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Safavi AH, Bryson E, Delibasic V, Tjong MC, Hallet J, Mahar A, Davis LE, Wright FC, Parmar A, Coburn NG, Louie AV. Enhancing Symptom Screening and Patient Education Among Patients with Metastatic Lung Cancer: a Qualitative Analysis. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2024; 39:86-95. [PMID: 37962792 DOI: 10.1007/s13187-023-02379-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 11/15/2023]
Abstract
We explored perspectives of patients with metastatic non-small cell lung cancer (mNSCLC) on symptom screening and population-level patient-reported outcome (PRO) data regarding common symptom trajectories in the year after diagnosis. A qualitative study of patients with mNSCLC was conducted at a Canadian tertiary cancer centre. English-speaking patients diagnosed ≥ 6 months prior to study invitation were recruited, and semi-structured one-on-one interviews were conducted. Patient and treatment characteristics were obtained via chart review. Anonymized interview transcripts underwent deductive-inductive coding and thematic content analysis. Among ten participants (5 (50%) females; median (range) age, 68 (56-77) years; median (range) time since diagnosis, 28.5 (6-72) months; 6 (60%) with smoking histories), six themes were identified in total. Two themes were identified regarding symptom screening: (1) screening is useful for symptom self-monitoring and disclosure to the healthcare team, (2) screening of additional quality-of-life (QOL) domains (smoking-related stigma, sexual dysfunction, and financial toxicity) is desired. Four themes were identified regarding population-level symptom trajectory PRO data: (1) data provide reassurance and motivation to engage in symptom self-management, (2) data should be disclosed after an oncologic treatment plan is developed, (3) data should be communicated via in-person discussion with accompanying patient-education resources, and (4) communication of data should include reassurance about symptom stabilization, acknowledgement of variability in patient experience, and strategies for symptom self-management. The themes and recommendations derived from the patient experience with mNSCLC provide guidance for enhanced symptom screening and utilization of population-level symptom trajectory data for patient education.
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Affiliation(s)
- Amir H Safavi
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Emily Bryson
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Victoria Delibasic
- Department of Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, T2 163M4N 3M5, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, T2 163M4N 3M5, Canada
| | - Alyson Mahar
- School of Nursing, Queen's University, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada
| | - Laura E Davis
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 2001 McGill College Suite 1200, Montreal, QC, H3A 1G1, Canada
| | - Frances C Wright
- Department of Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, T2 163M4N 3M5, Canada
| | - Ambica Parmar
- Division of Medical Oncology and Hematology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Natalie G Coburn
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, T2 163M4N 3M5, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, T2 163M4N 3M5, Canada.
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Kim MJ, Kim JY, Lim YH, Hong SJ, Jeong JH, Choi HR, Park SK, Kim JE, Lee MK, Kim JH. Actual situation and prescribing patterns of opioids by pain physicians in South Korea. Korean J Pain 2022; 35:475-487. [PMID: 36175347 PMCID: PMC9530690 DOI: 10.3344/kjp.2022.35.4.475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/10/2022] [Accepted: 09/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background Use of opioids for chronic intractable pain is increasing globally, and their proper use can improve patients’ quality of life. In contrast, opioid use disorders, such as abuse or addiction, caused by prescribing opioids, are a worldwide issue. This study aimed to understand current opioid prescribing patterns and pain physicians’ experiences with opioid use in South Korea. Methods Pain physicians in 42 university hospitals in South Korea were asked to complete anonymous questionnaires regarding opioid prescriptions. Results A total of 69 surveys were completed. Most pain physicians started prescribing opioids at a pain score of 7/10 and aimed to reduce pain by 50%. Most physicians (73.1%) actively explained the prescribed medications and possible side effects, and 61.2% of physicians preferred the prescription interval of 4 weeks. Immediate-release opioids were the most popular treatment for breakthrough pain (92.6%). The most common side effect encountered by physicians was constipation (43.3%), followed by nausea/vomiting (34.3%). Of the physicians, 56.5% replied that addiction and misuse prevalences were less than 5%. However, the most concerning side effect was addiction (33.0%). Conclusions The survey results showed that the prescribing patterns of pain physicians generally followed Korean guidelines. Physicians were most interested in the safety and effectiveness of opioid prescriptions. They were most concerned about respiratory depression and abuse or addiction. A significant number of physicians agreed that the NHIS regulations needed improvement for patient convenience and safe and effective treatment, though there were pros and cons of the NHIS restrictions on prescription conditions.
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Affiliation(s)
- Min Jung Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Ji Yeon Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Yun Hee Lim
- Department of Anesthesiology and Pain Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Sung Jun Hong
- Department of Anesthesiology and Pain Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Jae Hun Jeong
- Department of Anesthesiology and Pain Medicine, Jeong-clinic, Seoul, Korea
| | - Hey Ran Choi
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jung Eun Kim
- Department of Anesthesiology and Pain Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Min Ki Lee
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jae Hun Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea
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Noel CW, Sutradhar R, Gotlib Conn L, Forner D, Chan WC, Fu R, Hallet J, Coburn NG, Eskander A. Development and Validation of a Machine Learning Algorithm Predicting Emergency Department Use and Unplanned Hospitalization in Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2022; 148:764-772. [PMID: 35771564 DOI: 10.1001/jamaoto.2022.1629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Patient-reported symptom burden was recently found to be associated with emergency department use and unplanned hospitalization (ED/Hosp) in patients with head and neck cancer. It was hypothesized that symptom scores could be combined with administrative health data to accurately risk stratify patients. Objective To develop and validate a machine learning approach to predict future ED/Hosp in patients with head and neck cancer. Design, Setting, and Participants This was a population-based predictive modeling study of patients in Ontario, Canada, diagnosed with head and neck cancer from January 2007 through March 2018. All outpatient clinical encounters were identified. Edmonton Symptom Assessment System (ESAS) scores and clinical and demographic factors were abstracted. Training and test cohorts were randomly generated in a 4:1 ratio. Various machine learning algorithms were explored, including (1) logistic regression using a least absolute shrinkage and selection operator, (2) random forest, (3) gradient boosting machine, (4) k-nearest neighbors, and (5) an artificial neural network. Data analysis was performed from September 2021 to January 2022. Main Outcomes and Measures The main outcome was any 14-day ED/Hosp event following symptom assessment. The performance of each model was assessed on the test cohort using the area under the receiver operator characteristic (AUROC) curve and calibration plots. Shapley values were used to identify the variables with greatest contribution to the model. Results The training cohort consisted of 9409 patients (mean [SD] age, 63.3 [10.9] years) undergoing 59 089 symptom assessments (80%). The remaining 2352 patients (mean [SD] age, 63.3 [11] years) and 14 193 symptom assessments were set aside as the test cohort (20%). Several models had high predictive accuracy, particularly the gradient boosting machine (validation AUROC, 0.80 [95% CI, 0.78-0.81]). A Youden-based cutoff corresponded to a validation sensitivity of 0.77 and specificity of 0.66. Patient-reported symptom scores were consistently identified as being the most predictive features within models. A second model built only with symptom severity data had an AUROC of 0.72 (95% CI, 0.70-0.74). Conclusions and Relevance In this study, machine learning approaches predicted with a high degree of accuracy ED/Hosp in patients with head and neck cancer. These tools could be used to accurately risk stratify patients and may help direct targeted intervention.
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Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Lesley Gotlib Conn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Rui Fu
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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4
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Noel CW, Du Y(J, Baran E, Forner D, Husain Z, Higgins KM, Karam I, Chan KKW, Hallet J, Wright F, Coburn NG, Eskander A, Gotlib Conn L. Enhancing Outpatient Symptom Management in Patients With Head and Neck Cancer: A Qualitative Analysis. JAMA Otolaryngol Head Neck Surg 2022; 148:333-341. [PMID: 35238872 PMCID: PMC8895314 DOI: 10.1001/jamaoto.2021.4555] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
IMPORTANCE Patients with head and neck cancer manage a variety of symptoms at home on an outpatient basis. Clinician review alone often leaves patient symptoms undetected and untreated. Standardized symptom assessment using patient-reported outcomes (PROs) has been shown in randomized clinical trials to improve symptom detection and overall survival, although translation into real-world settings remains a challenge. OBJECTIVE To better understand how patients with head and neck cancer cope with cancer-related symptoms and to examine their perspectives on standardized symptom assessment. DESIGN, PARTICIPANTS, AND SETTING This was a qualitative analysis using semistructured interviews of patients with head and neck cancer and their caregivers from November 2, 2020, to April 16, 2021, at a regional tertiary center in Canada. Purposive sampling was used to recruit a varied group of participants (cancer subsite, treatment received, sociodemographic factors). Drawing on the Supportive Care Framework, a thematic approach was used to analyze the data. Data analysis was performed from November 2, 2020, to August 2, 2021. MAIN OUTCOMES AND MEASURES Patient perception of ambulatory symptom management and standardized symptom assessment. RESULTS Among 20 participants (median [range] age, 59.5 [33-74] years; 9 [45%] female; 13 [65%] White individuals), 4 themes were identified: (1) timely physical symptom management, (2) information as a tool for symptom management, (3) barriers to psychosocial support, and (4) external factors magnifying symptom burden. Participants' perceptions of standardized symptom assessment varied. Some individuals described the symptom monitoring process as facilitating self-reflection and symptom detection. Others felt disempowered by the process, particularly when symptom scores were inconsistently reviewed or acted on. CONCLUSIONS AND RELEVANCE This qualitative analysis provides a novel description of head and neck cancer symptom management from the patient perspective. The 4 identified themes and accompanying recommendations serve as guides for enhanced symptom monitoring.
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Affiliation(s)
- Christopher W. Noel
- Department of Otolaryngology−Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada
| | - Yue (Jennifer) Du
- Department of Otolaryngology−Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elif Baran
- Department of Otolaryngology−Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Division of Otolaryngology−Head and Neck Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin M. Higgins
- Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K. W. Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Frances Wright
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G. Coburn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,Ontario Health Cancer Care, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology−Head and Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,ICES, Toronto, Ontario, Canada,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lesley Gotlib Conn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada,Evaluative Clinical Sciences, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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5
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ALMouaalamy N, Alharbi ZM, Aldosari FM, Saif SA, Alsulimani EF, Aldawsari MK, AlRahimi J. The Practice of Pain Assessment and Management in a Tertiary Oncology Center. Cureus 2021; 13:e18837. [PMID: 34804692 PMCID: PMC8594563 DOI: 10.7759/cureus.18837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background Pain is one of the common and devastating symptoms that affects millions of cancer patients globally. Despite published guidelines and education on the assessment and management of cancer-related pain, underestimated or undertreated pain continues to be a considerable worldwide public health concern among cancer patients. In this study, we aimed to assess physicians’ adherence to the World Health Organization (WHO) guidelines in the management and assessment of pain in oncology patients based on the available score of pain in the Princess Noorah Oncology Center (PNOC) at the King Abdulaziz Medical City in Jeddah. Methodology This cross-sectional, retrospective chart review study studied 451 patients (selected through computerized random sampling) who were admitted to the PNOC during the study period. Results The pain was assessed using the Brief Pain Inventory in almost all patients (n = 450, 99.8%). The pain was categorized as mild in 386 (85.6%) patients, moderate in 46 (10.2%) patients, and severe in 19 (4.2%) patients. Opioid prescriptions were significantly higher among patients with moderate (76.1%) and severe pain (89.5%) compared to those with mild pain (39.1%; p < 0.0001). Conclusions The practice of pain documentation for cancer patients was adequate as indicated by reporting the pain scores of 99.8% of inpatients. Patients with moderate and severe pain were more likely to receive opioids and a combination of opioids plus non-opioid analgesics, whereas the prescription of analgesics was predicted by experiencing moderate cancer pain.
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Affiliation(s)
- Nabil ALMouaalamy
- Oncology Department/Palliative, Princess Noorah Oncology Center, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, SAU.,Research, King Abdullah International Medical Research Center, Jeddah, SAU.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Ziyad M Alharbi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Faisal M Aldosari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Saif A Saif
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Enad F Alsulimani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Mohammed K Aldawsari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Jamilah AlRahimi
- Cardiology, King Abdulaziz Medical City, King Faisal Cardiac Center, Jeddah, SAU.,Research, King Abdullah International Medical Research Center, Jeddah, SAU.,College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
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6
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Noel CW, Forner D, Chepeha DB, Baran E, Chan KKW, Parmar A, Husain Z, Karam I, Hallet J, Coburn NG, Eskander A. The Edmonton Symptom Assessment System: A narrative review of a standardized symptom assessment tool in head and neck oncology. Oral Oncol 2021; 123:105595. [PMID: 34775181 DOI: 10.1016/j.oraloncology.2021.105595] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Symptom burden is common in head and neck cancer patients though it frequently remains undetected and untreated. The Edmonton Symptom Assessment System - revised version (ESAS-r) is a generic symptom scale deployed in many outpatient settings worldwide. The ESAS-r is meant to improve symptom detection and management. We sought to review the ESAS-r and its psychometric properties in a head and neck oncology population. METHODS Narrative Review. RESULTS Over the past 30 years, the ESAS-r has emerged as one of the most used symptom scales for cancer patients. Its psychometric properties in a heterogenous cancer population are well supported, proving to be reliable and valid in a variety of settings. The linking of ESAS-r scores with Ontario administrative health data has led to a detailed assessment of validity in head and neck cancer. The ESAS-r can discriminate between high and low levels of symptom burden and is responsive to change over time in this patient population. ESAS-r scores have also been shown to be a strong predictor of future emergency department use and unplanned hospitalization in head and neck cancer patients. CONCLUSIONS The ESAS-r is reliable and valid in the head and neck cancer population and may serve as a useful clinical endpoint in research studies.
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Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Division of Otolaryngology Head & Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Douglas B Chepeha
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology Head & Neck Surgery/Surgical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Elif Baran
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ambica Parmar
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Otolaryngology - Head & Neck Surgery, Sunnybrook Health Sciences Centre and Michael Garron Hospital, University of Toronto, Toronto, Ontario, Canada.
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7
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Seow H, Guthrie DM, Stevens T, Barbera LC, Burge F, McGrail K, Chan KKW, Peacock SJ, Sutradhar R. Trajectory of End-of-Life Pain and Other Physical Symptoms among Cancer Patients Receiving Home Care. ACTA ACUST UNITED AC 2021; 28:1641-1651. [PMID: 33924801 PMCID: PMC8161760 DOI: 10.3390/curroncol28030153] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/15/2021] [Accepted: 04/23/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE To describe the trajectory of physical symptoms among cancer decedents who were receiving home care in the six months before death. PATIENTS AND METHODS An observational cohort study of cancer decedents in Ontario, Canada, who received home care services between 2007 and 2014. To be included, decedents had to use at least one home care service in the last six months of life. Outcomes were the presence of pain and several other physical symptoms at each week before death. RESULTS Our cohort included 27,295 cancer decedents (30,368 assessments). Forty-seven percent were female and 56% were age 75 years or older. The prevalence of all physical symptoms increased as one approached death, particularly in the last month of life. In the last weeks of life, 69% of patients reported having moderate-severe pain; however, only 20% reported that the pain was not controlled. Loss of appetite (63%), shortness of breath (59%), high health instability (50%), and self-reported poor health (44%) were also highly prevalent in the last week of life. Multivariate regression showed that caregiver distress, high health instability, social decline, uncontrolled pain, and signs of depression all worsened the odds of having a physical symptom in the last 3 months of life. CONCLUSION In this large home care cancer cohort, trajectories of physical symptoms worsened close to death. While presence of moderate-severe pain was common, it was also reported as mostly controlled. Covariates, such as caregiver distress and social decline, were associated with having more physical symptoms at end of life.
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Affiliation(s)
- Hsien Seow
- Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada;
- Correspondence: ; Tel.: +1-905-387-9711 (ext. 67175); Fax: +1-905-575-6308
| | - Dawn M. Guthrie
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, ON N2L 3C5, Canada; (D.M.G.); (T.S.)
| | - Tara Stevens
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, ON N2L 3C5, Canada; (D.M.G.); (T.S.)
| | - Lisa C. Barbera
- Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Kimberlyn McGrail
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
| | - Kelvin K. W. Chan
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada;
- Sunnybrook Odette Cancer Centre, Toronto, ON M4N 3M5, Canada
- Canadian Centre for Applied Research in Cancer Control, Vancouver, BC V5Z 1L3, Canada;
| | - Stuart J. Peacock
- Canadian Centre for Applied Research in Cancer Control, Vancouver, BC V5Z 1L3, Canada;
- British Columbia Cancer Agency, Vancouver, BC V5Z 1L3, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, ON M4N 3M5, Canada;
- Division of Biostatistics, University of Toronto, Toronto, ON M5S 1A1, Canada
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8
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Noel CW, Sutradhar R, Zhao H, Delibasic V, Forner D, Irish JC, Kim J, Husain Z, Mahar A, Karam I, Enepekides DJ, Chan KKW, Singh S, Hallet J, Coburn NG, Eskander A. Patient-Reported Symptom Burden as a Predictor of Emergency Department Use and Unplanned Hospitalization in Head and Neck Cancer: A Longitudinal Population-Based Study. J Clin Oncol 2021; 39:675-684. [PMID: 33405964 DOI: 10.1200/jco.20.01845] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To determine the association between patient-reported symptom burden and subsequent emergency department use and unplanned hospitalization (ED/Hosp) in a head and neck cancer (HNC) patient population. METHODS This was a population-based study of patients diagnosed with HNC who had completed at least one outpatient Edmonton Symptom Assessment System (ESAS) assessment between January 2007 and March 2018 in Ontario, Canada. Logistic regression models were used to determine the relationship between outpatient ESAS scores and subsequent 14-day ED/Hosp use. A generalized estimating equation approach with an exchangeable correlation structure was incorporated to account for patient-level clustering. RESULTS There were 11,761 patients identified, completing a total of 73,282 ESAS assessments and experiencing 5,203 ED/Hosp events. Six of the nine ESAS symptom scores were positively associated with ED/Hosp use, with pain, appetite, shortness of breath, and tiredness demonstrating the strongest associations. A global ESAS score was calculated by selecting the highest individual symptom score (h-ESAS). Among patients reporting a maximum h-ESAS score of 10, 15.1% had an ED/Hosp event within 14 days compared with 1.5% for those with the lowest possible score of zero. In adjusted analysis, the odds of ED/Hosp use increased with h-ESAS (1.23 per one-unit increase [95% CI, 1.22 to 1.25]). When treated as a categorical variable, patients with the maximum h-ESAS score of 10 had 9.23 (95% CI, 7.22 to 11.33) higher odds of ED/Hosp use, relative to the minimum score of zero. CONCLUSION ESAS scores are strongly associated with subsequent ED/Hosp events in patients with HNC. Clinician education around how ESAS data might inform patient care may enhance symptom detection and management.
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Affiliation(s)
- Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | | | | | - David Forner
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan C Irish
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jonathan Kim
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alyson Mahar
- Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Danny J Enepekides
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Simron Singh
- Department of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Surgical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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9
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Tervonen HE, Schaffer AL, Luckett T, Phillips J, Litchfield M, Todd A, Pearson SA. Patterns of opioid use in older people diagnosed with cancer in New South Wales, Australia. Pharmacoepidemiol Drug Saf 2020; 30:360-370. [PMID: 33047458 DOI: 10.1002/pds.5081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/14/2020] [Accepted: 06/29/2020] [Indexed: 11/08/2022]
Abstract
PURPOSE Opioids provide effective analgesia for most cancer patients, but little is known about individual-level opioid use after cancer diagnosis. We examined the patterns of and factors associated with opioid use in older people diagnosed with cancer. METHODS We used the Department of Veterans' Affairs (DVA) client data linked with the New South Wales (NSW) Cancer Registry and the Repatriation Pharmaceutical Benefits Scheme data. We included people aged ≥65 years diagnosed with cancer in NSW, Australia in 2005 to 2015. We examined patterns of opioid use in the 12 months after cancer diagnosis and used cause-specific hazards models to examine factors associated with opioid use. RESULTS Of 13 527 people diagnosed with cancer, 51% were dispensed opioids after their diagnosis. We observed the highest proportions of use in people diagnosed with pancreas, liver, or lung cancers. Opioid use was associated with female sex, younger age, more advanced degree of cancer spread, opioid use before cancer diagnosis, and multimorbidity. Forty-four percentages of all people dispensed opioids had a history of opioid use in the 12 months before their cancer diagnosis; these people had higher median number of different opioids and opioid dispensings, and a shorter time to first opioid dispensing than opioid-naive people. CONCLUSION Our study suggests that many older cancer patients were dispensed opioids before their cancer diagnosis. Previously opioid-treated people had more intense opioid use patterns after diagnosis than opioid-naïve people. Acknowledging the history of opioid use is important as it may complicate pain treatment in clinical practice.
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Affiliation(s)
- Hanna E Tervonen
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Kensington, New South Wales, Australia
| | - Andrea L Schaffer
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Kensington, New South Wales, Australia
| | - Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jane Phillips
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Melisa Litchfield
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Kensington, New South Wales, Australia
| | - Adam Todd
- School of Pharmacy, Faculty of Medical Sciences, Newcastle University, UK
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, UNSW Sydney, Kensington, New South Wales, Australia.,Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
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10
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Feder SL, Canavan ME, Wang S, Kent EE, Kapo J, Presley CJ, Ross J, Davidoff AJ. Patterns of Opioid Prescribing among Medicare Advantage Beneficiaries with Pain and Cardiopulmonary Conditions. J Palliat Med 2020; 24:195-204. [PMID: 32673139 DOI: 10.1089/jpm.2020.0193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Pain is common among patients with cardiopulmonary conditions; however, there are increasing concerns, but limited research, regarding use of opioids for pain in patients with noncancer conditions. Objective: To compare patterns of opioid prescribing among older adults reporting pain with cardiopulmonary conditions and/or cancer. Design: Observational study using data from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey resource linked to Medicare Part D prescription claims. Setting/Subjects: We identified patients who self-reported moderate-to-severe pain interference with daily activities. Patients were stratified by (1) self-reported history of cardiopulmonary conditions; (2) were within five years of cancer diagnosis; (3) had both conditions; or (4) neither. Measurements: We characterized opioid prescribing within 30 days of survey and one-year follow-up using logistic regression and Cox proportional hazard time-to-event analyses. Results: Of 10,516 patients with moderate-to-severe pain (1758 cardiopulmonary conditions, 3383 cancer, 2861 both, 2514 neither), 46% were aged ≥75 years, 65% were non-Hispanic white, and 10% non-Hispanic black. At survey, 1627 (15.5%) received opioids. Adjusted proportions of opioid use were lower for patients with cardiopulmonary conditions only (14%) compared with cancer only (17%; p < 0.001) and both conditions (17%; p < 0.001) but higher than patients with neither condition (13.1%; p < 0.001). There was no difference in time to initiation of opioids at follow-up among patients with cardiopulmonary conditions only, relative to cancer only (adjusted hazard ratio 1.03; 95% confidence interval 0.88-1.21). Conclusions: Opioid use is lower among patients with pain and cardiopulmonary conditions relative to patients with cancer. Findings emphasize the importance of pain assessment and management for patients with cardiopulmonary conditions.
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Affiliation(s)
| | - Maureen E Canavan
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shiyi Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA.,Yale School of Public Health, New Haven, Connecticut, USA
| | - Erin E Kent
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer Kapo
- Department of Internal Medicine, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Carolyn J Presley
- Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Joseph Ross
- Section of General Medicine and National Clinician Scholars Program, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Amy J Davidoff
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut, USA.,Yale School of Public Health, New Haven, Connecticut, USA
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11
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DEMİR SAKA S, GÖZÜM PDS. Toplumda yaşayan yaşlılarda ağrı prevalansı ve ağrı öz yönetim uygulamaları. CUKUROVA MEDICAL JOURNAL 2020. [DOI: 10.17826/cumj.639994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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12
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Patient-reported symptoms in metastatic gastric cancer patients in the last 6 months of life. Support Care Cancer 2020; 29:515-524. [DOI: 10.1007/s00520-020-05501-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
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13
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Presley CJ, Canavan M, Wang SY, Feder SL, Kapo J, Saphire ML, Sheinfeld E, Kent EE, Davidoff AJ. Severe functional limitation due to pain & emotional distress and subsequent receipt of prescription medications among older adults with cancer. J Geriatr Oncol 2020; 11:960-968. [PMID: 32169548 DOI: 10.1016/j.jgo.2020.02.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Certain cancer types and subsequent treatment can cause or worsen pain and emotional distress, leading to functional limitation, particularly among a growing population of older adults with cancer. METHODS We constructed a national sample of older adult Medicare beneficiaries with cancer using the 2007-2012 Surveillance, Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) database linked to Medicare Part D enrollment and prescription claims data. MHOS survey responses described functional limitations due to pain and emotional distress. Using multivariable logistic regression, we estimated the association between participant characteristics and patient-reported functional limitation due to pain and emotional distress and subsequent prescription medication use. RESULTS Among 9105 older adults with cancer, aged 66-102 years (y), 68.6% reported moderate to severe functional limitation due to pain, and 48.3% reported moderate to severe functional limitation due to emotional distress. Nearly 10% reported severe functional limitation due to co-occurring symptoms of pain and emotional distress. Significant predictors of severe functional limitation due to co-occurring symptoms included age ≥ 80y (ref: 66-69y, adjusted relative risk (aRR): 1.74; 95% confidence interval (CI) 1.39-2.18, p < .001), stage IV disease at diagnosis (ref: stage I, aRR: 2.08; CI 1.52-2.86, p < .001), and lung cancer (ref: breast cancer, aRR: 1.84; CI 1.30-2.61, p < .001). Among 892 participants reporting co-occurring symptoms, 32.5% received neither pain nor emotional distress prescription medication. CONCLUSIONS Functional limitation due to pain and emotional distress persist among older adults with cancer, particularly octogenarians. Efforts to identify and target unmet supportive care needs to maintain functional independence are needed.
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Affiliation(s)
- Carolyn J Presley
- The Ohio State University Comprehensive Cancer Center/The James Cancer Hospital & Solove Research Institute, B424 Starling Loving Hall, 320 W. 10th Avenue, Columbus, OH 43214, USA.
| | - Maureen Canavan
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, Yale Cancer Center, 333 Cedar Street, New Haven, CT 06510, USA
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, Yale Cancer Center, 333 Cedar Street, New Haven, CT 06510, USA; Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA
| | - Shelli L Feder
- National Clinical Scholars Program, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
| | - Jennifer Kapo
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, Yale Cancer Center, 333 Cedar Street, New Haven, CT 06510, USA
| | - Maureen L Saphire
- The Ohio State University Wexner Medical Center/The James Cancer Hospital, 410 W 10th Avenue, Columbus, OH 43210, USA
| | - Ella Sheinfeld
- Yale Fox Fellowship, 333 Cedar Street, New Haven, CT 06510, USA
| | - Erin E Kent
- National Cancer Institute, 9000 Rockville Pike, Bethesda, MD 20892, USA
| | - Amy J Davidoff
- Cancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine, Yale Cancer Center, 333 Cedar Street, New Haven, CT 06510, USA; Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA
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14
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Santivasi WL, Partain DK, Whitford KJ. The role of geriatric palliative care in hospitalized older adults. Hosp Pract (1995) 2020; 48:37-47. [PMID: 31825689 DOI: 10.1080/21548331.2019.1703707] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/10/2019] [Indexed: 06/10/2023]
Abstract
Take-Away Points:1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.
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Affiliation(s)
- Wil L Santivasi
- Center for Palliative Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel K Partain
- Center for Palliative Medicine & Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Center for Palliative Medicine & Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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15
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Hallet J, Davis LE, Isenberg-Grzeda E, Mahar AL, Zhao H, Zuk V, Moody L, Coburn NG. Gaps in the Management of Depression Symptoms Following Cancer Diagnosis: A Population-Based Analysis of Prospective Patient-Reported Outcomes. Oncologist 2020; 25:e1098-e1108. [PMID: 32100906 DOI: 10.1634/theoncologist.2019-0709] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 01/23/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND One of the most common psychological morbidities of cancer is depression. Routine depression symptoms screening (DSS) is recommended, but its ability to lead to psychosocial interventions in clinical practice is limited. We examined the use of and factors associated with psychosocial interventions for positive DSS following cancer diagnosis. MATERIALS AND METHODS We conducted a population-based cohort study of patients with diagnoses from 2010 to 2017 who reported ≥1 patient-reported Edmonton Symptom Assessment System (ESAS) score. Positive DSS was defined as ESAS ≥2 out of 10 for the depression item within 6 months of diagnosis. Outcomes were psychosocial interventions around the time of positive DSS: palliative care assessment, psychiatry/psychology assessment, social work referral, and antidepressant therapy (in patients ≥65 years of age with universal drug coverage). We examined reduction in depression symptom score (≥1 point) following intervention. Modified Poisson regression examined factors associated with interventions. RESULTS Of 142,270 patients, 65,424 (46.0%) reported positive DSS at a median of 66 days (interquartile range: 34-105) after diagnosis. Of those with depression symptoms, 17.1% received palliative assessment, 1.7% psychiatry/psychology assessment, 8.4% social work referral, and 4.3% antidepressant therapy. Depression symptom score decreased in 67.2% who received palliative assessment, 63.7% with psychiatry/psychology assessment, 67.3% with social work referral, and 71.4% with antidepressant therapy. On multivariable analysis, patients with older age, rural residence, lowest income quintile, and genitourinary or oropharyngeal cancer were more likely to not receive intervention other than palliative care. CONCLUSION The proportion of patients reporting positive DSS after cancer diagnosis receiving psychosocial intervention is low. We identified patients vulnerable to not receiving interventions, who may benefit from additional support. These data represent a call to action to modify practice and optimize the usefulness of systematic symptom screening. IMPLICATIONS FOR PRACTICE Patient-reported depression symptoms screening should be followed by targeted interventions to improve symptoms and patient-centered management.
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Affiliation(s)
- Julie Hallet
- Division of Surgical Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Laura E Davis
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Elie Isenberg-Grzeda
- Division of Psycho-Social Services, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Natalie G Coburn
- Division of Surgical Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Cancer Care Ontario, Toronto, Ontario, Canada
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16
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Tung S, Coburn NG, Davis LE, Mahar AL, Myrehaug S, Zhao H, Earle CC, Nathens A, Hallet J. Population-based study of the prevalence and management of self-reported high pain scores in patients with non-resected pancreatic adenocarcinoma. Br J Surg 2019; 106:1666-1675. [PMID: 31639208 DOI: 10.1002/bjs.11330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/09/2019] [Accepted: 07/09/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pain is a common debilitating symptom in pancreatic adenocarcinoma. This cohort study examined the use of, and factors associated with, pain-directed interventions for a high pain score in patients with non-curable pancreatic adenocarcinoma. METHODS Administrative databases were linked and patients with non-resected pancreatic adenocarcinoma diagnosed between 2010 and 2016, who reported one or more Edmonton Symptom Assessment System (ESAS) score, were identified. A high pain score was defined as an ESAS score of at least 4. Outcomes were pain-directed interventions: opiates (in patients aged 65 years or more with universal drug coverage), nerve block and radiation therapy for a high pain score. Reduction in pain score of at least 1 point after pain-directed intervention was also evaluated. Modified Poisson regression was used to examine factors associated with pain-directed intervention. RESULTS Among 2623 patients with a median age of 67 years, 1223 (46·6 per cent) were women, and 1621 (61·8 per cent) reported a high pain score at a median of 38 days after diagnosis. Of those with a high pain score, 75·6 per cent (688 of 910) received opiates, 13·5 per cent (219 of 1621) radiation and 1·2 per cent (19 of 1621) nerve block. The pain score decreased in 62·1 per cent of patients after administration of opiates, 73·4 per cent after radiation and all patients after nerve block. In multivariable analysis, no patient factor (age, sex, co-morbidity burden, rurality, income quintile) was associated with receipt of non-opiate pain-directed intervention for a high pain score. In patients aged at least 65 years, advanced age was associated with lower odds of opiate use. CONCLUSION Opiates are the most common pain-directed intervention for non-curable pancreatic adenocarcinoma, whereas radiation therapy and nerve blocks are seldom used. The lack of association between pain-directed interventions and patient factors points toward practice-driven patterns.
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Affiliation(s)
- S Tung
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - L E Davis
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - A L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S Myrehaug
- Divisions of Radiation Oncology, Odette Cancer Centre, Toronto, Canada
| | - H Zhao
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - C C Earle
- Divisions of Medical Oncology, Odette Cancer Centre, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A Nathens
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - J Hallet
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.,Divisions of General Surgery, Odette Cancer Centre, Toronto, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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17
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Patterns of pain medication use associated with reported pain interference in older adults with and without cancer. Support Care Cancer 2019; 28:3061-3072. [PMID: 31637515 DOI: 10.1007/s00520-019-05074-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
CONTEXT Concerns about the adequacy of pain management among older adults are increasing, particularly with restrictions on opioid prescribing. OBJECTIVES To examine associations between prescription pain medication receipt and patient-reported pain interference in older adults with and without cancer. METHODS Using the 2007-2012 Surveillance Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) database linked to Medicare Part D prescription claims, we selected MHOS respondents (N = 15,624) aged ≥ 66 years, ≤ 5 years of a cancer diagnosis (N = 9105), or without cancer (N = 6519). We measured receipt of opioids, non-steroidal anti-inflammatory drugs, and antiepileptics, and selected antidepressants within 30 days prior to survey. Patient-reported activity limitation due to pain (pain interference) within the past 30 days was summarized as severe, moderate, or mild/none. Logistic regression using predictive margins estimated associations between pain interference, cancer history, and pain medication receipt, adjusting for socio-demographics, chronic conditions, and Part D low-income subsidy. RESULTS Severe or moderate pain interference was reported by 21.3% and 46.1%, respectively. Pain medication was received by 21.5%, with 11.6% receiving opioids. Among adults reporting severe pain interference, opioid prescriptions were filled by 27.0% versus 23.8% (p = 0.040) with and without cancer, respectively. Over half (56%) of adults reporting severe pain in both groups failed to receive any prescription pain medication. CONCLUSIONS Older adults with cancer were more likely to receive prescription pain medications compared with adults without cancer; however, many older adults reporting severe pain interference did not receive medications. Improved assessment and management of pain among older adults with and without cancer is urgently needed.
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18
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O'Brien MA, Makuwaza T, Graham ID, Barbera L, Earle CC, Brouwers MC, Grunfeld E. Lessons learned from a cancer knowledge translation grants program: results of an evaluation. ACTA ACUST UNITED AC 2019; 26:272-284. [PMID: 31548808 DOI: 10.3747/co.26.5531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background A novel way to build capacity in knowledge translation (kt) is through kt-focused grant competitions. Since 2009, the Knowledge Translation Research Network (KT-Net) has had a cancer-related kt grants program. We undertook an evaluation of the program to determine if KT-Net was achieving its aims of building capacity in cancer kt, advancing the science of kt, building partnerships, and leveraging funding. Methods An adapted framework guided the evaluation. Nine funded studies from 4 competitions were included. Semi-structured telephone interviews were held with researchers, stakeholders (including knowledge users), members of grant review panels, and experts in kt. Interview transcripts were audio-recorded, transcribed, and analyzed thematically. A review of proposal and report documents was also conducted. Results Funded researchers indicated that the grant competition was an essential funding program for cancer kt research. Competitions were perceived to build capacity in cancer kt among early-career researchers and to encourage innovative cancer kt research for which alternative funding sources are limited. The grants program resulted in incremental gains in advancing the science of kt. Suggestions to improve the program included stronger partnerships between the funder and the provincial cancer-system organization to optimize the application of research that is relevant to the organization's strategic objectives. Conclusions The grants program met many of its aims by providing cancer researchers with an opportunity to gain capacity in cancer kt and by making incremental advances in kt science. Suggestions to improve the program included closer partnerships between the funder and the cancer-system organization.
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Affiliation(s)
- M A O'Brien
- Department of Family and Community Medicine, University of Toronto, Toronto, ON
| | - T Makuwaza
- Department of Family and Community Medicine, University of Toronto, Toronto, ON.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON
| | - I D Graham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON.,The Ottawa Hospital Research Institute, Ottawa, ON
| | - L Barbera
- Tom Baker Cancer Centre, Calgary, AB.,University of Calgary, Calgary, AB.,ices, Toronto, ON
| | - C C Earle
- Ontario Institute for Cancer Research, Toronto, ON
| | - M C Brouwers
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON.,Department of Oncology, McMaster University, Hamilton, ON
| | - E Grunfeld
- Department of Family and Community Medicine, University of Toronto, Toronto, ON.,Ontario Institute for Cancer Research, Toronto, ON
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Oh TK, Jeon YT, Choi JW. Trends in chronic opioid use and association with five-year survival in South Korea: a population-based cohort study. Br J Anaesth 2019; 123:655-663. [PMID: 31558315 DOI: 10.1016/j.bja.2019.08.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The Korean National Health Insurance Service (NHIS) was developed to provide population data for medical research. The aim of this study was to estimate trends in prescription opioid use in South Korea, and to determine the association between chronic opioid use and 5-yr mortality in cancer and non-cancer patients. METHODS A population-based cohort study was conducted amongst the South Korean adult population using data from the NHIS. Those prescribed a continuous supply of opioids for ≥90 days were defined as chronic opioid users. Multivariable Cox regression analysis was used to assess the association between chronic opioid use and 5-yr mortality. RESULTS The proportion of chronic weak opioid users increased from 1.03% in 2002 to 9.62% in 2015. The proportion of chronic strong opioid users increased from 0.04% in 2002 to 0.24% in 2015. In the 2010 cohort (n=822 214), compared with non-users, chronic weak opioid users had a significantly lower 5-yr mortality (hazard ratio [HR]: 0.93; 95% confidence interval [CI]: 0.89-0.96; P<0.001), and chronic strong opioid users had a significantly higher 5-yr mortality (HR: 1.45; 95% CI: 1.28-1.63; P<0.001). Similar results were observed in non-cancer patients, but chronic weak opioid users were not significantly associated with 5-yr mortality in cancer patients (P=0.063). CONCLUSIONS In South Korea, chronic opioid use has increased since 2002. Chronic strong opioid use was associated with a higher 5-yr mortality, and chronic weak opioid use was associated with a slightly lower 5-yr mortality. However, the findings regarding chronic weak opioid users should be interpreted carefully because there might be residual confounders in this study. Further study is needed to confirm these retrospective findings.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, South Korea.
| | - Jae Wook Choi
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea; Institute for Occupational and Environmental Health, Korea University, Seoul, South Korea.
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20
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Zhao XX, Cui M, Geng YH, Yang YL. A systematic review and meta-analysis of randomized controlled trials of palliative care for pain among Chinese adults with cancer. BMC Palliat Care 2019; 18:69. [PMID: 31395039 PMCID: PMC6688327 DOI: 10.1186/s12904-019-0456-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 08/02/2019] [Indexed: 02/06/2023] Open
Abstract
Background Pain is one of the most common symptoms that has a severe impact on quality of life and is associated with numerous psychosocial issues in cancer patients. Palliative care, which is a recent development in China, mainly focuses on symptom control and provides psychosocial support in order to improve quality of life for terminally ill patients. This meta-analysis aimed to evaluate the effects of palliative care on cancer pain in China. Methods The four most comprehensive Chinese academic databases-CNKI, Wanfang, Vip and CBM-were searched from their inception until July 2019. Medline/PubMed, Web of Science, EBSCO and internet search (Google and Google Scholar) were also searched. Randomized controlled studies assessing the effects of palliative care on cancer pain were analyzed. The pooled random-effect estimates of standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated. Subgroup analysis was conducted by moderating factors for heterogeneity. Results The present meta-analysis included 18 studies with a total of 1370 patients. The random-effect model showed a significant effect size of palliative care on cancer pain (SMD = 1.475, p < 0.001; 95% CI = 1.071–1.878). Age, pharmacological/non-pharmacological strategies and publication date could account for the heterogeneity through subgroup analysis to some extent. Conclusions Palliative care was largely effective for relieving pain among Chinese adults with cancer, indicating that an adequate system should be urgently established to provide palliative care for cancer patients in Chinese medical settings. However, given the extent of heterogeneity, our findings should be interpreted cautiously. Electronic supplementary material The online version of this article (10.1186/s12904-019-0456-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xin-Xin Zhao
- Hospice Ward, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meng Cui
- Hospice Ward, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yi-Hang Geng
- School of Public Health, China Medical University, Shenyang, China
| | - Yi-Long Yang
- Department of Social Medicine, School of Public Health, China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, 110122, People's Republic of China.
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21
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Barbera L, Sutradhar R, Howell D, Corn E, O'Brien MA, Seow H, Dudgeon D, Atzema C, Earle CC, DeAngelis C, Sussman J. Factors Associated With Opioid Use in Long-term Cancer Survivors. J Pain Symptom Manage 2019; 58:100-107.e2. [PMID: 30831238 DOI: 10.1016/j.jpainsymman.2019.02.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate factors associated with opioid use in patients with cancer surviving more than five years without recurrence. We evaluated exposures of opioid use before cancer diagnosis, opioid use between cancer diagnosis and five-year anniversary, surgeries, and chemotherapy. METHODS We conducted a retrospective cohort study using linked provincial administrative data. Patients were aged 24-70 years and eligible for government-funded pharmacare. The index date was the five-year anniversary from diagnosis. Patients were accrued between 2010 and 2015. The main outcome was opioid prescription rate after index date. The main exposures were opioid use before diagnosis, opioid use between diagnosis and index, surgeries, and chemotherapy. A negative binomial regression model was used to estimate relative rates (RR) of opioid use after index date. RESULTS Our cohort included 7431 individuals. The overall crude prescription rate after the index date was 2 per person-year. The factor most strongly associated with a higher rate of opioid use after index was continuous opioid use between diagnosis and index (RR 46.1, 95% confidence interval 34.8-61.2). Opioid use before diagnosis was also a factor (RR = 1.8, 95% confidence interval 1.44-2.19). A history of depression, comorbidity, and more than two years of diabetes were also associated with higher risk of post-index date opioid use. Significant interactions were identified between prior opioid use and opioid use between diagnosis and index. Most prescriptions are from family physicians. CONCLUSION Patients who use opioids continuously between diagnosis and index date are at increased risk of continued use after five years of survival. Safe and appropriate pain management is an important survivorship issue.
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Affiliation(s)
- Lisa Barbera
- Tom Baker Cancer Centre, Calgary, Alberta, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Doris Howell
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Elyse Corn
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Mary Ann O'Brien
- University of Toronto, Department of Family and Community Medicine, Toronto, Ontario, Canada
| | - Hsien Seow
- McMaster University, Department of Oncology, Hamilton, Ontario, Canada
| | - Deb Dudgeon
- Queen's University Department of Medicine and Oncology, Kingston, Ontario, Canada
| | - Clare Atzema
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Department of Emergency Services, Toronto, Ontario, Canada
| | - Craig C Earle
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Department of Medicine, Toronto, Ontario, Canada
| | - Carlo DeAngelis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Department of Pharmacy, Toronto, Ontario, Canada
| | - Jonathan Sussman
- McMaster University, Department of Oncology, Hamilton, Ontario, Canada
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22
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Prevalence of pain in patients with cancer aged 70 years or older: A prospective observational study. J Geriatr Oncol 2019; 10:637-642. [DOI: 10.1016/j.jgo.2019.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 11/16/2018] [Accepted: 01/07/2019] [Indexed: 12/27/2022]
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23
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Merchant SJ, Brogly SB, Booth CM, Goldie C, Nanji S, Patel SV, Lajkosz K, Baxter NN. Palliative Care and Symptom Burden in the Last Year of Life: A Population-Based Study of Patients with Gastrointestinal Cancer. Ann Surg Oncol 2019; 26:2336-2345. [PMID: 30969388 DOI: 10.1245/s10434-019-07320-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The symptom profile in cancer patients and the association between palliative care (PC) and symptoms has not been studied in the general population. We addressed these gaps in gastrointestinal (GI) cancer patients in the final year of life. METHODS Patients dying of esophageal, gastric, colon, and anorectal cancers during 2003-2015 were identified. Symptom scores were recorded in the year before death using the Edmonton Symptom Assessment System (ESAS), which includes scores from 0 to 10 in nine domains. Symptom severity was categorized as none-mild (≤ 3) or moderate-severe (≥ 4-10). Adjusted associations between outpatient PC and moderate-severe ESAS scores were determined, and the effect of PC initiation on ESAS scores was estimated. RESULTS The cohort included 11,242 patients who died (esophageal [17%], gastric [20%], colon [38%], and anorectal [26%] cancers). Fifty percent experienced moderate-severe scores in tiredness, lack of well-being, and lack of appetite earlier (weeks 18 to 12 before death), whereas 50% experienced moderate-severe scores in drowsiness, pain, and shortness of breath later (weeks 5 to 2 before death) in the disease course. Outpatient PC was associated with an increased likelihood of moderate-severe scores in all domains, with the highest score in pain (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.68-2.05). In PC-naïve patients with moderate-severe scores, initiation of outpatient PC was associated with a 1- to 3-point decrease in subsequent scores, with the greatest reductions in pain (OR - 1.91, 95% CI - 2.11 to - 1.70) and nausea (OR - 3.01, 95% CI - 3.31 to - 2.71). CONCLUSION GI cancer patients experience high symptom burden in the final year of life. Outpatient PC initiation is associated with a decrease in symptoms.
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Affiliation(s)
- Shaila J Merchant
- Department of Surgery, Queen's University, Kingston, ON, Canada. .,Division of General Surgery and Surgical Oncology, Kingston Health Sciences Centre, Kingston, ON, Canada.
| | - Susan B Brogly
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Craig Goldie
- Division of Palliative Care, Queen's University, Kingston, ON, Canada
| | - Sulaiman Nanji
- Department of Surgery, Queen's University, Kingston, ON, Canada.,Division of General Surgery and Surgical Oncology, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Sunil V Patel
- Department of Surgery, Queen's University, Kingston, ON, Canada.,Division of General Surgery and Surgical Oncology, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Katherine Lajkosz
- Institute for Clinical Evaluative Sciences, Queen's University, Kingston, ON, Canada
| | - Nancy N Baxter
- Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canada
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24
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Mahar AL, Davis LE, Bubis LD, Li Q, Sutradhar R, Coburn NG, Barbera L. Factors associated with receipt of symptom screening in the year after cancer diagnosis in a universal health care system: a retrospective cohort study. ACTA ACUST UNITED AC 2019; 26:e8-e16. [PMID: 30853804 DOI: 10.3747/co.26.4160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose Patient-reported symptom data are collected prospectively by a provincial cancer agency to mitigate the significant symptom burden that patients with cancer experience. However, an assessment of whether such symptom screening occurs uniformly for those patients has yet to be performed. In the present study, we investigated patient, disease, and health system factors associated with receipt of symptom screening in the year after a cancer diagnosis. Methods Patients diagnosed with cancer between 2007 and 2014 were identified. We measured whether 1 or more symptom screenings were recorded in the year after diagnosis. A multivariable modified Poisson regression with robust error variance was used to identify predictors [age, comorbidity, rurality, socioeconomic status, immigration status, cancer site, registration at a regional cancer centre (cc), and year of diagnosis] of being screened for symptoms. Results Of 425,905 patients diagnosed with cancer, 163,610 (38%) had 1 or more symptom screening records in the year after diagnosis, and 75% survived at least 1 year. We identified variability in symptom screening by primary cancer site, regional cc, age, sex, comorbidity, material deprivation, rurality of residence, and immigration status. Patients who had been diagnosed with melanoma or endocrine cancers, who were not registered at a regional cc, who lived in the most urban areas, who were elderly, and who were immigrants were least likely to undergo symptom screening after diagnosis. Conclusions Our evaluation of the implementation of a population-based symptom screening program in a universal health care system identified populations who are at risk for not receiving screening and who are therefore future targets for improvements in population symptom screening and better management of cancer-related symptoms at diagnosis.
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Affiliation(s)
- A L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB
| | - L E Davis
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON
| | - L D Bubis
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | | | - R Sutradhar
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,ICES, Toronto, ON
| | - N G Coburn
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,ICES, Toronto, ON.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON
| | - L Barbera
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,ICES, Toronto, ON.,Department of Radiation Oncology, University of Toronto, Toronto, ON
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25
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Barbera L, Sutradhar R, Chu A, Seow H, Howell D, Earle CC, O'Brien MA, Dudgeon D, Atzema C, Husain A, Liu Y, DeAngelis C. Comparison of Opioid Prescribing Among Cancer and Noncancer Patients Aged 18-64: Analysis Using Administrative Data. J Pain Symptom Manage 2018; 56:72-79. [PMID: 29548892 DOI: 10.1016/j.jpainsymman.2018.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Opioid prescribing has been increasingly scrutinized among noncancer patients. As an unintended consequence, opioids may be underprescribed for cancer patients. The purpose of this study was to compare trends in opioid prescribing in younger adults with and without cancer. METHODS From 2004 to 2013, Ontario residents aged 18-64 years eligible for government paid pharmacare were annually stratified into three groups: no cancer history, cancer diagnosis more than five years ago, and cancer diagnosis five years ago and less. We evaluated time trends in two annual outcomes: opioid prescription rate and mean daily opioid dose. RESULTS In 2013, 800,371 individuals were eligible for this study (3% with recent cancer and 2% with remote cancer). Across all years, compared with noncancer patients, overall opioid prescription rates were 43% and 26% higher for those with recent and remote cancer, respectively. Overall, a 1% relative annual increase was seen in those without cancer and a 1% decrease was seen in those with a recent cancer. Changes in prescription rates varied with drug class and cancer group. Notably, long-acting opioids had a relative annual increase of 7% in noncancer patients vs. 2% in recent cancer patients. Immediate-release combination agents had a relative annual decrease of 2% for all cancer groups. Trends in mean daily dose were similar between groups, but by 2013, they were lowest in recent cancer patients, regardless of drug class. INTERPRETATION Secular trends in opioid prescribing affect cancer and noncancer patients similarly. Further research is required to assess the potential impact on symptom management.
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Affiliation(s)
- Lisa Barbera
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada.
| | - Rinku Sutradhar
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Anna Chu
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Doris Howell
- University Health Network, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Craig C Earle
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mary Ann O'Brien
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Deb Dudgeon
- Department of Medicine and Oncology, Queen's University, Kingston, Ontario, Canada
| | - Clare Atzema
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Amna Husain
- Mount Sinai Hospital, Temmy Latner Centre for Palliative Care, Toronto, Ontario, Canada
| | - Ying Liu
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Carlo DeAngelis
- Department of Pharmacy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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26
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Bubis LD, Davis L, Mahar A, Barbera L, Li Q, Moody L, Karanicolas P, Sutradhar R, Coburn NG. Symptom Burden in the First Year After Cancer Diagnosis: An Analysis of Patient-Reported Outcomes. J Clin Oncol 2018; 36:1103-1111. [DOI: 10.1200/jco.2017.76.0876] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Purpose Improvement in the quality of life of patients with cancer requires attention to symptom burden across the continuum of care, with the use of patient-reported outcomes key to achieving optimal care. Yet there have been few studies that have examined symptoms in the early postdiagnosis period during which suboptimal symptom control may be common. A comprehensive analysis of temporal trends and risk factors for symptom burden in newly diagnosed patients with cancer is essential to guide supportive care strategies. Methods A retrospective observational study was performed of patients who were diagnosed with cancer between January 2007 and December 2014 and who survived at least 1 year. Patient-reported Edmonton Symptom Assessment System scores, which are prospectively collected at outpatient visits, were linked to provincial administrative health care data. We described the proportion of patients who reported moderate-to-severe symptom scores by month during the first year after diagnosis according to disease site. Multivariable logistic regression models were constructed to identify risk factors for moderate-to-severe symptom scores. Results Of 120,745 patients, 729,861 symptom assessments were recorded within 12 months of diagnosis. For most symptoms, odds of elevated scores were highest in the first month, whereas nausea had increased odds of elevated scores up to 6 months after diagnosis. On multivariable analysis, cancer site, younger age, higher comorbidity, female sex, lower income, and urban residence were associated with significantly higher odds of elevated symptom burden. Conclusion A high prevalence of moderate-to-severe symptom scores was observed in cancers of all sites. Patients are at risk of experiencing multiple symptoms in the immediate postdiagnosis period, which underscores the need to address supportive care requirements early in the cancer journey. Patient subgroups who are at higher risk of experiencing moderate-to-severe symptoms should be targeted for tailored supportive care interventions.
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Affiliation(s)
- Lev D. Bubis
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Laura Davis
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Alyson Mahar
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Lisa Barbera
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Qing Li
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Lesley Moody
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Paul Karanicolas
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Natalie G. Coburn
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
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Abstract
Managing cancer pain in older adults can be complex and challenging. Understanding the unique needs of older patients with cancer is important to safe and effective pain management. The goals of this review are to discuss the assessment of older adults with cancer-related pain, treatment of cancer pain, and adverse effects or potential risks from treatment that are unique to older patients. A detailed pain assessment and when possible utilizing the geriatric assessment are vital to developing a cancer pain management plan. The geriatric assessment can help clinicians uncover problems not routinely assessed in the standard oncologic evaluation. Opioid pain medications are safe and effective for older adults with cancer pain as long as these medications are closely monitored and titrated slowly. In addition to the well-known adverse effects of opioid medications, clinicians need to be aware of the unique risks in older adults, which could include delirium, polypharmacy, and falls.
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28
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Green E, Yuen D, Chasen M, Amernic H, Shabestari O, Brundage M, Krzyzanowska MK, Klinger C, Ismail Z, Pereira J. Oncology Nurses' Attitudes Toward the Edmonton Symptom Assessment System: Results From a Large Cancer Care Ontario Study. Oncol Nurs Forum 2017; 44:116-125. [PMID: 27991609 DOI: 10.1188/17.onf.116-125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To examine oncology nurses' attitudes toward and reported use of the Edmonton Symptom Assessment System (ESAS) and to determine whether the length of work experience and presence of oncology certification are associated with their attitudes and reported usage.
. DESIGN Exploratory, mixed-methods study employing a questionnaire approach.
. SETTING 14 regional cancer centers (RCCs) in Ontario, Canada.
. SAMPLE Oncology nurses who took part in a larger province-wide study that surveyed 960 interdisciplinary providers in oncology care settings at all of Ontario's 14 RCCs.
. METHODS Oncology nurses' attitudes and use of ESAS were measured using a 21-item investigator-developed questionnaire. Descriptive statistics and Kendall's tau-b or tau-c test were used for data analyses. Qualitative responses were analyzed using content analysis.
. MAIN RESEARCH VARIABLES Attitudes toward and self-reported use of standardized symptom screening and ESAS.
. FINDINGS More than half of the participants agreed that ESAS improves symptom screening, most said they would encourage their patients to complete ESAS, and most felt that managing symptoms is within their scope of practice and clinical responsibilities. Qualitative comments provided additional information elucidating the quantitative responses. Statistical analyses revealed that oncology nurses who have 10 years or less of work experience were more likely to agree that the use of standardized, valid instruments to screen for and assess symptoms should be considered best practice, ESAS improves symptom screening, and ESAS enables them to better manage patients' symptoms. No statistically significant difference was found between oncology-certified RNs and noncertified RNs on attitudes or reported use of ESAS.
. CONCLUSIONS Implementing a population-based symptom screening approach is a major undertaking. The current study found that oncology nurses recognize the value of standardized screening, as demonstrated by their attitudes toward ESAS.
. IMPLICATIONS FOR NURSING Oncology nurses are integral to providing high-quality person-centered care. Using standardized approaches that enable patients to self-report symptoms and understanding barriers and enablers to optimal use of patient-reported outcome tools can improve the quality of patient care.
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29
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Barbera L, Sutradhar R, Chu A, Seow H, Earle CC, O’Brien MA, Dudgeon D, DeAngelis C, Atzema C, Husain A, Liu Y, Howell D. Has Province-Wide Symptom Screening Changed Opioid Prescribing Rates in Older Patients With Cancer? J Oncol Pract 2017; 13:e927-e934. [DOI: 10.1200/jop.2017.025494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Purpose: Previous work in Ontario demonstrated that 33% of patients with cancer with severe pain did not receive opioids at the time of their pain assessment. With efforts to increase symptom screening and management since then, the objective of this study was to examine temporal trends in opioid prescribing. Methods: The cohort was comprised of Ontario residents ≥ 65 years of age with a cancer history who were eligible for the government pharmacare program and had a pain assessment using the Edmonton Symptom Assessment System. Use of the Edmonton Symptom Assessment System is part of a provincial initiative to screen ambulatory patients with cancer for symptoms. Annually between 2007 and 2013, we used the date of an individual’s highest pain score as the index date to calculate annual opioid prescription rates for claims within 30 days before and up to 7 days after the index date. A logistic regression model evaluated the association between index year and odds of receiving an opioid prescription. Results: During the study period, the number of individuals undergoing symptom assessment annually increased more than eight-fold. Opioid prescription rates were directly related to pain scores, but there was an annual 5% relative decrease in the odds of receiving an opioid prescription during the era from 2009 to 2013. Conclusion: We are doing better at screening for pain, but this has not led to an increase in analgesic intervention for those identified. Additional work is required to determine what opioid prescribing rate is optimal to ensure we are not missing opportunities to improve patient comfort.
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Affiliation(s)
- Lisa Barbera
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Rinku Sutradhar
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Anna Chu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Hsien Seow
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Craig C. Earle
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Mary Ann O’Brien
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Deborah Dudgeon
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Carlo DeAngelis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Clare Atzema
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Amna Husain
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Ying Liu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
| | - Doris Howell
- Odette Cancer Centre, Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre; Mount Sinai Hospital, Temmy Latner Centre for Palliative Care; University Health Network, Princess Margaret Hospital, Toronto; McMaster University, Hamilton; and Queen’s University, Kingston, Ontario, Canada
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Barbera L, Sutradhar R, Chu A, Seow H, Howell D, Earle CC, O'Brien MA, Dudgeon D, Atzema C, Husain A, Liu Y, DeAngelis C. Opioid Prescribing Among Cancer and Non-cancer Patients: Time Trend Analysis in the Elderly Using Administrative Data. J Pain Symptom Manage 2017; 54:484-492.e1. [PMID: 28734882 DOI: 10.1016/j.jpainsymman.2017.07.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 12/20/2022]
Abstract
CONTEXT In 2007, Cancer Care Ontario introduced a provincial symptom screening program, which included pain, for cancer patients. Over this same time, opioid prescribing has been increasingly scrutinized among non-cancer patients. The study purpose was to see if opioid prescribing changed among older adults after 2007 in the context of changing opioid regulations, and whether effects were different among patients with a cancer history. METHODS Ontario residents aged ≥65 years were identified from 2004 to 2013. Subjects were annually stratified into three groups: no cancer history, cancer diagnosis >5 years ago, and cancer diagnosis ≤5 years ago. We evaluated time trends by year for: 1) opioid prescription rate, comparing trends before and after 2007 and 2) mean daily opioid dose. RESULTS Between 2004 and 2013, opioid prescribing was relatively constant for cancer patients with no observed change in trends after 2007. For non-cancer patients, there was a 2% relative annual increase during this period. Significant changes were seen for opioid sub-classes (e.g., decreasing use of long-acting oxycodone). These were similar for those with or without a history of cancer. Among all groups, changes in the mean daily dose over time were similar in all drug classes. CONCLUSION Overall prescribing rates for cancer patients aged ≥65 years remain unchanged over time, in spite of the introduction of a provincial symptom screening program. Decreasing prescription rates in some drug sub-classes were observed. The potential impact of these changes on the quality of symptom control for cancer patients needs further investigation.
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Affiliation(s)
- Lisa Barbera
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Anna Chu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Doris Howell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; University Health Network, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Craig C Earle
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mary Ann O'Brien
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Deb Dudgeon
- Department of Medicine and Oncology, Queen's University, Kingston, Ontario, Canada
| | - Clare Atzema
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Amna Husain
- Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ying Liu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Carlo DeAngelis
- Department of Pharmacy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Spooner L, Fernandes K, Martins D, Juurlink D, Mamdani M, Paterson JM, Singh S, Gomes T. High-Dose Opioid Prescribing and Opioid-Related Hospitalization: A Population-Based Study. PLoS One 2016; 11:e0167479. [PMID: 27973601 PMCID: PMC5156349 DOI: 10.1371/journal.pone.0167479] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 11/15/2016] [Indexed: 11/19/2022] Open
Abstract
Aims To examine the impact of national clinical practice guidelines and provincial drug policy interventions on prevalence of high-dose opioid prescribing and rates of hospitalization for opioid toxicity. Design Interventional time-series analysis. Setting Ontario, Canada, from 2003 to 2014. Participants Ontario Drug Benefit (ODB) beneficiaries aged 15 to 64 years from 2003 to 2014. Interventions Publication of Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain (May 2010) and implementation of Ontario’s Narcotics Safety and Awareness Act (NSAA; November 2011). Measurements Three outcomes were explored: the rate of opioid use among ODB beneficiaries, the prevalence of opioid prescriptions exceeding 200 mg and 400 mg morphine equivalents per day, and rates of opioid-related emergency department visits and hospital admissions. Findings Over the 12 year study period, the rate of opioid use declined 15.2%, from 2764 to 2342 users per 10,000 ODB eligible persons. The rate of opioid use was significantly impacted by the Canadian clinical practice guidelines (p-value = .03) which led to a decline in use, but no impact was observed by the enactment of the NSAA (p-value = .43). Among opioid users, the prevalence of high-dose prescribing doubled (from 4.2% to 8.7%) over the study period. By 2014, 40.9% of recipients of long-acting opioids exceeded daily doses of 200 mg morphine or equivalent, including 55.8% of long-acting oxycodone users and 76.3% of transdermal fentanyl users. Moreover, in the last period, 18.7% of long-acting opioid users exceeded daily doses of 400 mg morphine or equivalent. Rates of opioid-related emergency department visits and hospital admissions increased 55.0% over the study period from 9.0 to 14.0 per 10,000 ODB beneficiaries from 2003 to 2013. This rate was not significantly impacted by the Canadian clinical practice guidelines (p-value = .68) or enactment of the NSAA (p-value = .59). Conclusions Although the Canadian clinical practice guidelines for use of opioids in chronic non-cancer pain led to a decline in opioid prescribing rates among ODB beneficiaries these guidelines and subsequent Ontario legislation did not result in a significant change in rates of opioid-related hospitalizations. Given the prevalence of high dose opioid prescribing in this population, this suggests that improved strategies and programs for the safe prescribing of long-acting opioids are needed.
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Affiliation(s)
- Luke Spooner
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | | | - Diana Martins
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - David Juurlink
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - J. Michael Paterson
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Samantha Singh
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Tara Gomes
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- * E-mail:
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Mercadante S, Mercadante A, Aielli F. Effect of aging on pain relief in the older cancer patients: pharmacokinetic and pharmacodynamic aspects. Expert Opin Drug Metab Toxicol 2016; 12:711-3. [PMID: 26895533 DOI: 10.1517/17425255.2016.1152263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Sebastiano Mercadante
- a Anesthesia and Intensive Care & Pain Relief and Supportive Care , La Maddalena Cancer Center and University of Palermo , Palermo , Italy
| | | | - Federica Aielli
- c Applied Clinical Sciences and Biotechnology , University of L'Aquila , L'Aquila , Italy
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Yokomichi N, Morita T, Nitto A, Takahashi N, Miyamoto S, Nishie H, Matsuoka J, Sakurai H, Ishihara T, Mori M, Tarumi Y, Ogawa A. Validation of the Japanese Version of the Edmonton Symptom Assessment System-Revised. J Pain Symptom Manage 2015; 50:718-23. [PMID: 26169339 DOI: 10.1016/j.jpainsymman.2015.05.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/07/2015] [Accepted: 05/18/2015] [Indexed: 12/25/2022]
Abstract
CONTEXT The Edmonton Symptom Assessment System-revised (ESAS-r) is a brief and widely used symptom measurement tool. OBJECTIVES To validate the Japanese version of the ESAS-r in Japanese patients with cancer. METHODS We assessed the internal consistency, test-retest reliability, concurrent validity, and known-group validity in 292 Japanese adult patients with cancer. They completed Japanese versions of the ESAS-r, M. D. Anderson Symptom Inventory, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. RESULTS Cronbach's alpha coefficient of the Japanese version of the ESAS-r was 0.87. The intraclass correlation coefficient in the test-retest examination ranged from 0.82 to 0.91 for each symptom score and was 0.90 for the total score. Pearson correlation coefficients of each ESAS-r symptom score with corresponding M. D. Anderson Symptom Inventory and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items ranged from 0.45 to 0.80. The total score of the ESAS-r was significantly higher in patients with an Eastern Cooperative Oncology Group performance status of 2-4 than in those with a performance status of 0 and 1 (P < 0.0001). CONCLUSION The Japanese version of the ESAS-r is a reliable and valid tool for measuring symptoms in Japanese adult patients with cancer.
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Affiliation(s)
| | - Tatsuya Morita
- Seirei Hospice, Shizuoka, Japan; Department of Palliative and Supportive Care, Shizuoka, Japan; Palliative Care Team, Seirei Hospice, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Akihiro Nitto
- Psycho-Oncology Division, National Cancer Center Hospital East, Kashiwa, Japan
| | | | - Shingo Miyamoto
- Department of Oncology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroyuki Nishie
- Department of Anesthesiology and Resuscitology, Okayama City, Japan
| | - Junji Matsuoka
- Department of Palliative Care, Okayama University Hospital, Okayama City, Japan
| | - Hiroki Sakurai
- Department of Palliative Care, St. Luke's International Hospital, Tokyo, Japan
| | - Tatsuhiko Ishihara
- Department of Palliative Care, Okayama Saiseikai General Hospital, Okayama, Japan
| | - Masanori Mori
- Department of Palliative Medicine, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Yoko Tarumi
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Asao Ogawa
- Psycho-Oncology Division, National Cancer Center Hospital East, Kashiwa, Japan.
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Age differences in the last week of life in advanced cancer patients followed at home. Support Care Cancer 2015; 24:1889-95. [PMID: 26471279 DOI: 10.1007/s00520-015-2988-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
Abstract
A retrospective analysis of a consecutive sample of patients admitted to a home care program was performed. Data were recorded in the last week through a backward analysis from the day before death as follows: 1 week before dying (-1W), 3 days before death (-3D), and the day before dying (-1D). Data to be collected included the Edmonton Symptom Assessment System (ESAS), background pain intensity, the prevalence of breakthrough pain, the use of opioids in the last week, and the need for palliative sedation, with indications, duration, and drugs used. Patients were distributed according to the following age ranges: adults (<65 years, A) and aged (≥65 years, O). Of the latter group, three subgroups were assessed: old (65-74 years, O1), very old (75-84 years, O2), and the oldest (≥85 years, O3). Four hundred eleven patients were assessed. At -W1, no statistical differences in intensity of ESAS items ≥4 among the age subgroups were found. For ESAS values at -1W, -3D, and -1D, no statistical differences were found unless for anorexia at -1W (p = 0.000) (more likely), depression at -3D (p = 0.000) (less likely), depression (p = 0.000), and dyspnea (p = 0.01) (less likely) at -1D in the oldest group (O3). No differences in pain intensity among the groups were found (p = 0.54). Opioid doses increased in time and were significantly lower in older patients (p = 0.000). The subcutaneous route was more frequently used at -3D and -1D in older patients. No differences in opioid switching were found among the groups (p = 0.56). Adult patients required more often palliative sedation (p = 0.003). Older patients have problems relatively similar to adult patients in the last week of life, unless for some symptoms. Older patients had also a lower opioid consumption, a more frequent use of the subcutaneous route, and a lower need for palliative sedation.
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Marengoni A, Nobili A, Corli O, Djade CD, Bertoni D, Tettamanti M, Pasina L, Corrao S, Salerno F, Marcucci M, Mannucci PM. The stigma of low opioid prescription in the hospitalized multimorbid elderly in Italy. Intern Emerg Med 2015; 10:305-13. [PMID: 25248643 DOI: 10.1007/s11739-014-1131-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 09/11/2014] [Indexed: 01/05/2023]
Abstract
The primary aim of this study was to evaluate the prevalence of opioid prescriptions in hospitalized geriatric patients. Other aims were to evaluate factors associated with opioid prescription, and whether or not there was consistency between the presence of pain and prescription. Opioid prescriptions were gathered from the REgistro POliterapie Societa` Italiana di Medicina Interna (REPOSI) data for the years 2008, 2010 and 2012. 1,380 in-patients, 65+ years old, were enrolled in the first registry run, 1,332 in the second and 1,340 in the third. The prevalence of opioid prescription was calculated at hospital admission and discharge. In the third run of the registry, the degree of pain was assessed by means of a numerical scale. The prevalence of patients prescribed with opioids at admission was 3.8% in the first run, 3.6% in the second and 4.1% in the third, whereas at discharge rates were slightly higher (5.8, 5.3, and 6.6%). The most frequently prescribed agents were mild opioids such as codeine and tramadol. The number of total prescribed drugs was positively associated with opioid prescription in the three runs; in the third, dementia and a better functional status were inversely associated with opioid prescription. Finally, as many as 58% of patients with significant pain at discharge were prescribed no analgesic at all. The conservative attitude of Italian physicians to prescribe opioids in elderly patients changed very little between hospital admission and discharge through a period of 5 years. Reasons for such a low opioid prescription should be sought in physicians' and patients' concerns and prejudices.
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Affiliation(s)
- Alessandra Marengoni
- Department of Clinical and Experimental Science, University of Brescia Italy, Piazzale Spedali Civili 1, 25123, Brescia, Italy
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Pain Characteristics and Analgesic Treatment in an Aged Adult Population: A 4-Week Retrospective Analysis of Advanced Cancer Patients Followed at Home. Drugs Aging 2015; 32:315-20. [DOI: 10.1007/s40266-015-0253-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Cabezón-Gutiérrez L, Gómez-Pavón J, Pérez-Cajaraville J, Viloria-Jiménez MA, Álamo-González C, Gil-Gregorio P. [Update on oncological pain in the elderly]. Rev Esp Geriatr Gerontol 2015; 50:289-97. [PMID: 25777946 DOI: 10.1016/j.regg.2015.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 02/04/2015] [Indexed: 01/05/2023]
Abstract
Pain is a prevalent symptom in cancer geriatric patients, appearing in up to 90% of patients with terminal cancer. This requires a multidimensional approach, as there is a high percentage of inappropriate assessments and treatments. Unrecognized or poorly treated pain in the geriatric population, especially in cancer patients, leads to the development of disabling symptoms such as depression, anxiety, isolation, sleep disturbances, and appetite, and very especially, loss of functional capacity and quality of life. In this review an analysis is made on the most relevant studies on the diagnosis and management of cancer pain in the geriatric population.
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Affiliation(s)
- Luis Cabezón-Gutiérrez
- Servicio de Oncología Médica, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España.
| | | | | | | | | | - Pedro Gil-Gregorio
- Servicio de Geriatría, Unidad de Cuidados Paliativos, Hospital Clínico Universitario San Carlos, Madrid, España; Coordinador del Comité de Expertos del Dolor de la Sociedad Española de Geriatría y Gerontología, España
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Abstract
Minimizing toxicity while maximizing efficacy is a common goal in the treatment of any condition but its importance is underscored in the discipline of oncology because of the serious nature of many chemotherapeutic toxicities and the risk of cancer recurrence or disease progression. The challenge of achieving an optimal therapeutic index is especially augmented in the elderly population because of age-related metabolism changes and interacting concurrent medications. Additional factors, such as germline mutations in drug-metabolizing enzymes and other pharmacogenomic alterations, may have more pronounced effects in elderly patients, given their predisposition to altered pharmacokinetics and pharmacodynamics with resulting increased risk of toxicity. Examples of the possible interplay of these factors will be discussed using tamoxifen, paclitaxel, codeine, and fluorouracil as starting points. Limited participation of the elderly in many cancer trials, especially trials assessing drug exposure, makes much knowledge on the interaction of these patient and environmental factors speculative in nature but presents an opportunity for future research to achieve better optimization of chemotherapeutic agents in the elderly.
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Yamagishi A, Sato K, Miyashita M, Shima Y, Kizawa Y, Umeda M, Kinoshita H, Shirahige Y, Akiyama M, Yamaguchi T, Morita T. Changes in quality of care and quality of life of outpatients with advanced cancer after a regional palliative care intervention program. J Pain Symptom Manage 2014; 48:602-10. [PMID: 24703945 DOI: 10.1016/j.jpainsymman.2013.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/12/2013] [Accepted: 11/12/2013] [Indexed: 11/16/2022]
Abstract
CONTEXT A recent mixed-methods study to evaluate the effects of a comprehensive regional palliative care program, the Japan Outreach Palliative Care Trial of the Integrated Model study, achieved broad positive outcomes at a regional level. This is a secondary analysis of patient outcomes. OBJECTIVES The primary aims were to explore: 1) the changes in domains of patient-reported quality of care and quality of life after interventions, and 2) the changes in quality of care and quality of life of patients with different characteristics (i.e., performance status, age, and anticancer treatment). METHODS A region-representative sample of metastatic/locally advanced cancer patients in outpatient settings participated in questionnaire surveys before and after regional intervention. Responses were obtained from 859 of 1880 and 857 of 2123 in the pre- and postintervention surveys, respectively. RESULTS All subdomain scores of the quality of care, except for help with decision making, significantly improved in the postintervention survey. The percentages of the patients who reported that improvement was necessary decreased from 13% to 5.0%. Although there were no or only a marginally significant difference in total and subdomain scores of quality of life between preintervention and postintervention surveys, the subgroups of patients with a poor performance status and those receiving no anticancer treatment achieved a significant improvement in the quality of life. CONCLUSION Although average changes in patient-reported outcomes were relatively small in the total sample of patients, the intervention seemed to provide tangible benefits for the patients with poor general conditions. A future regional intervention trial should include patient outcomes in those with a poor general condition to evaluate the net effects of the program.
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Affiliation(s)
- Akemi Yamagishi
- Department of Community Health Care, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
| | - Kazuki Sato
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | | | - Hiroya Kinoshita
- Department of Palliative Medicine, National Cancer Center Hospital, East, Kashiwa, Chiba, Japan
| | | | - Miki Akiyama
- Faculty of Environment and information Studies, Keio University, Tokyo, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
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Pereira J, Green E, Molloy S, Dudgeon D, Howell D, Krzyzanowska MK, Mahase W, Tabing R, Urowitz S, Macdougall L. Population-Based Standardized Symptom Screening: Cancer Care Ontario's Edmonton Symptom Assessment System and Performance Status Initiatives. J Oncol Pract 2014; 10:212-4. [DOI: 10.1200/jop.2014.001390] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To improve symptom management, the Ontario Cancer Symptom Management Collaborative uses common assessment and care management tools including Interactive Symptom Assessment and Collection, which allows patients to report their symptoms via kiosks or tablets directly to clinicians in real-time.
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Affiliation(s)
- José Pereira
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Esther Green
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Sean Molloy
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Deborah Dudgeon
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Doris Howell
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Monika K. Krzyzanowska
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Wenonah Mahase
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Reena Tabing
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Sara Urowitz
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
| | - Laura Macdougall
- Cancer Care Ontario; University of Ottawa, Ottawa; Queens University, Kingston; University Health Network; and University of Toronto, Toronto, Ontario, Canada
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Does a regional comprehensive palliative care program improve pain in outpatient cancer patients? Support Care Cancer 2014; 22:2445-55. [PMID: 24705857 DOI: 10.1007/s00520-014-2232-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/25/2014] [Indexed: 10/25/2022]
Abstract
CONTEXT Pain is still a major problem for cancer patients, and the effect of a population-based approach on patients' experience of pain is not fully understood. AIMS The primary aim of this study was to clarify the changes in pain intensity in outpatients before and after a regional palliative care program. The secondary aim was to clarify the prevalence of patients who had unmet needs for pain treatment and to clarify the reasons for not wanting pain treatment. SUBJECTS AND METHODS A regional palliative care program was implemented in four regions of Japan. A region-representative sample of metastatic/locally advanced cancer patients in outpatient settings took part in questionnaire surveys before and after the regional intervention. Responses were obtained from 859 from 1,880 and 857 from 2,123 in the preintervention and postintervention surveys, respectively. RESULTS After a regional palliative care program, neither worst, average, nor least pain levels in outpatients changed significantly. A total of 134 patients (16 %) reported that they needed more pain treatment. There were various reasons for not wanting pain treatment, namely, minimum interference with daily life, general nonpreference for medicines, longstanding symptoms before the diagnosis of cancer, concerns about tolerance and addiction, and experienced neuropsychiatric symptoms under current medications. CONCLUSION The regional palliative care program failed to demonstrate improvement of the pain intensity of cancer outpatients. One possible interpretation is that they are less likely to be regarded as target populations and that the study population experienced generally well-controlled pain. Future study including patients with more severe pain is needed, but to improve pain levels of cancer outpatients, intensive, patient-directed intervention seems to be more promising than region-based intervention.
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Ripamonti CI, Prandi C, Costantini M, Perfetti E, Pellegrini F, Visentin M, Garrino L, De Luca A, Pessi MA, Peruselli C. The effectiveness of the quality program Pac-IficO to improve pain management in hospitalized cancer patients: a before-after cluster phase II trial. BMC Palliat Care 2014; 13:15. [PMID: 24678911 PMCID: PMC3986604 DOI: 10.1186/1472-684x-13-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/19/2014] [Indexed: 11/10/2022] Open
Abstract
Background Cancer-related pain continues to be a major healthcare issue worldwide. Despite the availability of effective analgesic drugs, published guidelines and educational programs for Health Care Professionals (HCPs) the symptom is still under-diagnosed and its treatment is not appropriate in many patients. The objective of the study is to evaluate the efficacy of the Pac-IFicO programme in improving the quality of pain management in hospitalised cancer patients. Methods/design This is a before-after cluster phase II study. After the before assessment, the experimental intervention – the Pac-IFicO programme – will be implemented in ten medicine, oncology and respiratory disease hospital wards. The same assessment will be repeated after the completion of the intervention. The Pac-IFicO programme is a complex intervention with multiple components. It includes focus group with ward professionals for identifying possible local obstacles to optimal pain control, informative material for the patients, an educational program performed through guides from the wards, and an organisational intervention to the ward. The primary end-point of the study is the proportion of cancer patients with severe pain. Secondary end-points include opioids administered in the wards, knowledge in pain management, and quality of pain management. We plan to recruit about 500 cancer patients. This sample size should be sufficient, after appropriate statistical adjustments for clustering, to detect an absolute decrease in the primary end-point from 20% to 9%. Discussion This trial is aimed at exploring with an experimental approach the efficacy of a new quality improvement educational intervention. Trial registration ClinicalTrials.gov: NCT02035098
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Affiliation(s)
- Carla Ida Ripamonti
- Supportive Care in Cancer Unit, Department of Hematology and Pediatric Onco-Hematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy.
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Barbera L, Molloy S, Earle CC. Frequency of non-cancer-related pain in patients with cancer. J Clin Oncol 2013; 31:2837. [PMID: 23816961 DOI: 10.1200/jco.2013.49.8311] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Seow H, Barbera L, Dudgeon D, Howell D, Husain A, Atzema C, Sussman J, Liu Y, Earle C, Sutradhar R. The association of the palliative performance scale and hazard of death in an ambulatory cancer population. J Palliat Med 2012; 16:156-62. [PMID: 23249402 DOI: 10.1089/jpm.2012.0239] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Previous studies have reported survival estimates in palliative populations using the Palliative Performance Scale (PPS) (where 100=best status, 0=death). However, little research has examined the association of the PPS with hazard of death in ambulatory populations. OBJECTIVE We examined the association between performance status and the instantaneous hazard of death in ambulatory cancer patients, using longitudinal PPS scores. METHODS This retrospective, population-based cohort study included cancer outpatients who had at least one PPS assessment completed between 2007 and 2009. PPS scores were recorded opportunistically by health care providers at clinic or home care visits. We used a Cox proportional hazards model to determine the relative hazard of death based on repeated measures of PPS score, while controlling for other covariates. RESULTS Among 11,342 qualifying cancer patients, there were 54,207 PPS assessments. The distribution of PPS scores at first assessment were 23%, 56%, 20%, and 1% for PPS scores of 100, 90-70, 60-40, and ≤ 30, respectively. A quarter of the cohort died within 6 months of the first assessment. The relative hazard of death increases by a factor of 1.69 (95% confidence interval [CI]: 1.72-1.67) for each 10-point decrease in PPS score. Thus the hazard of death increases by 8.2 (1.69(4)) times for a person with PPS score of 30 compared with a person with a score of 70. CONCLUSION The PPS was significantly associated with hazard of death in ambulatory cancer patients; the relative hazard of death increased based on lowered PPS scores. Providers should consider broadening its use to include patients throughout their disease trajectory.
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Affiliation(s)
- Hsien Seow
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Seow H, Sussman J, Martelli-Reid L, Pond G, Bainbridge D. Do high symptom scores trigger clinical actions? An audit after implementing electronic symptom screening. J Oncol Pract 2012; 8:e142-8. [PMID: 23598849 DOI: 10.1200/jop.2011.000525] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Standardized, electronic, symptom assessment is purported to help identify symptom needs. However, little research examines clinical processes related to symptom management, such as whether patients with worsening symptoms receive clinical actions more often. This study examined whether patient visits with higher symptom scores are associated with higher rates of symptom documentation in the chart and symptom-specific actions being taken. METHODS Retrospective chart reviews on cancer patient visits at a regional cancer center. An electronic Edmonton Symptom Assessment Scale (ESAS), a validated tool to measure symptoms, was implemented center-wide to standardize symptom screening at every patient visit. The independent variable was ESAS scores for pain and shortness of breath, categorized by severity: 0 (none), 1-3, 4-6, 7-10 (severe). Outcomes included symptom documentation in the chart on the visit date and symptom-related action(s) taken within 1 week. RESULTS Nine hundred twelve visits were identified. Pain and shortness of breath were documented in 51.8% and 29.7% of charts, and a related-action occurred in 16.9% and 3.9% of charts, respectively. As ESAS severity score category increased from none to severe, the proportion of visits with pain documented increased significantly (36.9%, 49.2%, 55.2%, and 71.4%; P < .001). Likewise, as ESAS score severity increased, the proportion of visits with a pain-related action increased significantly (4.2%, 10.6%, 21.3%, and 37.0%; P < .001). Trends were similar for shortness of breath. CONCLUSION Results show a positive association between higher symptom scores and higher rates of documentation and clinical actions taken. However, symptom-related actions were documented in a minority of visits in which symptoms were noted as severe.
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Affiliation(s)
- Hsien Seow
- Department of Oncology, McMaster University, 699 Concession St, Hamilton, Ontario L8V 5C2, Canada.
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Opioids are underprescribed in elderly patients. Nat Rev Clin Oncol 2012. [DOI: 10.1038/nrclinonc.2012.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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