this patient group.

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.

Management of Respiratory Symptoms in Those with Serious Illness

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

Acupuncture for Breathlessness in Advanced Diseases: A Systematic Review and Meta-analysis

CONTEXT

Nonpharmacological approaches are effective strategies for difficult to palliate breathlessness. Although acupuncture is effective for dyspnea in early-stage chronic obstructive pulmonary disease (COPD), little is known about its effects in patients with advanced (non)malignant diseases.

OBJECTIVES

The objective of this study was to identify and examine the evidence of acupuncture on breathlessness in advanced malignant and nonmalignant diseases.

METHODS

Systematic literature review of randomized controlled trials of acupuncture and acupressure searched in five databases. Included were adult participants with at least 25% having advanced diseases such as cancer or COPD with severe breathlessness. Primary outcome was severity of dyspnea on Visual Analogue Scale or Borg Scale. Secondary outcomes included quality of life, function, and acceptability. Data were pooled using a random effects model of standardized mean differences.

RESULTS

Twelve studies with 597 patients (347 COPD, 190 advanced cancer) were included. For breathlessness severity, significant differences were obtained in a meta-analysis (10 studies with 480 patients; standardized mean difference (SMD) = -1.77 [95% CI -3.05, -0.49; P = 0.007; I² = 90%]) and in a subgroup analysis of using sham acupuncture control groups and a treatment duration of at least three weeks (6 studies with 302 patients; SMD = -2.53 [95% CI -4.07, -0.99; P = 0.001; I² = 91%]). Exercise tolerance (6-minute walk test) improved significantly in the acupuncture group (6 studies with 287 patients; SMD = 0.93 [95% CI 0.27, 1.59; P = 0.006; I² = 85%]). In four of six studies, quality of life improved in the acupuncture group.

CONCLUSION

Acupuncture improved breathlessness severity in patients with advanced diseases. The methodological heterogeneity, low power, and potential morphine-sparing effects of acupuncture as add-on should be further addressed in future trials.

Oral morphine drops for prompt relief of breathlessness in patients with advanced cancer-a randomized, double blinded, crossover trial of morphine sulfate oral drops vs. morphine hydrochloride drops with ethanol (red morphine drops)

PURPOSE

Episodic breathlessness is frequent in palliative cancer patients. Opioids are the only pharmacological agents with sufficient evidence in treatment. In Denmark, the main recommendation is red morphine drops (RMD), an off-label solution of morphine, ethanol, and red color (cochenille) described since 1893 (Pharmacopoea Danica). In 2015, the Danish Medicines Agency increased focus on off-label medicines and recommended registered morphine drops without ethanol instead. However, our palliative patients told us that RMD was better. For that reason, we conducted a clinical trial to clarify any perceived difference between the two types of drops.

METHODS

We conducted a randomized, double blinded, crossover trial. Patients were asked to perform standardized activity (2-min walk) aiming to provoke breathlessness. Primary endpoint (breathlessness NRS) and secondary endpoints (saturation, pulse, respiratory frequency) were measured before (t = 0) and after test medicine at t = 1, t = 3, t = 5, t = 10, and t = 20 min. After 2-4 days (washout period), the patients repeated the test, receiving the alternative drops in a blinded setup (crossover).

RESULTS

In the first 3 min, the relative drop in breathlessness for morphine drops with ethanol (RMD) was significant more than for morphine drops without ethanol. We found no significant difference in secondary endpoints.

CONCLUSIONS

A conclusion could be that ethanol might facilitate morphine absorption in the mouth. Our results needs further research of opioid absorption in the mouth as well as trials, testing morphine vs. more lipophilic opioids. The RMD drops are cheap, easy to use, and noninvasive and keep the patient independent of health care professionals.

Pancreatic cancer-A disease in need: Optimizing and integrating supportive care

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that continues to be challenging to treat. PDAC has the lowest 5-year relative survival rate compared with all other solid tumor malignancies and is expected to become the second-leading cause of cancer-related death in the United States by 2030. Given the high mortality, there is an increasing role for concurrent anticancer and supportive care in the management of patients with PDAC with the aims of maximizing length of life, quality of life, and symptom control. Emerging trends in supportive care that can be integrated into the clinical management of patients with PDAC include standardized supportive care screening, early integration of supportive care into routine cancer care, early implementation of outpatient-based advance care planning, and utilization of electronic patient-reported outcomes for improved symptom management and quality of life. The most common symptoms experienced are nausea, constipation, weight loss, diarrhea, anorexia, and abdominal and back pain. This review article includes current supportive management strategies for these and others. Common disease-related complications include biliary and duodenal obstruction requiring endoscopic procedures and venous thromboembolic events. Patients with PDAC continue to have a poor prognosis. Systemic therapy options are able to palliate the high symptom burden but have a modest impact on overall survival. Early integration of supportive care can lead to improved outcomes.

The Current Practice of Opioid for Cancer Dyspnea: The Result From the Nationwide Survey of Japanese Palliative Care Physicians

CONTEXT

Morphine is recommended as the first-line pharmacological therapy for cancer dyspnea. However, the detailed practice of morphine has not been evaluated and consensus about other opioids for cancer dyspnea has not been established.

OBJECTIVES

To explore the physician-reported practice of opioid for cancer dyspnea.

METHODS

A nationwide mail-questionnaire survey was conducted among 536 Japanese certified palliative care physicians. We randomly selected 268 and asked the following: 1) how the physicians themselves initiate and use morphine for cancer dyspnea, 2) opioid choice for dyspnea in patients who have already used opioid other than morphine regularly, and 3) opioid choice for dyspnea in patients with various degrees of renal impairment in their daily practice.

RESULTS

Overall, 192 physicians responded (response rate, 71.6%). The major (58.3%) practice of initiating morphine was "immediate-release morphine as needed" in opioid-naïve patients, and the mean % increase when they titrate morphine for cancer dyspnea was 29.4 ± 11.3% of the baseline dose. Although "titrate baseline oxycodone" was the most frequent (42.3%) for low-to-moderate-dose regular oxycodone cases, "stepwise switch to morphine" (30.0%) and "add morphine on baseline oxycodone" (27.1%) were the more frequent practices for high-dose regular oxycodone. Regardless of the baseline dose, "add morphine on baseline fentanyl" was the most frequent practice for regular transdermal fentanyl cases. Oxycodone was the most frequent choice in renal insufficiency cases, regardless of its degree.

CONCLUSIONS

Among Japanese palliative care physicians, using oxycodone for cancer dyspnea was relatively popular practice, whereas fentanyl was not. Oxycodone was the most preferred opioid for cancer dyspnea in the setting of renal insufficiency among Japanese palliative care physicians. We should conduct studies to confirm the safety and effectiveness of these opioid practices for cancer dyspnea.

Immune Checkpoint Inhibitor Outcomes for Patients With Non-Small-Cell Lung Cancer Receiving Baseline Corticosteroids for Palliative Versus Nonpalliative Indications

PURPOSE

Baseline use of corticosteroids is associated with poor outcomes in patients with non-small-cell lung cancer (NSCLC) treated with programmed cell death-1 axis inhibition. To approach the question of causation versus correlation for this association, we examined outcomes in patients treated with immunotherapy depending on whether corticosteroids were administered for cancer-related palliative reasons or cancer-unrelated indications.

PATIENTS AND METHODS

Clinical outcomes in patients with NSCLC treated with immunotherapy who received ≥ 10 mg prednisone were compared with outcomes in patients who received 0 to < 10 mg of prednisone.

RESULTS

Of 650 patients, the 93 patients (14.3%) who received ≥ 10 mg of prednisone at the time of immunotherapy initiation had shorter median progression-free survival (mPFS) and median overall survival (mOS) times than patients who received 0 to < 10 mg of prednisone (mPFS, 2.0 v 3.4 months, respectively; P = .01; mOS, 4.9 v 11.2 months, respectively; P < .001). When analyzed by reason for corticosteroid administration, mPFS and mOS were significantly shorter only among patients who received ≥ 10 mg prednisone for palliative indications compared with patients who received ≥ 10 mg prednisone for cancer-unrelated reasons and with patients receiving 0 to < 10 mg of prednisone (mPFS, 1.4 v 4.6 v 3.4 months, respectively; log-rank P < .001 across the three groups; mOS, 2.2 v 10.7 v 11.2 months, respectively; log-rank P < .001 across the three groups). There was no significant difference in mPFS or mOS in patients receiving ≥ 10 mg of prednisone for cancer-unrelated indications compared with patients receiving 0 to < 10 mg of prednisone.

CONCLUSION

Although patients with NSCLC treated with ≥ 10 mg of prednisone at the time of immunotherapy initiation have worse outcomes than patients who received 0 to < 10 mg of prednisone, this difference seems to be driven by a poor-prognosis subgroup of patients who receive corticosteroids for palliative indications.

Airflow relieves chronic breathlessness in people with advanced disease: An exploratory systematic review and meta-analyses

BACKGROUND

Chronic breathlessness is a neglected symptom of advanced diseases.

AIM

To examine the effect of airflow for chronic breathlessness relief.

DESIGN

Exploratory systematic review and meta-analysis.

DATA SOURCES

Medline, CINAHL, AMED and Cochrane databases were searched (1985-2018) for observational studies or randomised controlled trials of airflow as intervention or comparator. Selection against predefined inclusion criteria, quality appraisal and data extraction was conducted by two independent reviewers with access to a third for unresolved differences. 'Before and after' breathlessness measures from airflow arms were analysed. Meta-analysis was carried out where possible.

RESULTS

In all, 16 of 78 studies (n = 929) were included: 11 randomised controlled trials of oxygen versus medical air, 4 randomised controlled trials and 1 fan cohort study. Three meta-analyses were possible: (1) Fan at rest in three studies (n = 111) offered significant benefit for breathlessness intensity (0-100 mm visual analogue scale and 0-10 numerical rating scale), mean difference -11.17 (95% confidence intervals (CI) -16.60 to -5.74), p = 0.06 I² 64%. (2) Medical air via nasal cannulae at rest in two studies (n = 89) improved breathlessness intensity (visual analogue scale), mean difference -12.0 mm, 95% CI -7.4 to -16.6, p < 0.0001 I² = 0%. (3) Medical airflow during a constant load exercise test before and after rehabilitation (n = 29) in two studies improved breathlessness intensity (modified Borg scale, 0-10), mean difference -2.9, 95% CI -3.2 to -2.7, p < 0.0001 I² = 0%.

CONCLUSION

Airflow appears to offer meaningful relief of chronic breathlessness and should be considered as an adjunct treatment in the management of breathlessness.

Care of Geriatric Patients with Advanced Illnesses and End-of-Life Needs in the Emergency Department

Older patients with advanced illness are presenting more frequently to emergency departments (EDs). These patients have complex needs, which challenge busy EDs tuned to provide emergent, life-sustaining interventions, and rapid dispositions. This article outlines communication skills to assess patient goals so that the ED provider can create a care plan that matches level of medical intervention with patient wishes. Furthermore, this article outlines symptom-based care for the actively dying geriatric patient in the ED, specifically, acute pain, dyspnea, terminal delirium, secretions, dry mouth, fever, and bereavement.

Effects of Oral Morphine on Dyspnea in Patients with Cancer: Response Rate, Predictive Factors, and Clinically Meaningful Change (CJLSG1101)

BACKGROUND

Although the efficacy of parenteral morphine for alleviating dyspnea has been previously demonstrated in several studies, little is known regarding the efficacy of oral morphine for dyspnea among patients with cancer, including its response rate and predictive factors of effectiveness. Therefore, the aim of this study was to clarify the effectiveness of oral morphine on dyspnea in patients with cancer and elucidate the predictive factors of its effectiveness.

SUBJECTS, MATERIALS, AND METHODS

In this multicenter prospective observational study, we investigated the change in dyspnea intensity in patients with cancer before and after the administration of oral morphine by using a visual analog scale (VAS). We also administered a self-assessment questionnaire to determine whether the patients believed oral morphine was effective.

RESULTS

Eighty patients were enrolled in the study, and 71 of these patients were eligible. The least square mean of the VAS scores for dyspnea intensity was 53.5 at baseline, which decreased significantly to 44.7, 40.8, and 35.0 at 30, 60, and 120 minutes after morphine administration, respectively. Fifty-four patients (76.1%) reported that oral morphine was effective on the self-assessment questionnaire. Among the background factors, a high score for "sense of discomfort" on the Cancer Dyspnea Scale (CDS) and a smoking history of fewer pack-years were associated with greater effectiveness.

CONCLUSION

Oral morphine was effective and feasible for treating cancer-related dyspnea. A higher score for "sense of discomfort" on the CDS and a smaller cumulative amount of smoking may be predictive factors of the effectiveness of oral morphine.

IMPLICATIONS FOR PRACTICE

This study demonstrated that oral morphine was effective in alleviating cancer-related dyspnea due to multiple factors including primary lung lesions, airway narrowing, and pleural effusion. Approximately 76% of patients reported that oral morphine was effective. A higher score for "sense of discomfort" on the Cancer Dyspnea Scale and a lower cumulative amount of smoking may be predictive factors for the effectiveness of oral morphine. Interestingly, respiratory rates in patients who reported the morphine to be effective decreased significantly after oral morphine administration, unlike the respiratory rates in "morphine-ineffective" patients.

Impact of Baseline Steroids on Efficacy of Programmed Cell Death-1 and Programmed Death-Ligand 1 Blockade in Patients With Non-Small-Cell Lung Cancer

PURPOSE

Treatment with programmed cell death-1 or programmed death ligand 1 (PD-(L)1) inhibitors is now standard therapy for patients with lung cancer. The immunosuppressive effect of corticosteroids may reduce efficacy of PD-(L)1 blockade. On-treatment corticosteroids for treatment of immune-related adverse events do not seem to affect efficacy, but the potential impact of baseline corticosteroids at the time of treatment initiation is unknown. Clinical trials typically excluded patients who received baseline corticosteroids, which led us to use real-world data to examine the effect of corticosteroids at treatment initiation.

METHODS

We identified patients who were PD-(L)1-naïve with advanced non-small-cell lung cancer from two institutions-Memorial Sloan Kettering Cancer Center and Gustave Roussy Cancer Center-who were treated with single-agent PD-(L)1 blockade. Clinical and pharmacy records were reviewed to identify corticosteroid use at the time of beginning anti-PD-(L)1 therapy. We performed multivariable analyses using Cox proportional hazards regression model and logistic regression.

RESULTS

Ninety (14%) of 640 patients treated with single-agent PD-(L)1 blockade received corticosteroids of ≥ 10 mg of prednisone equivalent daily at the start of the PD-(L)1 blockade. Common indications for corticosteroids were dyspnea (33%), fatigue (21%), and brain metastases (19%). In both independent cohorts, Memorial Sloan Kettering Cancer Center (n = 455) and Gustave Roussy Cancer Center (n = 185), baseline corticosteroids were associated with decreased overall response rate, progression-free survival, and overall survival with PD-(L)1 blockade. In a multivariable analysis of the pooled population, adjusting for smoking history, performance status, and history of brain metastases, baseline corticosteroids remained significantly associated with decreased progression-free survival (hazard ratio, 1.3; P = .03), and overall survival (hazard ratio, 1.7; P < .001).

CONCLUSION

Baseline corticosteroid use of ≥ 10 mg of prednisone equivalent was associated with poorer outcome in patients with non-small-cell lung cancer who were treated with PD-(L)1 blockade. Prudent use of corticosteroids at the time of initiating PD-(L)1 blockade is recommended.

Palliative and End-of-Life Care for Patients with Malignancy

Patients with cancer continue to have unmet palliative care needs. Concurrent palliative care is tailored to the needs of patients as well as their families to relieve suffering. Specialty palliative care referral is associated with improved symptom management, improved end-of-life quality, and higher family-rated satisfaction. Optimal timing for palliative care referral has not been determined. Barriers to palliative care referral include workforce limitations, provider attitudes and perceptions, and potential ethnic and racial disparities in access to palliative care. Future work should focus on novel, patient-centered approaches to identify and address unmet palliative care needs for patients living with cancer.

Dyspnea and Delirium at the End of Life

This article focuses on the symptoms of dyspnea and delirium, which can be extremely distressing to patients with cancer at the end of life. Oncology nurses are well suited to detect and treat these symptoms.

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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.

Effectiveness of Corticosteroid Monotherapy for Dyspnea Relief in Patients with Terminal Cancer

Dyspnea is a common symptom in patients with cancer, particularly those with late-stage terminal disease. It markedly affects terminal cancer patients, reducing their quality of life. Reduced quality of life also affects survival; therefore, dyspnea is a prognostic factor. However, the role of corticosteroids, which often are used to alleviate dyspnea, has not been sufficiently validated. In this study, we retrospectively investigated whether corticosteroid monotherapy was effective for dyspnea palliation. The effectiveness rate of corticosteroid therapy was 45% in nine male and two female study subjects (mean age: 74.5 years; range: 64-86 years). No significant differences were found between responders and nonresponders in the first-day corticosteroid doses (25.5 ± 10.86 vs. 36.1 ± 16.39 mg, P = .29) or doses administered on 2 days (47.7 ± 25.99 vs. 72.2 ± 32.78 mg, P = .25). The mean ± standard error assessment score changed significantly from 2.7 ± 0.14 at the beginning of corticosteroid administration to 1.5 ± 0.37 at the time of maximum effect (P = .028); however, the decrease to 2.1 ± 0.25 at the final administration was not significant (P = .068). This indicates that corticosteroid therapy relieved dyspnea and could provide an early-stage treatment option.

Morphine versus methylprednisolone or aminophylline for relieving dyspnea in patients with advanced cancer in China: a retrospective study

Context

Dyspnea is one of the most common and distressing symptoms that occurs in terminal cancer patients. However, there are no existing treatment guidelines for this condition in China.

Objective

This single-center, retrospective, observational study aimed to compare the efficacy of using morphine, methylprednisolone, or aminophylline to relieve the symptom of breathlessness in patients with advanced malignant tumors and to investigate the safety of these regimens during the treatment of dyspnea.

Methods

Between August 2011 and January 2015 we retrospectively reviewed the medical records of 343 terminally ill cancer patients with dyspnea who received morphine, methylprednisolone, or aminophylline. The therapeutic effect of each treatment by means of visual analogue scale (VAS) scores was assessed and compared. Statistical methods included Chi square and analysis of variance tests. Differences were considered significant when P < 0.05.

Results

VAS scores after treatment were (16.82 ± 10.89), (25.72 ± 15.03), and (31.95 ± 16.00) points in the morphine, methylprednisolone, and aminophylline group, respectively. These differences were found to be significantly different (P < 0.05). The effectiveness ratings were 86.44, 62.16, and 49.12%, respectively (P < 0.05).

Conclusions

We found that morphine subcutaneous injection for advanced cancer patients with dyspnea was safe and typically more effective than methylprednisolone or aminophylline. Therefore, morphine treatment could significantly improve the quality of life in terminal cancer patients with short life expectancies who are experiencing shortness of breath.

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.

Does home oxygen therapy (HOT) in addition to standard care reduce disease severity and improve symptoms in people with chronic heart failure? A randomised trial of home oxygen therapy for patients with chronic heart failure

BACKGROUND

Home oxygen therapy (HOT) is commonly used for patients with severe chronic heart failure (CHF) who have intractable breathlessness. There is no trial evidence to support its use.

OBJECTIVES

To detect whether or not there was a quality-of-life benefit from HOT given as long-term oxygen therapy (LTOT) for at least 15 hours per day in the home, including overnight hours, compared with best medical therapy (BMT) in patients with severely symptomatic CHF.

DESIGN

A pragmatic, two-arm, randomised controlled trial recruiting patients with severe CHF. It included a linked qualitative substudy to assess the views of patients using home oxygen, and a free-standing substudy to assess the haemodynamic effects of acute oxygen administration.

SETTING

Heart failure outpatient clinics in hospital or the community, in a range of urban and rural settings.

PARTICIPANTS

Patients had to have heart failure from any aetiology, New York Heart Association (NYHA) class III/IV symptoms, at least moderate left ventricular systolic dysfunction, and be receiving maximally tolerated medical management. Patients were excluded if they had had a cardiac resynchronisation therapy device implanted within the past 3 months, chronic obstructive pulmonary disease fulfilling the criteria for LTOT or malignant disease that would impair survival or were using a device or medication that would impede their ability to use LTOT.

INTERVENTIONS

Patients received BMT and were randomised (unblinded) to open-label LTOT, prescribed for 15 hours per day including overnight hours, or no oxygen therapy.

MAIN OUTCOME MEASURES

The primary end point was quality of life as measured by the Minnesota Living with Heart Failure (MLwHF) questionnaire score at 6 months. Secondary outcomes included assessing the effect of LTOT on patient symptoms and disease severity, and assessing its acceptability to patients and carers.

RESULTS

Between April 2012 and February 2014, 114 patients were randomised to receive either LTOT or BMT. The mean age was 72.3 years [standard deviation (SD) 11.3 years] and 70% were male. Ischaemic heart disease was the cause of heart failure in 84%; 95% were in NYHA class III; the mean left ventricular ejection fraction was 27.8%; and the median N-terminal pro-B-type natriuretic hormone was 2203 ng/l. The primary analysis used a covariance pattern mixed model which included patients only if they provided data for all baseline covariates adjusted for in the model and outcome data for at least one post-randomisation time point (n = 102: intervention, n = 51; control, n = 51). There was no difference in the MLwHF questionnaire score at 6 months between the two arms [at baseline the mean score was 54.0 (SD 18.4) for LTOT and 54.0 (SD 17.9) for BMT; at 6 months the mean score was 48.1 (SD 18.5) for LTOT and 49.0 (SD 20.2) for BMT; adjusted mean difference -0.10, 95% confidence interval (CI) -6.88 to 6.69; p = 0.98]. At 3 months, the adjusted mean MLwHF questionnaire score was lower in the LTOT group (-5.47, 95% CI -10.54 to -0.41; p = 0.03) and breathlessness scores improved, although the effect did not persist to 6 months. There was no effect of LTOT on any secondary measure. There was a greater number of deaths in the BMT arm (n = 12 vs. n = 6). Adherence was poor, with only 11% of patients reporting using the oxygen as prescribed.

CONCLUSIONS

Although the study was significantly underpowered, HOT prescribed for 15 hours per day and subsequently used for a mean of 5.4 hours per day has no impact on quality of life as measured by the MLwHF questionnaire score at 6 months. Suggestions for future research include (1) a trial of patients with severe heart failure randomised to have emergency oxygen supply in the house, supplied by cylinders rather than an oxygen concentrator, powered to detect a reduction in admissions to hospital, and (2) a study of bed-bound patients with heart failure who are in the last few weeks of life, powered to detect changes in symptom severity.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN60260702.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 75. See the NIHR Journals Library website for further project information.

Combined Effect of Opioids and Corticosteroids for Alleviating Dyspnea in Terminal Cancer Patients: A Retrospective Review

Dyspnea is a prognostic factor that affects the quality of life of terminal cancer patients, and many reports have described opioid treatment for dyspnea alleviation. Here, we retrospectively evaluated differences in the effects of various opioids administered concomitantly with corticosteroids on dyspnea in 20 terminal-stage cancer patients (13 men, 7 women; mean age [range]: 71 [49-94] years) who received opioids concomitantly with corticosteroids. Effectiveness was assessed throughout administration using the Support Team Assessment Schedule, Japanese version (STAS-J), particularly the subscale indicating how strongly a patient is affected by symptoms. The effectiveness of combined opioid and corticosteroid therapy against dyspnea and the opioid dose comprised the primary and secondary foci, respectively. Among concomitantly treated patients, STAS-J scores at initiation (mean ± SD: 3.1 ± 0.24) and lowest recorded STAS-J scores (1.4 ± 0.22) differed significantly (P = .0034) among those receiving morphine, but not among those receiving oxycodone (P = .068) or fentanyl (P = .18). Concomitant opioid and corticosteroid treatment was associated with a ≥2-point STAS-J score improvement in 14/20 patients (effectiveness: 70%). The opioid dose did not significantly affect dyspnea alleviation. We conclude that concomitant opioid and corticosteroid treatment can effectively alleviate dyspnea in terminal cancer patients.

Opioids for the Management of Dyspnea in Cancer Patients: Evidence of the Last 15 Years--A Systematic Review

The objective of this study was to review the evidence on the use of opioids for treatment of the dyspnea in adult cancer patients. A systematic literature review was conducted in the databases MEDLINE, CINAHL (EBSCO), ScienceDirect, and Cochrane Library of trials testing the effect of opioids in relieving dyspnea in cancer patients. Fourteen trials met the criteria for inclusion in the review. Eight randomized trials and six nonrandomized trials. All randomized clinical trials analyzed present risks of bias. Morphine has been the most studied strong opioid showing efficacy in alleviating dyspnea when administered, either orally or subcutaneously, in cancer patients. The potential benefit of the strong opioids in the alleviation of dyspnea in cancer patients is modest and limited to some opioids. More studies are needed to sufficiently support the role of opioids in dyspnea at rest, at exertion, and for breakthrough dyspnea and to clarify the safety issues.

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.

Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial

BACKGROUND

Breathlessness is common in advanced cancer. The Breathlessness Intervention Service (BIS) is a multi-disciplinary complex intervention theoretically underpinned by a palliative care approach, utilising evidence-based non-pharmacological and pharmacological interventions to support patients with advanced disease. We sought to establish whether BIS was more effective, and cost-effective, for patients with advanced cancer and their carers than standard care.

METHODS

A single-centre Phase III fast-track single-blind mixed-method randomised controlled trial (RCT) of BIS versus standard care was conducted. Participants were randomised to one of two groups (randomly permuted blocks). A total of 67 patients referred to BIS were randomised (intervention arm n = 35; control arm n = 32 received BIS after a two-week wait); 54 completed to the key outcome measurement. The primary outcome measure was a 0 to 10 numerical rating scale for patient distress due to breathlessness at two-weeks. Secondary outcomes were evaluated using the Chronic Respiratory Questionnaire, Hospital Anxiety and Depression Scale, Client Services Receipt Inventory, EQ-5D and topic-guided interviews.

RESULTS

BIS reduced patient distress due to breathlessness (primary outcome: -1.29; 95% CI -2.57 to -0.005; P = 0.049) significantly more than the control group; 94% of respondents reported a positive impact (51/53). BIS reduced fear and worry, and increased confidence in managing breathlessness. Patients and carers consistently identified specific and repeatable aspects of the BIS model and interventions that helped. How interventions were delivered was important. BIS legitimised breathlessness and increased knowledge whilst making patients and carers feel 'not alone'. BIS had a 66% likelihood of better outcomes in terms of reduced distress due to breathlessness at lower health/social care costs than standard care (81% with informal care costs included).

CONCLUSIONS

BIS appears to be more effective and cost-effective in advanced cancer than standard care.

TRIAL REGISTRATION

RCT registration at ClinicalTrials.gov NCT00678405 (May 2008) and Current Controlled Trials ISRCTN04119516 (December 2008).

Caspase-dependent cell death-associated release of nucleosome and damage-associated molecular patterns

Apoptosis, which is anti-inflammatory, and necrosis, which is pro-inflammatory, represent the extremes of the cell death spectrum. Cell death is complex and both apoptosis and necrosis can be observed in the same cells or tissues. Here, we introduce a novel combined mode of cellular demise--caspase-dependent regulated necrosis. Most importantly, it is mainly characterized with release of marked amount of oligo- or poly-nucleosomes and their attached damage-associated molecular patterns (DAMPs) and initiated by caspase activation. Caspase-activated DNase has dual roles in nucleosomal release as it can degrade extracellularly released chromatin into poly- or oligo-nucleosomes although it prohibits release of nucleosomes. In addition, osmotically triggered water movement following Cl(-) influx and subsequent Na(+) influx appears to be the major driving force for nucleosomal and DAMPs release. Finally, Ca(2+)-activated cysteine protease, calpain, is an another essential factor in nucleosomal and DAMPs release because of complete reversion to apoptotic morphology from necrotic one and blockade of nucleosomal and DAMPs release by its inhibition.