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Pandey S, Bradley L, Del Fabbro E. Updates in Cancer Cachexia: Clinical Management and Pharmacologic Interventions. Cancers (Basel) 2024; 16:1696. [PMID: 38730648 PMCID: PMC11083841 DOI: 10.3390/cancers16091696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
Despite a better understanding of the mechanisms causing cancer cachexia (CC) and development of promising pharmacologic and supportive care interventions, CC persists as an underdiagnosed and undertreated condition. CC contributes to fatigue, poor quality of life, functional impairment, increases treatment related toxicity, and reduces survival. The core elements of CC such as weight loss and poor appetite should be identified early. Currently, addressing contributing conditions (hypothyroidism, hypogonadism, and adrenal insufficiency), managing nutrition impact symptoms leading to decreased oral intake (nausea, constipation, dysgeusia, stomatitis, mucositis, pain, fatigue, depressed mood, or anxiety), and the addition of pharmacologic agents when appropriate (progesterone analog, corticosteroids, and olanzapine) is recommended. In Japan, the clinical practice has changed based on the availability of Anamorelin, a ghrelin receptor agonist that improved lean body mass, weight, and appetite-related quality of life (QoL) compared to a placebo, in phase III trials. Other promising therapeutic agents currently in trials include Espindolol, a non-selective β blocker and a monoclonal antibody to GDF-15. In the future, a single therapeutic agent or perhaps multiple medications targeting the various mechanisms of CC may prove to be an effective strategy. Ideally, these medications should be incorporated into a multimodal interdisciplinary approach that includes exercise and nutrition.
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Affiliation(s)
- Sudeep Pandey
- Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.P.); (L.B.)
| | - Lauren Bradley
- Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.P.); (L.B.)
| | - Egidio Del Fabbro
- Department of Medicine, Division of Palliative Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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Mukhopadhyay ND, Khorasanchi A, Pandey S, Nemani S, Parker G, Deng X, Arthur DW, Urdaneta A, Del Fabbro E. Melatonin Supplementation for Cancer-Related Fatigue in Patients With Early Stage Breast Cancer Receiving Radiotherapy: A Double-Blind Placebo-Controlled Trial. Oncologist 2024; 29:e206-e212. [PMID: 37699115 PMCID: PMC10836305 DOI: 10.1093/oncolo/oyad250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/19/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Fatigue is common in patients undergoing radiotherapy (RT) and can significantly impact quality of life. Melatonin, a safe inexpensive natural supplement, may improve symptoms and attenuate the side effects of RT. The purpose of this randomized double-blind placebo-controlled phase III trial was to assess the effects of melatonin for preventing fatigue and other symptoms in patients with breast cancer undergoing RT. METHODS Female early stage or Ductal carcinoma in situ patients with breast cancer ≥18 years of age with Eastern Cooperative Oncology Group (ECOG) performance status <3, hemoglobin ≥9 g/dL, planned for outpatient RT treatment with curative intent, were randomized 1:1 to melatonin 20 mg or placebo, orally, starting the night before RT initiation until 2 weeks post-RT. Randomization was stratified according to treatment duration (<3 weeks, ≥3 weeks) and prior chemotherapy. The primary endpoint was the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue scale), and secondary endpoints were FACIT-F subscales, Edmonton Symptom Assessment Scale (ESAS), and Patient-Reported Outcomes Measurement Information System (PROMIS) scores obtained at baseline, and 2 and 8 weeks post-RT. A 2-sided ANOVA F-test at a 4.5% significance level for the primary endpoint was used. Secondary analyses were reported using an F-test at a 5% significance level. The goal was to recruit approximately 140 patients with interim analysis planned mid-recruitment. RESULTS Eighty-five patients were screened for eligibility; 79 patients were randomized: 40 to melatonin and 39 to placebo; 78 patients were treated and included in the interim analysis at the mid-recruitment point. Baseline patient characteristics of age, race, and ECOG performance status were similar in both arms. The treatment effect was studied using a longitudinal mixed effects model with the effect of treatment over time (treatment × time) as the primary outcome parameter. The treatment × time for FACIT-Fatigue did not demonstrate statistical significance (P-value .83) in the melatonin group compared to placebo. In addition, secondary analyses of FACIT physical, social, emotional, and functional well-being scores did not demonstrate statistical significance (P-values of .35, .06, .62, and .71, respectively). Total PROMIS scores, collected as secondary outcome reported by patients, did not demonstrate statistically significant change over time either (P-value is .34). The other secondary scale, ESAS, was analyzed for each individual item and found to be nonsignificant, anxiety (P = .56), well-being (.82), drowsiness (.83), lack of appetite (.35), nausea (.79), pain (.50), shortness of breath (.77), sleep (.45), and tiredness (.56). Depression was the only item demonstrating statistical significance with a decrease of 0.01 unit in the placebo group, a change not considered clinically significant. Melatonin was well-tolerated with no grade 3 or 4 adverse events reported. The most common side effects were headache, somnolence, and abdominal pain. No patients died while participating in this study. Two patients died within a year of study completion from breast cancer recurrence. Sixteen patients withdrew prior to study completion for various reasons including adverse events, hospitalizations unrelated to study drug, RT discontinuation, and COVID-19 precautions. CONCLUSIONS In this double-blind placebo-controlled phase III trial, melatonin did not prevent or significantly improve fatigue and other symptoms in patients with early stage breast cancer undergoing RT. The analysis, showing little evidence of an effect, at mid-recruitment, assured early termination of the trial.
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Affiliation(s)
- Nitai D Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Adam Khorasanchi
- Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Sudeep Pandey
- Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Srinidhi Nemani
- Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Gwendolyn Parker
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - Xiaoyan Deng
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - Alfredo Urdaneta
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - Egidio Del Fabbro
- Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
- Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Arthur J, Childers J, Del Fabbro E. Should Urine Drug Screen be Done Universally or Selectively in Palliative Care Patients on Opioids? J Pain Symptom Manage 2023; 66:e687-e692. [PMID: 37429531 DOI: 10.1016/j.jpainsymman.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/30/2023] [Indexed: 07/12/2023]
Abstract
Urine drug screen (UDS) is a useful test conducted in patients receiving opioids for chronic pain to aid in validating patient adherence to opioid treatment and to detect any nonmedical opioid use (NMOU). One controversial topic regarding its use in palliative care is whether to conduct the test universally and randomly in all patients who are receiving opioids for chronic pain irrespective of their level of risk for NMOU, or to conduct the test selectively in only those with a high risk for engaging in NMOU behaviors. In this "Controversies in Palliative Care" article, 3 expert clinicians independently answer this question. Specifically, each expert provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. They all agreed that UDS has some utility in routine palliative care practice but acknowledged the insufficient existing evidence supporting its efficacy. They also underscored the need to improve clinician proficiency in UDS interpretation to enhance its utility. Two experts endorsed random UDS in all patients receiving opioids regardless of their risk profile while the other expert recommended targeted UDS until there is more clinical evidence to support universal, random testing. Use of more methodologically robust study designs in UDS research, examination of the cost-effectiveness of UDS tests, development of innovative programs to manage NMOU behaviors, and investigation of the impact of improved clinician proficiency in UDS interpretation on clinical outcomes, were important areas of future research that the experts identified.
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Affiliation(s)
- Joseph Arthur
- Department of Palliative Care (J.A.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
| | - Julie Childers
- Section of Palliative Care and Medical Ethics (J.C.), Section of Treatment, Research, and Education in Addiction Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Egidio Del Fabbro
- Division of Palliative Medicine (E.D.F.), Medical College of Georgia, Augusta University, Augusta, Georgia
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Revoredo S, Del Fabbro E. Hepatocellular carcinoma and sarcopenia: a narrative review. Ann Palliat Med 2023; 12:1295-1309. [PMID: 37872128 DOI: 10.21037/apm-23-332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 09/20/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Hepatocellular carcinoma (HCC) affects millions of people each year and is associated with high mortality and morbidity. Sarcopenia, a condition of muscle wasting, and decreased muscle performance is common among aging adults, and is associated with poor clinical outcomes. Individuals with HCC and chronic liver disease (CLD) are at high risk of sarcopenia because of the adverse effects of chronic inflammation, endocrine dysfunction, and hyperammonemia on muscle metabolism and adequate nutrition. Our aim is to review the clinical relationship between HCC and sarcopenia, and the assessment and management of these patients. METHODS A narrative review based on a literature search using PubMed. Keywords related to HCC and sarcopenia were used to identify relevant articles, primarily those published 2018-2023. The information was synthesized to provide a narrative review focused on the most recent literature. KEY CONTENT AND FINDINGS Sarcopenia frequently co-exists with HCC and increases risk for adverse clinical outcomes such as symptom burden, quality of life (QoL), survival, and side effects of antineoplastic therapy. Tools are available to screen, assess and manage patients with HCC, and although there is no specific pharmacologic agent approved for sarcopenia in the United States, multimodal therapy is feasible in daily practice. Comprehensive management by an interdisciplinary team should include nutritional counseling, an exercise regimen and control of symptoms affecting nutrition and function. CONCLUSIONS Sarcopenia has adverse effects on prognosis and tolerability of surgical and medical therapy in HCC. Patients with CLD and/or HCC would benefit from early identification, assessment, and therapeutic intervention. Management should be comprehensive, interdisciplinary, and include both pharmacologic and non-pharmacologic treatments. Further research is needed to identify individual agents that may mitigate muscle wasting and trials are needed to evaluate the benefit of multimodal therapy in HCC.
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Affiliation(s)
- Stephanie Revoredo
- Division of Palliative Medicine, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Egidio Del Fabbro
- Division of Palliative Medicine, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Reddy A, Sinclair C, Crawford GB, McPherson ML, Mercadante S, Hui D, Haider A, Arthur J, Tanco K, Dalal S, Dev R, Amaram-Davila J, Adile C, Liu D, Schuler U, Jammi S, Shelal Z, Del Fabbro E, Davis M, Bruera E. Opioid Rotation and Conversion Ratios Used by Palliative Care Professionals: An International Survey. J Palliat Med 2022; 25:1557-1562. [PMID: 35930252 PMCID: PMC9836667 DOI: 10.1089/jpm.2022.0266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 01/22/2023] Open
Abstract
Background: The opioid rotation ratios (ORRs) and conversion ratios (CRs) used worldwide among palliative care (PC) professionals to perform opioid rotations (ORs) and route conversions may have a wide variation. Methods: We surveyed PC professionals on opioid ratios used through email to the Multinational Association of Supportive Care in Cancer's PC study group and Twitter and Facebook posts between September and November 2020. Results: We received 370 responses from respondents from 53 countries: 276 (76%) were physicians, 46 (13%) advanced practice providers, 39 (11%) pharmacists, and 9 respondents did not report their profession. There were statistically significant variations in median CR from intravenous (IV) to oral morphine (2-3), IV to oral hydromorphone (2-4.5), ORR from IV hydromorphone to oral morphine (10-20), and ORR from transdermal fentanyl mcg/hour to oral morphine (2-3.5) across various groups. Conclusion: This survey highlights the wide variation in ORRs and CRs among PC clinicians worldwide and the need for further research to standardize practice.
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Affiliation(s)
- Akhila Reddy
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Christian Sinclair
- Division of Palliative Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gregory B. Crawford
- Northern Adelaide Local Health Network, Adelaide, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Mary Lynn McPherson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ali Haider
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Arthur
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kimberson Tanco
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shalini Dalal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaya Amaram-Davila
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Claudio Adile
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Diane Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ulrich Schuler
- Universitätsklinikum Carl Gustav Carus, PalliativCentrum & Medizinische Klinik, Dresden, Germany
| | - Sheetal Jammi
- Candidate for Bachelor of Science in Biology and Bachelor of Science in Psychology, University of Houston, Houston, Texas, USA
| | - Zeena Shelal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Egidio Del Fabbro
- Department of Internal Medicine, Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
| | - Mellar Davis
- Department of Palliative Care, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Khorasanchi A, Mukhopadhyay N, Pandey S, Nemani S, Parker GL, Urdaneta A, Deng X, Del Fabbro E. Melatonin supplementation for preventing cancer-related fatigue in patients receiving radiotherapy for early-stage breast cancer: A double-blind placebo-controlled phase III trial. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e24079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24079 Background: Fatigue is common in patients undergoing radiotherapy (RT). Melatonin, an inexpensive natural supplement, may improve symptoms and attenuate the side effects of RT. The effect of melatonin for prevention of fatigue and other symptoms was evaluated in a double-blind placebo-controlled trial. Methods: Early-stage or ductal carcinoma in-situ breast cancer patients ≥ 18 years, female, Eastern Cooperative Oncology Group performance status (ECOG PS) < 3, hemoglobin ≥9 g/dL. RT with curative intent, randomized 1:1 to melatonin 20 mg or oral placebo, starting night before RT initiation until 2 weeks post-RT. Sample size of 142 evaluable patients in each arm for 80% power and interim analysis at mid recruitment using the unified family method rho = 0.3. Randomization stratified to RT duration (< 3 weeks, ≥3 weeks) and prior chemotherapy. Primary outcome : Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue subscale after completion of RT with additional scores measured at baseline, 2 and 8 weeks post-RT. Secondary outcomes : FACIT-F subscales, Edmonton Symptom Assessment System (ESAS) and Patient Reported Outcomes Measurement Information System (PROMIS) Fatigue-Short Form 8a. Secondary analyses reported using an F-test at a 5% significance level. Results: For this interim analysis, 85 patients screened; 80 randomized; 39 received melatonin and 38 placebo. 72 included in the analysis as 5 patients had no post baseline FACIT score. Characteristics of age, race, and ECOG PS similar in both arms. Treatment X time for FACIT-Fatigue not significant for melatonin compared to placebo (p .83). FACIT physical, emotional, and functional well-being scores not significantly different (p .35, .62, and .71) but showing a trend for social well-being (p .06). PROMIS scores not changed over time (p .34). ESAS individual symptoms of anxiety, well-being, drowsiness, poor appetite, nausea, pain, shortness of breath, sleep and tiredness not significant, except for depression (p.04). However, a decrease of 0.01 unit in depression score is not considered clinically significant. No grade 3 or 4 adverse events. No participants died during study, 2 died after study completion from breast cancer recurrence. 16 withdrew prior to study completion because of adverse events, unrelated hospitalizations, RT discontinuation, and COVID-19 precautions. Trial was stopped based on statistical analysis demonstrating no difference for primary outcome and imminent expiry of available drug. Discontinuation was approved by Data Safety Monitoring Committee. Conclusions: Melatonin did not prevent fatigue in patients with early stage breast cancer undergoing RT. Melatonin also demonstrated no benefit for other symptoms, except depression. Analysis showed little evidence of an effect, and the trial was terminated early. Clinical trial information: NCT02332928.
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Khorasanchi A, Nemani S, Pandey S, Del Fabbro E. Managing Nutrition Impact Symptoms in Cancer Cachexia: A Case Series and Mini Review. Front Nutr 2022; 9:831934. [PMID: 35308290 PMCID: PMC8928189 DOI: 10.3389/fnut.2022.831934] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/07/2022] [Indexed: 12/31/2022] Open
Abstract
Malnutrition is common in cancer patients and can occur throughout a patient’s disease course. The contributors to the clinical syndrome of cancer cachexia are often multifactorial, and produced by the cancer and associated pro-inflammatory response. Since cancer cachexia is a multifactorial syndrome, a multimodal therapeutic approach is ideal. A key component of therapy is identifying and managing symptom barriers to adequate oral intake, known as nutritional impact symptoms (NIS). NIS are associated with reduced intake and weight loss in patients with advanced cancer, and aggregate NIS are a predictor of survival in patients with Head and Neck Cancer and in patients undergoing surgery for esophageal cancer. Currently, there are no guidelines regarding the specific management of NIS in oncology patients. Experience from specialist centers suggest relatively simple assessments and inexpensive interventions are available for the diagnosis and treatment of NIS. We present three patient cases from a cachexia clinic, where NIS management decreased symptom burden and improved clinical outcomes such as weight and physical performance.
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Affiliation(s)
- Adam Khorasanchi
- Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, United States
| | - Srinidhi Nemani
- Virginia Commonwealth University, Richmond, VA, United States
| | - Sudeep Pandey
- Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, United States
| | - Egidio Del Fabbro
- Department of Internal Medicine, Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, United States
- *Correspondence: Egidio Del Fabbro,
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Davis M, Hui D, Davies A, Ripamonti C, Capela A, DeFeo G, Del Fabbro E, Bruera E. MASCC antiemetics in advanced cancer updated guideline. Support Care Cancer 2021; 29:8097-8107. [PMID: 34398289 DOI: 10.1007/s00520-021-06437-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nausea and vomiting are a common clinical symptom in the advanced cancer patient. Pharmacologic management is important. Evidence for drug choices and guidelines are needed to help clinicians manage nausea and vomiting in this population METHODS: Evidence from a systematic review published in 2010, initial MASCC guidelines developed from a systematic review of literature to 2015, and a new systematic review of randomized trials published between 2015 and February 2, 2021, was combined to establish a new guideline. RESULTS A search of the literature between 2015 and February 2, 2021, revealed 257 abstracts of which there was one systematic review and 4 randomized trials which were used to modify the guideline. The new guideline is as follows: First Line: Metoclopramide (II) multiple small RCTs including a placebo-controlled trial, haloperidol (II) multiple non-placebo-controlled RCTs, high consensus. Second line: Methotrimeprazine (II) 1 well-powered non-placebo-controlled RCT, olanzapine (II) 1 placebo-controlled pilot RCT, high consensus. Third line: Tropisetron (II) large unblinded lower quality non-placebo-controlled RCT, levosulpiride (II) 1 blinded non-placebo-controlled pilot RCT, high consensus. DISCUSSION Haloperidol, metoclopramide, methotrimeprazine, olanzapine tropisetron, and levosulpiride have been antiemetics used in randomized trials with antiemetic activity demonstrated. There are only three placebo-controlled randomized trials we could find in our literature review. Placebo responses varied significantly between two randomized trials. More randomized placebo-controlled trials with either metoclopramide or haloperidol rescue are needed to clarify antiemetic choices in advanced cancer. CONCLUSION First-line antiemetics for nausea and vomiting in advanced cancer are metoclopramide and haloperidol, and second-line medications are methotrimeprazine and olanzapine.
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Affiliation(s)
| | - David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew Davies
- Trinity College Dublin, University College Dublin, and Our Lady's Hospice Dublin, Dublin, Ireland
| | - Carla Ripamonti
- Supportive Care in Cancer Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Onco-Haematology, Milan, Italy
| | - Andreia Capela
- Associação de Investigação de Cuidados de Suporte em Oncologia (AICSO) and Centro Hospitalar Vila Nova de Gaia, Espinho, Portugal
| | - Giulia DeFeo
- Supportive Care in Cancer Unit, Fondazione IRCCS, Istituto Nazionale dei Tumori, Onco-Haematology, Milan, Italy
| | - Egidio Del Fabbro
- Palliative Care Endowed Chair Division of Hematology, Oncology & Palliative Care Virginia Commonwealth University Massey Cancer Center, Richmond, VA, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Del Fabbro E. Improving the perception of physician compassion, communication skills, and professionalism in the outpatient clinic. Cancer 2021; 127:3924-3925. [PMID: 34264521 DOI: 10.1002/cncr.33776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/04/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Egidio Del Fabbro
- Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, Virginia
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10
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Legakis LP, Woo W, Cassel JB, Del Fabbro E. Comparison of opioid rotation on pain, symptoms, and daily opioid dose in a supportive care clinic. Ann Palliat Med 2021; 10:6336-6343. [PMID: 34118844 DOI: 10.21037/apm-21-325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/10/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Opioid rotation (OR) is used to decrease patients' cancer-related pain and mitigate opioid-induced adverse effects. There is limited evidence regarding its effect on symptoms and morphine equivalent daily dose (MEDD). The objective of this study was to investigate the effects of OR on pain scores, Edmonton Symptom Assessment Score (ESAS), and MEDD in patients with cancer. METHODS Retrospective observational study in an outpatient supportive care clinic using a within-subject design to analyze data collected over 34 months. Study included 676 patients with 217 rotations identified in 128 patients at supportive care clinic at a National Cancer Institute (NCI) Cancer Center. OR were identified and analysis compared the pre-visit data with the subsequent post-visit data following OR using paired t-tests. Primary endpoints included pain scores, total ESAS, and MEDD for OR and these endpoints were compared amongst rotations to specific opioid analgesics. RESULTS Following OR, there was a statistically significant reduction in mean pain scores from 6.25 at the pre-visit to 5.75 following OR. Of the 194 ORs, 29.90% were successful in reducing patients' pain by either 30% or by 2-points. Only rotations to morphine, oxycodone, and methadone correlated with significant decreases in pain scores. Overall, OR did not correlate with significant changes in ESAS or MEDD. Only rotations to methadone correlated with a significant reduction in MEDD. CONCLUSIONS These findings suggest OR is associated with decreased pain scores without increasing MEDD. Of the agents compared, only rotations to methadone correlated with both a significant reduction in pain scores and in MEDD.
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Affiliation(s)
- Luke P Legakis
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Wendy Woo
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - J Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Egidio Del Fabbro
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
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Caillaud M, Aung Myo YP, McKiver BD, Osinska Warncke U, Thompson D, Mann J, Del Fabbro E, Desmoulière A, Billet F, Damaj MI. Key Developments in the Potential of Curcumin for the Treatment of Peripheral Neuropathies. Antioxidants (Basel) 2020; 9:antiox9100950. [PMID: 33023197 PMCID: PMC7600446 DOI: 10.3390/antiox9100950] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 12/11/2022] Open
Abstract
Peripheral neuropathies (PN) can be triggered after metabolic diseases, traumatic peripheral nerve injury, genetic mutations, toxic substances, and/or inflammation. PN is a major clinical problem, affecting many patients and with few effective therapeutics. Recently, interest in natural dietary compounds, such as polyphenols, in human health has led to a great deal of research, especially in PN. Curcumin is a polyphenol extracted from the root of Curcuma longa. This molecule has long been used in Asian medicine for its anti-inflammatory, antibacterial, and antioxidant properties. However, like numerous polyphenols, curcumin has a very low bioavailability and a very fast metabolism. This review addresses multiple aspects of curcumin in PN, including bioavailability issues, new formulations, observations in animal behavioral tests, electrophysiological, histological, and molecular aspects, and clinical trials published to date. The, review covers in vitro and in vivo studies, with a special focus on the molecular mechanisms of curcumin (anti-inflammatory, antioxidant, anti-endoplasmic reticulum stress (anti-ER-stress), neuroprotection, and glial protection). This review provides for the first time an overview of curcumin in the treatment of PN. Finally, because PN are associated with numerous pathologies (e.g., cancers, diabetes, addiction, inflammatory disease...), this review is likely to interest a large audience.
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Affiliation(s)
- Martial Caillaud
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA 23298, USA; (Y.P.A.M.); (B.D.M.); (U.O.W.); (D.T.); (J.M.)
- Correspondence: (M.C.); (M.I.D.)
| | - Yu Par Aung Myo
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA 23298, USA; (Y.P.A.M.); (B.D.M.); (U.O.W.); (D.T.); (J.M.)
| | - Bryan D. McKiver
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA 23298, USA; (Y.P.A.M.); (B.D.M.); (U.O.W.); (D.T.); (J.M.)
| | - Urszula Osinska Warncke
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA 23298, USA; (Y.P.A.M.); (B.D.M.); (U.O.W.); (D.T.); (J.M.)
| | - Danielle Thompson
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA 23298, USA; (Y.P.A.M.); (B.D.M.); (U.O.W.); (D.T.); (J.M.)
| | - Jared Mann
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA 23298, USA; (Y.P.A.M.); (B.D.M.); (U.O.W.); (D.T.); (J.M.)
| | - Egidio Del Fabbro
- Division of Hematology/Oncology and Palliative Care, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA;
- Translational Research Initiative for Pain and Neuropathy at VCU, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Alexis Desmoulière
- Myelin Maintenance and Peripheral Neuropathies EA6309, Faculties of Medicine and Pharmacy, University of Limoges, F-87000 Limoges, France; (A.D.); (F.B.)
| | - Fabrice Billet
- Myelin Maintenance and Peripheral Neuropathies EA6309, Faculties of Medicine and Pharmacy, University of Limoges, F-87000 Limoges, France; (A.D.); (F.B.)
| | - M. Imad Damaj
- Department of Pharmacology and Toxicology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA 23298, USA; (Y.P.A.M.); (B.D.M.); (U.O.W.); (D.T.); (J.M.)
- Translational Research Initiative for Pain and Neuropathy at VCU, Virginia Commonwealth University, Richmond, VA 23298, USA
- Correspondence: (M.C.); (M.I.D.)
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Dang M, Noreika D, Ryu S, Sima A, Ashton H, Ondris B, Coley F, Nestler J, Fabbro ED. Feasibility of Delivering an Avatar-Facilitated Life Review Intervention for Patients with Cancer. J Palliat Med 2020; 24:520-526. [PMID: 32896200 DOI: 10.1089/jpm.2020.0020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Life review, a narrative-based intervention, helps individuals organize memories into a meaningful whole, providing a balanced view of the past, present, and future. Examining how the content of memories contributes to life's meaning improves some clinical outcomes for oncology patients. Combining life review with other modalities may enhance therapeutic efficacy. We hypothesized a life review intervention might be enhanced when combined with a kinetic, digital representation (avatar) chosen by the patient. Our goal was to determine the feasibility of an avatar-based intervention for facilitating life review in patients with advanced cancer. Methods: We conducted an observational, feasibility trial in a supportive care clinic. Motion capture technology was used to synchronize voice and movements of the patient onto an avatar in a virtual environment. Semistructured life review questions were adapted to the stages of child, teenager, adult, and elder. Outcome measures included adherence, recruitment, comfort of study procedure, patients' perceived benefits, and ability to complete questionnaires, including the Edmonton Symptom Assessment System (ESAS) and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp). Results: Seventeen patients were approached, with 11/12 completing the intervention. The total visit time of a single intervention averaged 67 minutes. The post-intervention survey found all patients agreed or strongly agreed (Likert Scale 1-5) they would participate again, would recommend it to others, and found the experience beneficial. After one month, ESAS scores were either unchanged or improved in 80% of patients. Conclusion: An avatar-facilitated life review was feasible with a high rate of adherence, completion, and acceptability by patients. The findings support the need for a clinical trial to test the efficacy of this novel intervention. Clinical Trial Number NCT03996642.
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Affiliation(s)
- Malisa Dang
- Division of Hematology, Oncology, and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Danielle Noreika
- Division of Hematology, Oncology, and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Semi Ryu
- Department of Kinetic Imaging School of the Arts, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Adam Sima
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Holly Ashton
- Department of Kinetic Imaging School of the Arts, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Brianna Ondris
- Department of Kinetic Imaging School of the Arts, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Felicia Coley
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Nestler
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Egidio Del Fabbro
- Division of Hematology, Oncology, and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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13
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Ulker E, Del Fabbro E. Best Practices in the Management of Nonmedical Opioid Use in Patients with Cancer-Related Pain. Oncologist 2019; 25:189-196. [PMID: 31872911 DOI: 10.1634/theoncologist.2019-0540] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/06/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Nonmedical opioid use (NMOU) in patients with cancer is a term covering a spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. OBJECTIVES The objectives of this study were to (A) evaluate current literature regarding management of NMOU in patients with cancer-related pain; (B) provide best practice recommendations based on evidence; and (C) integrate practices derived from the management of noncancer pain, where clinically appropriate or when the oncology literature is limited. METHODS This study is a narrative review. IMPLICATIONS Although harm from NMOU was thought to be rare among oncology patients, about one in five patients with cancer is at risk of adverse outcomes including prolonged opioid use, high opioid doses, and increased health care utilization. The management of NMOU can be challenging because pain is a multidimensional experience encompassing physical, psychological, and spiritual domains. An interdisciplinary team approach is most effective, and management strategies may include (A) education of patients and families; (B) harm reduction, including opioid switching, decreasing the overall daily dose, avoiding concurrent sedative use, and using adjuvant medications for their opioid-sparing potential; (C) managing psychological and spiritual distress with an interdisciplinary team and techniques such as brief motivational interviewing; and (D) risk mitigation by pill counts, frequent clinic visits, and accessing statewide prescription drug monitoring plans. CONCLUSION Although many of the management strategies for NMOU in patients with cancer-related pain are modeled on those for chronic non-cancer-related pain, there is emerging evidence that education and harm-reduction initiatives specifically for cancer-related pain are effective. IMPLICATIONS FOR PRACTICE Nonmedical opioid use (NMOU) in patients with cancer is a term covering a broad spectrum of nonprescribed opioid use. The extent to which an individual uses opioids in a nonprescribed manner will influence propensity for adverse effects such as neurotoxicity, substance use disorder, overdose, and death. This review evaluates the evidence for best practices in oncology and addresses limitations in the literature with supplemental evidence from noncancer chronic pain. Management recommendations for NMOU are provided, based on a combination of literature-based evidence and best clinical practice. Effective management of NMOU in oncology has the potential to improve quality of life, decrease health utilization, and improve survival.
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Affiliation(s)
- Esad Ulker
- Virginia Commonwealth University, Richmond, Virginia, USA
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14
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Affiliation(s)
- Emily B. Rivet
- Division of Bariatric and Gastrointestinal Surgery, Departments of Surgery and Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond
| | - Egidio Del Fabbro
- Division of Hematology, Department of Internal Medicine, Oncology and Palliative Care, Virginia Commonwealth University School of Medicine, Richmond
| | - Paula Ferrada
- Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond
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15
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May P, Normand C, Del Fabbro E, Fine RL, Morrison RS, Ottewill I, Robinson C, Cassel JB. Economic Analysis of Hospital Palliative Care: Investigating Heterogeneity by Noncancer Diagnoses. MDM Policy Pract 2019; 4:2381468319866451. [PMID: 31535032 PMCID: PMC6737878 DOI: 10.1177/2381468319866451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 06/18/2019] [Indexed: 01/03/2023] Open
Abstract
Background. Single-disease-focused treatment and hospital-centric care are poorly suited to meet complex needs in an era of multimorbidity. Understanding variation in palliative care’s association with treatment choices is essential to optimizing interdisciplinary decision making in care of complex patients. Aim. To estimate the association between palliative care and hospital costs by primary diagnosis and multimorbidity for adults with one of six life-limiting conditions: heart failure, chronic obstructive pulmonary disease (COPD), liver failure, kidney failure, neurodegenerative conditions including dementia, and HIV/AIDS. Methods. Data from four studies (2002–2015) were pooled to provide an analytic dataset of 73,304 participants with mean costs $10,483, of whom 5,348 (7%) received palliative care. We estimated average effect of palliative care on direct hospital costs among the treated, using propensity scores to control for observed confounding. Results. Palliative care was associated with a statistically significant reduction in total direct costs for heart failure (estimated treatment effect: −$2666; 95% confidence interval [CI]: −$3440 to −$1892), neurodegenerative conditions (−$3523; −$4394 to −$2651), COPD (−$1613; −$2217 to −$1009), kidney failure (−$3589; −$5132 to −$2045), and liver failure (−$7574; −$9232 to −$5916). The association for liver failure patients was statistically significantly larger than for any other disease group. Cost-saving associations were also statistically larger for patients with multimorbidity than single disease for two of the six groups: neurodegenerative and liver failure. Conclusions. Heterogeneity in treatment effect estimates was observable in assessing association between palliative care and hospital costs for adults with serious life-limiting illnesses other than cancer. The results illustrate the importance of careful definition of palliative care populations in research and practice, and raise further questions about the role of interdisciplinary decision making in treatment of complex medical illness.
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Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Egidio Del Fabbro
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | | | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai, New York
| | - Isabel Ottewill
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | | | - J Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
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16
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Toma W, Kyte SL, Bagdas D, Jackson A, Meade JA, Rahman F, Chen ZJ, Del Fabbro E, Cantwell L, Kulkarni A, Thakur GA, Papke RL, Bigbee JW, Gewirtz DA, Damaj MI. The α7 nicotinic receptor silent agonist R-47 prevents and reverses paclitaxel-induced peripheral neuropathy in mice without tolerance or altering nicotine reward and withdrawal. Exp Neurol 2019; 320:113010. [PMID: 31299179 DOI: 10.1016/j.expneurol.2019.113010] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/05/2019] [Accepted: 07/08/2019] [Indexed: 12/13/2022]
Abstract
Various antitumor drugs, including paclitaxel, frequently cause chemotherapy-induced peripheral neuropathy (CIPN) that can be sustained even after therapy has been completed. The current work was designed to evaluate R-47, an α7 nAChR silent agonist, in our mouse model of CIPN. R-47 was administered to male C57BL/6J mice prior to and during paclitaxel treatment. Additionally, we tested if R-47 would alter nicotine's reward and withdrawal effects. The H460 and A549 non-small cell lung cancer (NSCLC) cell lines were exposed to R-47 for 24-72 h, and tumor-bearing NSG mice received R-47 prior to and during paclitaxel treatment. R-47 prevents and reverses paclitaxel-induced mechanical hypersensitivity in mice in an α7 nAChR-dependent manner. No tolerance develops following repeated administration of R-47, and the drug lacks intrinsic rewarding effects. Additionally, R-47 neither changes the rewarding effect of nicotine in the Conditioned Place Preference test nor enhances mecamylamine-precipitated withdrawal. Furthermore, R-47 prevents paclitaxel-mediated loss of intraepidermal nerve fibers and morphological alterations of microglia in the spinal cord. Moreover, R-47 does not increase NSCLC cell viability, colony formation, or proliferation, and does not interfere with paclitaxel-induced growth arrest, DNA fragmentation, or apoptosis. Most importantly, R-47 does not increase the growth of A549 tumors or interfere with the antitumor activity of paclitaxel in tumor-bearing mice. These studies suggest that R-47 could be a viable and efficacious approach for the prevention and treatment of CIPN that would not interfere with the antitumor activity of paclitaxel or promote lung tumor growth.
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Affiliation(s)
- Wisam Toma
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States of America.
| | - S Lauren Kyte
- Center for Veterinary Medicine, U.S. Food and Drug Administration, Rockville, MD, United States of America
| | - Deniz Bagdas
- Department of Psychiatry, Yale University School of Medicine, Yale Tobacco Center of Regulatory Science, New Haven, CT, United States of America
| | - Asti Jackson
- Department of Psychiatry, Yale University School of Medicine, Yale Tobacco Center of Regulatory Science, New Haven, CT, United States of America
| | - Julie A Meade
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Faria Rahman
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Zhi-Jian Chen
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Egidio Del Fabbro
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States of America; Translational Research Initiative for Pain and Neuropathy, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Lucas Cantwell
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, United States of America
| | - Abhijit Kulkarni
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, United States of America
| | - Ganesh A Thakur
- Department of Pharmaceutical Sciences, Northeastern University, Boston, MA, United States of America
| | - Roger L Papke
- Department of Pharmacology and Therapeutics, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - John W Bigbee
- Department of Anatomy and Neurobiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, United States of America
| | - David A Gewirtz
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States of America
| | - M Imad Damaj
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, United States of America; Translational Research Initiative for Pain and Neuropathy, Virginia Commonwealth University, Richmond, VA, United States of America
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17
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May P, Garrido MM, Del Fabbro E, Noreika D, Normand C, Skoro N, Cassel JB. Evaluating Hospital Readmissions for Persons With Serious and Complex Illness: A Competing Risks Approach. Med Care Res Rev 2019; 77:574-583. [PMID: 30658539 DOI: 10.1177/1077558718823919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Hospital readmission rate is a ubiquitous measure of efficiency and quality. Individuals with life-limiting illnesses account heavily for admissions but evaluation is complicated by high-mortality rates. We report a retrospective cohort study examining the association between palliative care (PC) and readmissions while controlling for postdischarge mortality with a competing risks approach. Eligible participants were adult inpatients admitted to an academic, safety-net medical center (2009-2015) with at least one diagnosis of cancer, heart failure, chronic obstructive pulmonary disease, liver failure, kidney failure, AIDS/HIV, and selected neurodegenerative conditions. PC was associated with reduced 30-, 60-, and 90-day readmissions (subhazard ratios = 0.57, 0.53, and 0.52, respectively [all p < .001]). Hospital PC is associated with a reduction in readmissions, and this is not explained by higher mortality among PC patients. Performance measures only counting those alive at a given end point may underestimate systematically the effects of treatments with a high-mortality rate.
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Affiliation(s)
- Peter May
- Trinity College Dublin, Dublin, Ireland
| | - Melissa M Garrido
- James J. Peters VA Medical Center, Bronx, NY, USA.,Icahn School of Medicine at Mount Sinai, NY, USA
| | | | | | - Charles Normand
- Trinity College Dublin, Dublin, Ireland.,King's College London, England, UK
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Abstract
PRACTICAL APPLICATIONS Recognize patients at higher risk for nonmedical opioid use. Learn about screening for chemical coping risk. Diagnose nonmedical opioid use. Manage nonmedical opioid use in the clinical oncology setting. Understand clinical criteria for referral to supportive and palliative care teams.
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Affiliation(s)
- Eduardo Bruera
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Virginia Commonwealth University, Massey Cancer Center, Richmond, VA
| | - Egidio Del Fabbro
- From The University of Texas MD Anderson Cancer Center, Houston, TX; Virginia Commonwealth University, Massey Cancer Center, Richmond, VA
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Abstract
The US population of inmates continues to increase along with a rapid escalation in the number of elderly prisoners. Previous studies have demonstrated multiple barriers to providing palliative care for seriously ill inmates. The aim of this study was to assess the frequency of palliative care consultation and nature of consultation requests for inmates who died while hospitalized at a large tertiary care hospital. A retrospective chart review of all inmate decedents over a 10-year time period was conducted. The reason and timing of consultation was noted in addition to symptoms identified and interventions recommended by the palliative care team. Characteristics of patients who were transferred to the inpatient palliative care unit were also recorded. Forty-five percent of inmates were seen by palliative care prior to their death. Timing of consultation was close to the day of death. Inmates with cancer were significantly more likely to have a palliative care consultation prior to death. The most frequent intervention recommended was opiates for pain or dyspnea. Delirium was often missed by the primary team but was identified by the palliative care team. Nearly, 5000 prisoners die each year, mostly in community hospitals. These patients exhibit similar symptoms to free-living patients. Given that the inmate population has a higher rate of comorbid conditions, there is a need for more research to identify areas of need for incarcerated patients and where palliative care can best serve these individuals.
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Affiliation(s)
- Stephanie L. Stephens
- Division of Hematology, Oncology and Palliative Care, Department of Internal Medicine, VCU School of Medicine, Richmond, VA, USA
| | - J. Brian Cassel
- Division of Hematology, Oncology and Palliative Care, Department of Internal Medicine, VCU School of Medicine, Richmond, VA, USA
| | - Danielle Noreika
- Division of Hematology, Oncology and Palliative Care, Department of Internal Medicine, VCU School of Medicine, Richmond, VA, USA
| | - Egidio Del Fabbro
- Division of Hematology, Oncology and Palliative Care, Department of Internal Medicine, VCU School of Medicine, Richmond, VA, USA
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20
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Abstract
Since Cancer cachexia is defined as a "multifactorial syndrome", an effective therapeutic approach might be comprehensive multi-faceted treatment that targets different pathophysiological mechanisms simultaneously. The defining features of cancer cachexia, such as weight loss, reduced food intake, and chronic inflammation, might provide both a framework for classification of cachexia and a rationale for identifying multiple therapeutic targets. Past efforts to treat cachexia with nutritional or medical interventions may have disappointed because they were directed at a single domain of the syndrome, such as anorexia or muscle wasting, usually with a single therapeutic agent. Preliminary trials combining pharmacological and non-pharmacological therapy have been shown to be feasible and also to improve selected clinical outcomes. The choice of specific pharmacological agents has varied based on mechanistic considerations or on prior promising single intervention or multimodal trials. Despite the variations in therapy composition, most multimodal regimens share a common purpose in simultaneously modulating the major mechanisms causing cachexia, identifying patients early in the illness trajectory, and including supportive care measures such as symptom management, exercise, and nutritional counseling/supplementation.
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May P, Normand C, Cassel JB, Del Fabbro E, Fine RL, Menz R, Morrison CA, Penrod JD, Robinson C, Morrison RS. Economics of Palliative Care for Hospitalized Adults With Serious Illness: A Meta-analysis. JAMA Intern Med 2018; 178:820-829. [PMID: 29710177 PMCID: PMC6145747 DOI: 10.1001/jamainternmed.2018.0750] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Economics of care for adults with serious illness is a policy priority worldwide. Palliative care may lower costs for hospitalized adults, but the evidence has important limitations. OBJECTIVE To estimate the association of palliative care consultation (PCC) with direct hospital costs for adults with serious illness. DATA SOURCES Systematic searches of the Embase, PsycINFO, CENTRAL, PubMed, CINAHL, and EconLit databases were performed for English-language journal articles using keywords in the domains of palliative care (eg, palliative, terminal) and economics (eg, cost, utilization), with limiters for hospital and consultation. For Embase, PsycINFO, and CENTRAL, we searched without a time limitation. For PubMed, CINAHL, and EconLit, we searched for articles published after August 1, 2013. Data analysis was performed from April 8, 2017, to September 16, 2017. STUDY SELECTION Economic evaluations of interdisciplinary PCC for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders. DATA EXTRACTION AND SYNTHESIS Eight eligible studies were identified, all cohort studies, of which 6 provided sufficient information for inclusion. The study estimated the association of PCC within 3 days of admission with direct hospital costs for each sample and for subsamples defined by primary diagnoses and number of comorbidities at admission, controlling for confounding with an instrumental variable when available and otherwise propensity score weighting. Treatment effect estimates were pooled in the meta-analysis. MAIN OUTCOMES AND MEASURES Total direct hospital costs. RESULTS This study included 6 samples with a total 133 118 patients (range, 1020-82 273), of whom 93.2% were discharged alive (range, 89.0%-98.4%), 40.8% had a primary diagnosis of cancer (range, 15.7%-100.0%), and 3.6% received a PCC (range, 2.2%-22.3%). Mean Elixhauser index scores ranged from 2.2 to 3.5 among the studies. When patients were pooled irrespective of diagnosis, there was a statistically significant reduction in costs (-$3237; 95% CI, -$3581 to -$2893; P < .001). In the stratified analyses, there was a reduction in costs for the cancer (-$4251; 95% CI, -$4664 to -$3837; P < .001) and noncancer (-$2105; 95% CI, -$2698 to -$1511; P < .001) subsamples. The reduction in cost was greater in those with 4 or more comorbidities than for those with 2 or fewer. CONCLUSIONS AND RELEVANCE The estimated association of early hospital PCC with hospital costs may vary according to baseline clinical factors. Estimates may be larger for primary diagnosis of cancer and more comorbidities compared with primary diagnosis of noncancer and fewer comorbidities. Increasing palliative care capacity to meet national guidelines may reduce costs for hospitalized adults with serious and complex illnesses.
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Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland.,Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, King's College London, London, England
| | - J Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond
| | | | | | | | | | - Joan D Penrod
- James J. Peters Veterans Affairs Medical Center, New York, New York.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - R Sean Morrison
- James J. Peters Veterans Affairs Medical Center, New York, New York.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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May P, Garrido MM, Del Fabbro E, Noreika D, Normand C, Skoro N, Cassel JB. Does Modality Matter? Palliative Care Unit Associated With More Cost-Avoidance Than Consultations. J Pain Symptom Manage 2018; 55:766-774.e4. [PMID: 28842218 PMCID: PMC5860672 DOI: 10.1016/j.jpainsymman.2017.08.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/11/2017] [Accepted: 08/12/2017] [Indexed: 01/23/2023]
Abstract
CONTEXT Inpatient palliative care (PC) is associated with reduced costs, but the optimal model for providing inpatient PC is unknown. OBJECTIVES To estimate the effect of palliative care consultations (PCCs) and care in a palliative care unit (PCU) on cost of care, in comparison with usual care (UC) only and in comparison with each other. METHODS Retrospective cohort study, using multinomial propensity scoring to control for observed confounding between treatment groups. Participants were adults admitted as inpatients between 2009 and 2015, with at least one of seven life-limiting conditions who died within a year of admission (N = 6761). RESULTS PC within 10 days of admission is estimated to reduce costs compared with UC in the case of both PCU (-$6333; 95% CI: -7871 to -4795; P < 0.001) and PCC (-$3559; 95% CI: -5732 to -1387; P < 0.001). PCU is estimated to reduce costs compared with PCC (-$2774; 95% CI: -5107 to -441; P = 0.02) and length of stay compared with UC (-1.5 days; -2.2 to -0.9; P < 0.001). The comparatively larger effect of PCU over PCC is not observable when the treatment groups are restricted to those who received PC early in their admission (within six days). CONCLUSION Both PCU and PCC are associated with lower hospital costs than UC. PCU is associated with a greater cost-avoidance effect than PCC, except where both interventions are provided early in the hospitalization. Both timely provision of PC for appropriate patients and creation of more PCUs may decrease hospital costs.
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Affiliation(s)
| | - Melissa M Garrido
- James J. Peters VA Medical Center, Bronx, New York, USA; Icahn School of Medicine at Mount Sinai, New York, USA
| | - Egidio Del Fabbro
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Danielle Noreika
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | | | - Nevena Skoro
- Virginia Commonwealth University Massey Cancer Center, Richmond, Virginia, USA
| | - J Brian Cassel
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.
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Kyte SL, Toma W, Bagdas D, Meade JA, Schurman LD, Lichtman AH, Chen ZJ, Del Fabbro E, Fang X, Bigbee JW, Damaj MI, Gewirtz DA. Nicotine Prevents and Reverses Paclitaxel-Induced Mechanical Allodynia in a Mouse Model of CIPN. J Pharmacol Exp Ther 2017; 364:110-119. [PMID: 29042416 DOI: 10.1124/jpet.117.243972] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 10/16/2017] [Indexed: 01/03/2023] Open
Abstract
Chemotherapy-induced peripheral neuropathy (CIPN), a consequence of peripheral nerve fiber dysfunction or degeneration, continues to be a dose-limiting and debilitating side effect during and/or after cancer chemotherapy. Paclitaxel, a taxane commonly used to treat breast, lung, and ovarian cancers, causes CIPN in 59-78% of cancer patients. Novel interventions are needed due to the current lack of effective CIPN treatments. Our studies were designed to investigate whether nicotine can prevent and/or reverse paclitaxel-induced peripheral neuropathy in a mouse model of CIPN, while ensuring that nicotine will not stimulate lung tumor cell proliferation or interfere with the antitumor properties of paclitaxel. Male C57BL/6J mice received paclitaxel every other day for a total of four injections (8 mg/kg, i.p.). Acute (0.3-0.9 mg/kg, i.p.) and chronic (24 mg/kg per day, s.c.) administration of nicotine respectively reversed and prevented paclitaxel-induced mechanical allodynia. Blockade of the antinociceptive effect of nicotine with mecamylamine and methyllycaconitine suggests that the reversal of paclitaxel-induced mechanical allodynia is primarily mediated by the α7 nicotinic acetylcholine receptor subtype. Chronic nicotine treatment also prevented paclitaxel-induced intraepidermal nerve fiber loss. Notably, nicotine neither promoted proliferation of A549 and H460 non-small cell lung cancer cells nor interfered with paclitaxel-induced antitumor effects, including apoptosis. Most importantly, chronic nicotine administration did not enhance Lewis lung carcinoma tumor growth in C57BL/6J mice. These data suggest that the nicotinic acetylcholine receptor-mediated pathways may be promising drug targets for the prevention and treatment of CIPN.
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Affiliation(s)
- S Lauren Kyte
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - Wisam Toma
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - Deniz Bagdas
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - Julie A Meade
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - Lesley D Schurman
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - Aron H Lichtman
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - Zhi-Jian Chen
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - Egidio Del Fabbro
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - Xianjun Fang
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - John W Bigbee
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - M Imad Damaj
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
| | - David A Gewirtz
- Departments of Pharmacology and Toxicology (S.L.K., W.T., D.B., J.A.M., L.D.S., A.H.L., M.I.D., D.A.G.), Neurology (Z.-J.C.), Internal Medicine (E.D.F.), Biochemistry and Molecular Biology (X.F.), and Anatomy and Neurobiology (J.W.B.), and Massey Cancer Center (D.A.G.), Virginia Commonwealth University, Richmond, Virginia; and Experimental Animals Breeding and Research Center, Uludag University, Bursa, Turkey (D.B.)
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Rivet EB, Ferrada P, Albrecht T, Cassel JB, Broering B, Noreika D, Del Fabbro E. Characteristics of palliative care consultation at an academic level one trauma center. Am J Surg 2017; 214:657-660. [PMID: 28689992 DOI: 10.1016/j.amjsurg.2017.06.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/08/2017] [Accepted: 06/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The current status of palliative care consultation for trauma patients has not been well characterized. We hypothesized that palliative care consultation currently is requested for patients too late to have any clinical significance. METHODS A retrospective chart review was performed for traumatically injured patients' ≥18 years of age who received palliative care consultation at an academic medical center during a one-year period. RESULTS The palliative care team evaluated 82 patients with a median age of 60 years. Pain and end of life were the most common reasons for consultation; interventions performed included delirium management and discussions about nutritional support. For decedents, median interval from palliative care consultation to death was 1 day. Twenty seven patients died (11 in the palliative care unit, 16 in an ICU). Nine patients were discharged to hospice. CONCLUSIONS Most consultations were performed for pain and end of life management in the last 24 h of life, demonstrating the opportunity to engage the palliative care service earlier in the course of hospitalization.
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Affiliation(s)
- Emily B Rivet
- Departments of Surgery and Internal Medicine, VCU School of Medicine, Richmond, VA, USA.
| | - Paula Ferrada
- Department of Surgery, VCU School of Medicine, Richmond, VA, USA.
| | - Tara Albrecht
- VCU School of Nursing and Massey Cancer Center, School of Nursing, Richmond, VA, USA.
| | - J Brian Cassel
- Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care, VCU School of Medicine, Richmond, VA, USA.
| | - Beth Broering
- VCU Medical Center Trauma Program, Richmond, VA, USA.
| | - Danielle Noreika
- Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care, VCU School of Medicine, Richmond, VA, USA.
| | - Egidio Del Fabbro
- Department of Internal Medicine, Division of Hematology, Oncology and Palliative Care, VCU School of Medicine, Richmond, VA, USA.
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Abstract
102 Background: Intrathecal pumps (ITP) are used to manage severe malignancy related pain by delivering analgesics directly into the cerebrospinal fluid, in theory allowing for a reduced opioid dose and fewer complications. Although there is literature to support efficacy in patients with cancer, including improved survival, this mode of drug delivery also carries a risk of serious complications. Reports of complications in non-malignant pain suggest the risks and mortality related to ITP may be under-appreciated and that injury and liability occur with both ITP placement and ITP maintenance. Additional burdens to consider in patients with cancer include accurate prognostication to identify appropriate candidates, and the logistics of providing ITP maintenance. Methods: A retrospective chart review of 26 consecutive patients that underwent implantation of a programmable ITP at a National Cancer Institute center between 2008 and 2014 for malignancy related pain. Results: 53% (n = 14) of patients experienced major and minor ITP complications. Major complications occurred in 35% (9) including leg weakness post operatively requiring wheelchair use for months; granuloma formation causing leg weakness and requiring repeat operation; pump infection leading to sepsis and death; intra-abdominal abscess; significant bleeding requiring discontinuation of therapeutic anticoagulation for PE; and neurological complications including delirium and protracted seizures requiring ICU admission. Minor complications occurred in 31% (8) and included wound infections, urinary retention requiring catheterization, foot drop, and spinal headaches related to CSF leaks. 42% (11) died < 90 days after ITP implantation; 19% (5) died < 30 days after ITP implantation. 7 patients (27%) were either lost to follow up, relocated, transitioned to hospice, or had difficulty finding providers to refill the pump. Conclusions: More than a third of patients with cancer receiving an ITP at our institution experienced major complications including death, sepsis, and neurological problems.
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Cassel JB, Del Fabbro E, Arkenau T, Higginson IJ, Hurst S, Jansen LA, Poklepovic A, Rid A, Rodón J, Strasser F, Miller FG. Phase I Cancer Trials and Palliative Care: Antagonism, Irrelevance, or Synergy? J Pain Symptom Manage 2016; 52:437-45. [PMID: 27233136 DOI: 10.1016/j.jpainsymman.2016.02.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 02/06/2016] [Accepted: 02/26/2016] [Indexed: 12/19/2022]
Abstract
This article synthesizes the presentations and conclusions of an international symposium on Phase 1 oncology trials, palliative care, and ethics held in 2014. The purpose of the symposium was to discuss the intersection of three independent trends that unfolded in the past decade. First, large-scale reviews of hundreds of Phase I trials have indicated there is a relatively low risk of serious harm and some prospect of clinical benefit that can be meaningful to patients. Second, changes in the design and analysis of Phase I trials, the introduction of "targeted" investigational agents that are generally less toxic, and an increase in Phase I trials that combine two or more agents in a novel way have changed the conduct of these trials and decreased fears and apprehensions about participation. Third, the field of palliative care in cancer has expanded greatly, offering symptom management to late-stage cancer patients, and demonstrated that it is not mutually exclusive with disease-targeted therapies or clinical research. Opportunities for collaboration and further research at the intersection of Phase 1 oncology trials and palliative care are highlighted.
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Affiliation(s)
- J Brian Cassel
- Virginia Commonwealth University, Richmond, Virginia, USA.
| | | | - Tobias Arkenau
- Sarah Cannon Research Institute and University College London, London, United Kingdom
| | - Irene J Higginson
- Cicely Saunders Institute, King's College London, London, United Kingdom
| | - Samia Hurst
- Institut d'éthique biomedicale, Centre médical universitaire, Geneva, Switzerland
| | - Lynn A Jansen
- Oregon Health and Science University, Portland, Oregon, USA
| | | | - Annette Rid
- King's College London, London, United Kingdom
| | - Jordi Rodón
- Vall d'Hebron Institut d'Oncologia, Barcelona, Spain
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Tsukanov J, Fabbro ED. Palliative care and symptom management in amyloidosis: A review. Curr Probl Cancer 2016; 40:220-228. [DOI: 10.1016/j.currproblcancer.2016.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/04/2016] [Accepted: 09/14/2016] [Indexed: 12/27/2022]
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Henry Gomez T, Holkova B, Noreika D, Del Fabbro E. Warfarin improves neuropathy in monoclonal gammopathy of undetermined significance. BMJ Case Rep 2016; 2016:bcr-2016-215518. [DOI: 10.1136/bcr-2016-215518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
Background The misuse and abuse of opioid medications in many developed nations is a health crisis, leading to increased health-system utilization, emergency department visits, and overdose deaths. There are also increasing concerns about opioid abuse and diversion in patients with cancer, even at the end of life. Aims To evaluate the current literature on opioid misuse and abuse, and more specifically the identification and assessment of opioid-abuse risk in patients with cancer. Our secondary aim is to offer the most current evidence of best clinical practice and suggest future directions for research. Materials and methods Our integrative review included a literature search using the key terms “identification and assessment of opioid abuse in cancer”, “advanced cancer and opioid abuse”, “hospice and opioid abuse”, and “palliative care and opioid abuse”. PubMed, PsycInfo, and Embase were supplemented by a manual search. Results We found 691 articles and eliminated 657, because they were predominantly non cancer populations or specifically excluded cancer patients. A total of 34 articles met our criteria, including case studies, case series, retrospective observational studies, and narrative reviews. The studies were categorized into screening questionnaires for opioid abuse or alcohol, urine drug screens to identify opioid misuse or abuse, prescription drug-monitoring programs, and the use of universal precautions. Conclusion Screening questionnaires and urine drug screens indicated at least one in five patients with cancer may be at risk of opioid-use disorder. Several studies demonstrated associations between high-risk patients and clinical outcomes, such as aberrant behavior, prolonged opioid use, higher morphine-equivalent daily dose, greater health care utilization, and symptom burden.
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Affiliation(s)
- Ashley-Nicole Carmichael
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura Morgan
- School of Pharmacy, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Egidio Del Fabbro
- Division of Hematology, Oncology, and Palliative Care, Virginia Commonwealth University, Richmond, VA, USA
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Abstract
157 Background: Stem cell/bone marrow transplantation (SC/BMT) is intensive therapy that creates the potential for a number of physical and emotional symptoms. Despite the symptom burden and support needs of these patients there are no publications describing palliative care involvement in the course of treatment. Methods: Retrospective chart review was performed on 37 patients followed over a 6-month period by a palliative care service embedded within the SC/BMT clinic. Results: 37 patients were referred by SC/BMT clinic physicians or nurses to a palliative care team embedded within the clinic (including a physician, physical therapist, and psychologist). Almost all patients were referred for symptom management rather than goals of care; only three (9%) died during the review period and for none of them was the reason for consultation goals of care/hospice referral. Patients were seen between once and eight times during the six month period by various members of the team. Most (77%) were allogenic transplant patients and most were seen within 6 months of their transplantation. The most common reasons for referral were fatigue (57%), anorexia (27%), pain (38%) and depression and/or anxiety (35%). At initial assessment the highest-rated symptoms were lack of appetite (mean 4.78, SD 3.08), fatigue (4.51 [2.59]), and diminished feeling of well-being (4.16, [2.51]). At initial assessment, 73% of patients had 3 or more different symptoms that they rated at 4+; this dropped to 39.1% at follow-up (n = 23). Of the 9 symptoms assessed at both initial and follow-up visits, 7 decreased significantly (all but fatigue and dyspnea) and none increased. For example appetite improved from 5.52 (2.98) to 3.13 (2.96); pain improved from 3.52 (2.92) to 1.78 (1.88) (n = 23, p < .01). SC/BMT providers requested an expansion of the service after three months of experience. Conclusions: Patients who have undergone SC/BMT experience many physical and emotional symptoms. Palliative care embedded within the bone marrow transplant clinic can provide benefit by lessening the symptomatic burden of patients.
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Del Fabbro E, Jatoi A, Davis M, Fearon K, di Tomasso J, Vigano A. Health professionals’ attitudes toward the detection and management of cancer-related anorexia-cachexia syndrome, and a proposal for standardized assessment. J Community Support Oncol 2015; 13:181-7. [DOI: 10.12788/jcso.0133] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2015] [Indexed: 11/20/2022]
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Dev R, Hui D, Chisholm G, Delgado-Guay M, Dalal S, Del Fabbro E, Bruera E. Hypermetabolism and symptom burden in advanced cancer patients evaluated in a cachexia clinic. J Cachexia Sarcopenia Muscle 2015; 6:95-8. [PMID: 26136416 PMCID: PMC4435101 DOI: 10.1002/jcsm.12014] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/15/2014] [Accepted: 10/31/2014] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Elevated resting energy expenditure (REE) may contribute to weight loss and symptom burden in cancer patients. AIMS The aim of this study was to compare the velocity of weight loss, symptom burden (fatigue, insomnia, anxiety, and anorexia-combined score as measured by the Edmonton Symptom Assessment Score), high-sensitivity C-reactive protein, and survival among cancer patients referred to a cachexia clinic with hypermetabolism, elevated REE > 110% of predicted, with normal REE. METHODS A retrospective analysis of 60 advanced cancer patients evaluated in a cachexia clinic for either >5% weight loss or anorexia who underwent indirect calorimetry to measure REE. Patients were dichotomized to either elevated or normal REE. Descriptive statistics were generated, and a two-sample Student's t-tests were used to compare the outcomes between the groups. Kaplan-Meier and Cox regression methodology were used to examine the survival times between groups. RESULTS Thirty-seven patients (62%) were men, 41 (68%) were White, 59 (98%) solid tumours, predominantly 23 gastrointestinal cancers (38%), with a median age of 60 (95% confidence interval 57.0-62.9). Thirty-five patients (58%) were hypermetabolic. Non-Caucasian patients were more likely to have high REE [odds ratio = 6.17 (1.56, 24.8), P = 0.01]. No statistical difference regarding age, cancer type, gender, active treatment with chemotherapy, and/or radiation between hypermetabolic and normal REE was noted. The velocity of weight loss over a 3 month period (-8.5 kg vs. -7.2 kg, P = 0.68), C-reactive protein (37.3 vs. 55.6 mg/L, P = 0.70), symptom burden (4.2 vs. 4.5, P = 0.54), and survival (288 vs. 276 days, P = 0.68) was not significantly different between high vs. normal REE, respectively. CONCLUSION Hypermetabolism is common in cancer patients with weight loss and noted to be more frequent in non-Caucasian patients. No association among velocity of weight loss, symptom burden, C-reactive protein, and survival was noted in advanced cancer patients with elevated REE.
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Affiliation(s)
- Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary Chisholm
- Department of Biostatisitics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marvin Delgado-Guay
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalini Dalal
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Egidio Del Fabbro
- Division of Hematology/Oncology and Palliative Care, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Many important advances have occurred in the field of cancer cachexia over the past decade, including progress in understanding the mechanisms of the cancer anorexia-cachexia syndrome (CACS) and the development of promising pharmacologic and supportive care interventions. However, no approved agents for cancer cachexia currently exist, emphasizing the unmet need for an effective pharmacologic therapy. This article reviews the key elements of CACS assessment in daily practice, the contribution of nutritional impact symptoms (NIS), the evidence for current pharmacologic options, and promising anticachexia agents in perclinical and clinical trials. It also proposes a model for multimodality therapy and highlights issues pertinent to CACS in patients with pancreatic, gastric, and esophageal cancer.
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Affiliation(s)
- Egidio Del Fabbro
- From the Palliative Care Program, Virginia Commonwealth University, Richmond, VA
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Del Fabbro E, Vigano AA. A preliminary study of attitudes toward the assessment and management of cancer cachexia among medical oncologists and nurses. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.31_suppl.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
44 Background: A recent international consensus on the definition and classification of the cancer anorexia / cachexia syndrome (CACS) will facilitate clinical trial design, development of practice guidelines, and routine clinical management. Non-pharmacological interventions such as dietary counseling and promising new drugs have demonstrated improved outcomes in preliminary trials. Management of nutritional impact symptoms such as severe pain, depression, early satiety and chronic nausea also produce weight gain. These important advances contrast with the apparent low priority given to this condition by oncological societies worldwide. Our objective was to evaluate the attitudes of medical oncologists and nurses in the assessment and management of CACS in non-small cell lung cancer. Methods: Surveys were administered electronically to US-based, community medical oncologists (n=76 respondents) and oncology nurses (n=25), members of the Sermo research database which includes over 275,000 active healthcare providers, pre-qualified through telephone or online screening. A proprietary MedPulse tool achieved random geographic distribution of respondents through a staged query–response process. Results: 67% of medical oncologists selected weight loss as the most important criterion for diagnosing CACS in their daily practice, consistent with the consensus definition. However, only 4% of respondents described CACS as inevitable or very likely to develop in patients maintaining good performance status through first-line therapy. Community providers identified the management of symptoms that affect appetite as very important (58.8%), important (31.4%) or somewhat important (7.8%), but only 9.8% indicated they currently use a formal tool to evaluate these symptoms. 72% would consider using a brief assessment tool in clinical practice. Conclusions: Our surveys suggest community oncologists recognize the core criteria for the diagnosis of CACS, although there may be under-recognition of the condition’s prevalence. There is considerable interest in adopting a brief symptom assessment tool for screening, management and referral of affected or at-risk patients.
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Del Fabbro E, Borneman TR, Graffigna G, Cecchini I. The importance of communication about cachexia as experienced by patients and caregivers: A qualitative cross-cultural study. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.31_suppl.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
37 Background: Cancer Anorexia-Cachexia Syndrome (CACS) is a multifactorial condition defined by an ongoing loss in body weight that cannot be fully reversed through conventional nutritional support and leads to progressive functional impairment. This condition has for a long time been misrecognized and underdiagnosed. Furthermore, the burden of CACS as experienced and depicted by patients and caregivers has not been deeply explored so far. Methods: This was a narrative qualitative cross-cultural study (IT, ES, UK, DE, US) based on the collection of 30 weekly emotional diaries followed by 30 semi-structured in-depth interviews to caregivers (i.e. relatives, partners, close friends) of patients diagnosed with CACS. The aim was to understand how the disease is experienced by patients and caregivers, their feelings and unmet needs. Results: Caregivers and patients demonstrate a poor knowledge of CACS: while they spontaneously refer to a pattern of CACS symptoms, they do not verbalize the term “cachexia”. The awareness and levels of engagement in managing CACS by caregivers appear to be dependent on the degree and timing of communication on this condition with the physician: those who express a higher sense of powerlessness and despair also report that their doctor has never explicitly mentioned CACS, nor indicated any strategies to manage it. On the other hand, those who appear more confident and engaged in managing CACS report a more detailed and earlier communication on the subject. Conclusions: Scarce and/or late communication on CACS and its management options with patients and caregivers may result in a sense of powerlessness and ignorance on how to manage its symptoms. In line with the recently reported importance of an early CACS recognition [(Aapro M et al, Ann Oncol (2014). 2014 May 2)], an earlier and thorough discussion about CACS with patients and caregivers would improve their level of engagement and help relieve some of their distress.
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Jennings C, Cassel B, Fletcher D, Wang A, Archer KJ, Skoro N, Yanni L, Del Fabbro E. Response to Pain Management among Patients with Active Cancer, No Evidence of Disease, or Chronic Nonmalignant Pain in an Outpatient Palliative Care Clinic. J Palliat Med 2014; 17:990-4. [DOI: 10.1089/jpm.2013.0593] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Cara Jennings
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
- Division of Hematology, Oncology, and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Brian Cassel
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
- Division of Hematology, Oncology, and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Devon Fletcher
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
- Division of Hematology, Oncology, and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Aiping Wang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Kellie J. Archer
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Nevena Skoro
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Leanne Yanni
- Palliative Medicine, Bon Secours Richmond Health System, Richmond, Virginia
| | - Egidio Del Fabbro
- Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
- Division of Hematology, Oncology, and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
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Abstract
Chemical coping is a working definition that describes patients' intake of opioids on a scale that spans the range between normal nonaddictive opioid use for pain all the way to opioid addiction. Most patients will fall somewhere between the two extremes in using opioid analgesics to cope with their psychological or spiritual distress. The degree to which patients use their medications in a maladaptive manner will determine their susceptibility to drug toxicity and harm. When there are no obvious cancer-related causes for increased pain intensity, chemical coping and other patient-related factors such as delirium, somatization, and depression should be considered. As part of the initial evaluation of patients with cancer-related pain, a brief screening tool such as the CAGE questionnaire should be used to identify patients who may be at risk for chemical coping. Identifying patients at risk will allow clinicians to avoid unnecessary opioid toxicity, control pain, and improve quality of life. A structured approach for managing opioid use should be adopted, including standardized documentation, opioid treatment agreements, urine drug screens, frequent visits, and restricted quantities of breakthrough opioids. All patients at risk should receive brief motivational interviewing with an objective, nonjudgmental, and empathic style that includes personalized feedback, particularly about markers of risk or harm. For chemical copers approaching the addiction end of the spectrum, with evidence of compulsive use and destructive behavior, referral should be made to substance abuse specialists.
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Affiliation(s)
- Egidio Del Fabbro
- From Virginia Commonwealth University, Massey Cancer Center, Richmond, VA
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Del Fabbro E, Skoro N, Cassel B. The prevalence of cachexia among patients with solid and hematologic malignancies at a National Cancer Institute (NCI)-designated cancer center in the 12 months prior to death. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.e20642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Dev R, Hui D, Del Fabbro E, Delgado-Guay MO, Sobti N, Dalal S, Bruera E. Association between hypogonadism, symptom burden, and survival in male patients with advanced cancer. Cancer 2014; 120:1586-93. [PMID: 24577665 DOI: 10.1002/cncr.28619] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 11/05/2013] [Accepted: 12/20/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND A high frequency of hypogonadism has been reported in male patients with advanced cancer. The current study was performed to evaluate the association between low testosterone levels, symptom burden, and survival in male patients with cancer. METHODS Of 131 consecutive male patients with cancer, 119 (91%) had an endocrine evaluation of total (TT), free (FT), and bioavailable testosterone (BT); high-sensitivity C-reactive protein (CRP); vitamin B12; thyroid-stimulating hormone; 25-hydroxy vitamin D; and cortisol levels when presenting with symptoms of fatigue and/or anorexia-cachexia. Symptoms were evaluated by the Edmonton Symptom Assessment Scale. The authors examined the correlation using the Spearman test and survival with the log-rank test and Cox regression analysis. RESULTS The median age of the patients was 64 years; the majority of patients were white (85 patients; 71%). The median TT level was 209 ng/dL (normal: ≥ 200 ng/dL), the median FT was 4.4 ng/dL (normal: ≥ 9 ng/dL), and the median BT was 22.0 ng/dL (normal: ≥ 61 ng/dL). Low TT, FT, and BT values were all associated with worse fatigue (P ≤ .04), poor Eastern Cooperative Oncology Group performance status (P ≤ .05), weight loss (P ≤ .01), and opioid use (P ≤ .005). Low TT and FT were associated with increased anxiety (P ≤ .04), a decreased feeling of well-being (P ≤ .04), and increased dyspnea (P ≤ .05), whereas low BT was only found to be associated with anorexia (P = .05). Decreased TT, FT, and BT values were all found to be significantly associated with elevated CRP and low albumin and hemoglobin. On multivariate analysis, decreased survival was associated with low TT (hazards ratio [HR], 1.66; P = .034), declining Eastern Cooperative Oncology Group performance status (HR, 1.55; P = .004), high CRP (HR, 3.28; P < .001), and decreased albumin (HR, 2.52; P < .001). CONCLUSIONS In male patients with cancer, low testosterone levels were associated with systemic inflammation, weight loss, increased symptom burden, and decreased survival. A high frequency of hypogonadism has been reported in male patients with advanced cancer. In the current study, an increased symptom burden, systemic inflammation, weight loss, opioid use, and poor survival were found to be associated with decreased testosterone levels in male patients with cancer. Cancer 2014;120:1586-1593. © 2014 American Cancer Society.
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Affiliation(s)
- Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Wei J, Del Fabbro E. Palliative Care Vignettes. Colorectal Cancer 2014. [DOI: 10.1002/9781118337929.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Cassel B, Kerr K, Del Fabbro E. Making the (business) case for outpatient and home-based palliative care for cancer patients. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.31_suppl.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
266 Background: Randomized controlled trials by Temel (2010) and Brumley (2003, 2007) have demonstrated the positive clinical, psycho-social, and utilization impact of providing early clinic or home-based palliative care (PC) concurrently with standard disease-focused treatment. Despite clear benefits, the growth of outpatient PC has been constrained by lack of clarity about the “business case” for hospitals or health systems to develop and fund PC services outside the inpatient setting. Methods: We will present findings from Virginia Commonwealth University (VCU) that provide a compelling quantification of the risks for hospitals to continue “business as usual” in this changing environment. Our approach measures quality, quantity, and costs of care for patients with cancer over a period of 6-12 months prior to death. Performance on some of these measures impact revenues in the prevailing fee-for-service reimbursement model; others are utilized in national, public ratings of quality; and still others influence organizational ability to compete in the population health management model that rewards quality and efficiency over time. Results: We used these data to highlight VCU Health System’s exposure to financial risks to create a strong business case for outpatient palliative care in which patient-centered and hospital-centered outcomes are aligned. This approach elevated our proposal to be included in a broader strategic initiative by our health system to manage complex care more efficiently, and to manage population health more proactively. Our analytic approach was then replicated by a diverse group of California provider groups who adopted or adapted the VCU model to advance their community-based palliative care programs as part of the California Health Care Foundation’s “Palliative Care Action Community” initiative. Conclusions: Our analytic model and articulation of the business case for community-based palliative care can help others to create and sustain quality-driven, patient-centered, cost-effective PC programs in their own institutions.
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Affiliation(s)
- Brian Cassel
- Virginia Commonwealth University Massey Cancer Center, Richmond, VA
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Dev R, Coulson L, Del Fabbro E, Palla SL, Yennurajalingam S, Rhondali W, Bruera E. A prospective study of family conferences: effects of patient presence on emotional expression and end-of-life discussions. J Pain Symptom Manage 2013; 46:536-45. [PMID: 23507128 DOI: 10.1016/j.jpainsymman.2012.10.280] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 10/03/2012] [Accepted: 10/17/2012] [Indexed: 02/03/2023]
Abstract
CONTEXT Limited research has taken place examining family conferences (FCs) with patients with advanced cancer and their caregivers in the palliative care setting. OBJECTIVES To characterize the FCs involving cancer patients in a palliative care unit at a comprehensive cancer center and examine the effects of patient participation on emotional expression by the participants and end-of-life discussions. METHODS A data collection sheet was completed immediately after 140 consecutive FCs that documented the number of participants, caregiver demographics, expressions of emotional distress, dissatisfaction with care, and the topics discussed. Patient demographics and discharge disposition also were collected. RESULTS Seventy (50%) patients were female, 64 (46%) were white, and 127 (91%) had solid tumors. Median age of patients was 59 years. Patients participated in 68 of 140 FCs (49%). Primary caregivers (n = 140) were female (66%), white (49%), and the spouse/partner (59%). Patients verbalized distress frequently (73%). Primary caregivers' verbal expression of emotional distress was high (82%) but not significantly affected by patient presence (82% vs. 82%, P = 0.936). Verbal expressions of emotional distress by other family members were more common when patients were absent (87%) than when present (73%), P = 0.037. Questions concerning advance directives (21%), symptoms anticipated at death (31%), and caregiver well-being (29%) were infrequent. Patient presence was significantly associated with increased discussions regarding goals of care (P = 0.009) and decreased communication concerning prognosis (P = 0.004) and what symptoms dying patients may experience (P < 0.001). CONCLUSION There was a high frequency of expression of emotional distress by patients and family members in FCs. Patient participation was significantly associated with decreased verbal emotional expression by family members but not the primary caregiver and was associated with fewer discussions regarding prognosis and what dying patients may experience.
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Affiliation(s)
- Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
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Cassel B, Coyne PJ, Skoro N, Kerr K, Del Fabbro E. Evaluating the impact of early versus late inpatient palliative care consultation for cancer patients. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.6638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6638 Background: Access to specialist palliative care (hospital-based or hospice) is a recognized measure of quality in cancer care. Most cancer centers do have palliative care consult services, although the availability of a comprehensive program that includes a palliative care unit and outpatient clinic (Hui 2010) is inconsistent. A simultaneous integrated model of palliative care that facilitates earlier access to a specialized palliative care team may improve clinical outcomes. Palliative care programs should measure the access, timing and impact of their clinical service. Methods: Hospital claims data were linked to Social Security Death Index (SSDI) data from the US Department of Commerce. 3,128 adult cancer patients died between January 2009 and July 2011 and had contact with our inpatient palliative care team in their last six months of life. We determined whether IPC earlier than 1 month prior to death had an impact on hospitalizations, in-hospital mortality and referral to hospice. Results: 27.5% of cancer decedents accessed IPC, median of 22 days before death. 13.2% were discharged to hospice, median of 13 days before death. Patients with IPC earlier than 1 month until death were more likely to have hospice and fewer in-hospital deaths but there was no association between early IPC and a 30-day mortality admission. Conclusions: Palliative care services are accessed by a minority of patients and typically in the last 2-3 weeks of life. Although in-hospital deaths were reduced by earlier palliative care consultation, 30 day mortality did not improve. Hospitals may need to implement other strategies including early integration of outpatient palliative care among cancer patients, to achieve an impact on 30-day mortality admissions. [Table: see text]
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Del Fabbro E, Dev R, Cabanillas ME, Busaidy NL, Rodriguez EC, Bruera E. Extreme hypothyroidism associated with sunitinib treatment for metastatic renal cancer. J Chemother 2013; 24:221-5. [PMID: 23040687 DOI: 10.1179/1973947812y.0000000022] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Although thyroid abnormalities are reported with the use of tyrosine kinase inhibitors, patients rarely require replacement therapy. The initial multicentre studies of sunitinib for metastatic renal cancer did not report hypothyroidism in fatigued patients, and thyroid tests were not routinely monitored. More recent studies, however, suggest that up to 70% of patients develop thyroid test abnormalities during treatment with sunitinib. Despite these concerns, the clinical relevance of sunitinib-induced hypothyroidism is uncertain since thyroid gland recovery is the norm in most patients. We report a case of a patient with metastatic papillary renal cell cancer on combination anti-angiogenic therapy with sunitinib, who developed unusually high thyroid stimulating hormone levels and severe symptoms despite receiving L-thyroxine. Our case also illustrates the complexity of managing sunitinib-associated thyroid dysfunction, which may be accompanied by transient thyroiditis, hyperthyroidism, and profound hypothyroidism.
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Affiliation(s)
- Egidio Del Fabbro
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Del Fabbro E, Dev R, Hui D, Palmer L, Bruera E. Effects of melatonin on appetite and other symptoms in patients with advanced cancer and cachexia: a double-blind placebo-controlled trial. J Clin Oncol 2013; 31:1271-6. [PMID: 23439759 DOI: 10.1200/jco.2012.43.6766] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Prior studies have suggested that melatonin, a frequently used integrative medicine, can attenuate weight loss, anorexia, and fatigue in patients with cancer. These studies were limited by a lack of blinding and absence of placebo controls. The primary purpose of this study was to compare melatonin with placebo for appetite improvement in patients with cancer cachexia. PATIENTS AND METHODS We performed a randomized, double-blind, 28-day trial of melatonin 20 mg versus placebo in patients with advanced lung or GI cancer, appetite scores ≥ 4 on a 0 to 10 scale (10 = worst appetite), and history of weight loss ≥ 5%. Assessments included weight, symptoms by the Edmonton Symptom Assessment Scale, and quality of life by the Functional Assessment of Anorexia/Cachexia Therapy (FAACT) questionnaire. Differences between groups from baseline to day 28 were analyzed using one-sided, two-sample t tests or Wilcoxon two-sample tests. Interim analysis halfway through the trial had a Lan-DeMets monitoring boundary with an O'Brien-Fleming stopping rule. Decision boundaries were to accept the null hypothesis of futility if the test statistic z < 0.39 (P ≥ .348) and reject the null hypothesis if z > 2.54 (P ≤ .0056). RESULTS After interim analysis of 48 patients, the study was closed for futility. There were no significant differences between groups for appetite (P = .78) or other symptoms, weight (P = .17), FAACT score (P = .95), toxicity, or survival from baseline to day 28. CONCLUSION In cachectic patients with advanced cancer, oral melatonin 20 mg at night did not improve appetite, weight, or quality of life compared with placebo.
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Affiliation(s)
- Egidio Del Fabbro
- The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Dev R, Del Fabbro E, Miles M, Vala A, Hui D, Bruera E. Growth of an academic palliative medicine program: patient encounters and clinical burden. J Pain Symptom Manage 2013; 45:261-71. [PMID: 22889857 PMCID: PMC3905688 DOI: 10.1016/j.jpainsymman.2012.02.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 02/13/2012] [Accepted: 02/20/2012] [Indexed: 10/28/2022]
Abstract
CONTEXT Information regarding the challenges of clinical growth and staffing of palliative care programs is limited. OBJECTIVES Our aim was to describe the growth and staffing structure of a palliative care program at a comprehensive cancer center. METHODS During fiscal years ending in 2000 through 2010, we recorded all billed palliative care consultations and follow-ups. To determine the yearly clinical burden per physician, advanced practice nurse (APN), and physician assistant (PA), we calculated the mean number of patient encounters per clinical full-time equivalents. Increase in absolute number of patient encounters and relative (%) growth from year to year were calculated. RESULTS Over the 10-year history of the program, the number of outpatient consultations tripled, whereas the inpatient consultations increased from 73 to 1880. In all cases, with the exception of the first year of operation, the vast majority of clinical activity was in the inpatient hospital setting. Growth in the ratio of inpatient consultations per operational hospital beds was noted during the first five years of the program followed by a more modest increase in the succeeding five years. In fiscal year 2010, palliative care physicians had 6.2 patient encounters per working day, and APNs/PAs independently evaluated and treated 4.0 additional patients. CONCLUSION Over the 10-year history, there has been an increase in the number of patient consultations seen by our palliative care program. The clinical burden was manageable during the first three years but quickly became too burdensome. Active recruitment of new faculty was required to sustain the increased clinical activity.
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Affiliation(s)
- Rony Dev
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Cassel B, Skoro N, Kerr K, Shickle L, Coyne PJ, Del Fabbro E. Retrospective assessment of quality of cancer care in last 6 months of life. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.34_suppl.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
234 Background: National organizations such as the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF) have developed metrics that assess the quality of cancer care. These metrics include consensus standards by the NQF for management of symptoms and end-of-life-care. Cancer centers need feasible methods for self-evaluating their performance on such metrics. Methods: Claims for our cancer patients were matched to Social Security Death Index data to determine date of death.3,128 adult cancer patients died between January 2009 and July 2011 and had at least 1 contact with our center in their last six month of life. All inpatient and outpatient claims data generated in the last six months of life at our hospital were analyzed. Results: 32% of patients had an admission in their last 30 days of life, with 15% dying in the hospital. 19% had at least one 30-day readmission in their last six months of life. 6.7% had chemotherapy in the 2 weeks prior to death, and 11.4% in the last month. 27.5% had some contact with the specialist palliative care (SPC) team. Solid tumor patients with SPC earlier than 1 month until death had fewer in-hospital deaths (15.6%) versus those with later or no SPC (19.5%), p=.041. There was no SPC difference for 30-day mortality, or 14- or 30-day chemotherapy metrics. Conclusions: Hospitals can self-evaluate their own performance on NQF endorsed measures, and CMS outcome measures. These data provide additional impetus for earlier integration of specialist palliative care teams. SPC in the last 1-3 weeks of life did not improve most utilization metrics.[Table: see text]
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Cassel B, Skoro N, Kerr K, Shickle L, Del Fabbro E, Coyne PJ. An analytic framework for capturing trends in utilization, costs, and quality metrics in cancer patients’ last 6 months of life. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.34_suppl.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
240 Background: Increasingly, reimbursement models are shifting to bundled payments and pay-for-performance models. While cancer care is often profitable for hospitals in the fee for service model, it is important to monitor outcomes that could influence reimbursement, such as 30-day readmissions; possible indicators of poor quality, such as 30-day mortality admissions; and to utilize longitudinal measures of costs and revenues. Methods: We evaluated trends in the outpatient and inpatient care at an academic cancer center for patients across their last 6 months of life. All-payor hospital claims data were linked to Social Security Death Index data to determine patients’ date of death even if they did not die in-hospital. All utilization at our center was analyzed for the 3,128 cancer patients who died between January 2009 and June 2011. Results: Admissions increased over the final six months, with sharp increases in ICU and total bed days in the final three months. 31% of admissions were 30-day re-admissions; 40% had a negative net margin; and all (1,178) in the final month were 30-day mortality admissions. 63% of hospice referrals occur in the final month. Conclusions: With each month this hospital is increasingly exposed to the risks of 30-day mortality and 30-day readmissions. Are the escalating costs and risks justified in terms of outcomes or quality? These findings reinforce the need for care practices that ensure that care is aligned with patient and family preferences, and that alternate care options are available and presented to patients and families in a timely fashion. [Table: see text]
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Del Fabbro E, Parsons H, Warneke CL, Pulivarthi K, Litton JK, Dev R, Palla SL, Brewster A, Bruera E. The relationship between body composition and response to neoadjuvant chemotherapy in women with operable breast cancer. Oncologist 2012; 17:1240-5. [PMID: 22903527 DOI: 10.1634/theoncologist.2012-0169] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Overweight women diagnosed with breast cancer have greater recurrence and mortality risks. Recent studies in advanced cancer showed that the combination of sarcopenia and an overweight or obese body mass index (BMI) is associated with poor clinical outcomes. OBJECTIVES To compare pathological complete response (pCR) cases with controls and evaluate associations among a pCR, survival outcome, and sarcopenia as well as the combination of both sarcopenia and a BMI ≥25 kg/m(2). METHODS Sixty-seven breast cancer patients with a pCR to neoadjuvant chemotherapy (NC) were matched with controls who did not have a pCR to NC. Patients were matched by age, Black's nuclear grading system, clinical cancer stage, and estrogen receptor and progesterone receptor status. Body composition was analyzed using computed tomography images taken prior to NC. RESULTS BMI was associated with pCR. Among normal weight patients, the pCR rate was higher in sarcopenic patients and the progression-free survival (PFS) interval was significantly longer than in overweight or obese BMI patients. The death hazard was 2% higher for each unit higher skeletal muscle index and 0.6% higher for each unit higher visceral adipose tissue. CONCLUSIONS Overweight patients treated with NC had a lower pCR rate and shorter PFS time. Among patients with a normal BMI, the pCR rate was better in sarcopenic patients. More research is required to evaluate the negative impact of sarcopenic obesity on prognosis and the contributors to better response rates in operable, normal weight breast cancer patients with sarcopenia.
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Affiliation(s)
- Egidio Del Fabbro
- Division of Hematology/Oncology and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia 23284, USA.
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Yennurajalingam S, Willey JS, Palmer JL, Allo J, Del Fabbro E, Cohen EN, Tin S, Reuben JM, Bruera E. The role of thalidomide and placebo for the treatment of cancer-related anorexia-cachexia symptoms: results of a double-blind placebo-controlled randomized study. J Palliat Med 2012; 15:1059-64. [PMID: 22880820 DOI: 10.1089/jpm.2012.0146] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To determine the effects of thalidomide and placebo on anorexia-cachexia and its related symptoms, body composition, resting metabolic rate, and serum cytokines and their receptors in patients with advanced cancer. METHODS Included in the study were patients with advanced cancer with weight loss greater than 5% in 6 months and who reported anorexia, fatigue, and one of the following: anxiety, depression, or sleep disturbances. Patients on chemotherapy within 2 weeks prior or during the study were excluded from the study. Patients were randomly assigned to either 100 mg thalidomide or placebo once a day for 14 days. The Edmonton Symptom Assessment Scale (ESAS), Functional Assessment of Anorexia/Cachexia Therapy (FAACT), Functional Assessment of Cancer Illness Therapy (FACIT-F), Hospital Anxiety Depression Scale (HADS) Pittsburgh Sleep Quality Index (PSQI) were utilized, and in addition body composition, Resting Energy Expenditure (REE), and serum cytokine levels were assessed. RESULTS Of the 31 patients entered in the study, 15 were assigned to the thalidomide group and 16 to the placebo group. However only 21/31 patients were able to complete the study. Compared with their baseline values, both the thalidomide and the placebo groups showed significant reduction in cytokines. Tumor necrosis factor (TNF)-α (p=0.04) and its receptors TNFR1 (p=0.04), TNFR2 (p=0.04), and interleukin (IL)-8 (p=0.04) were statistically significant in the thalidomide group. In the placebo group, TNF-α (p=0.008), TNFR1 (p=0.005), TNFR2 (p=0.005), IL-RA (p=0.005), IL-6 (p=0.005), and IL-8 (p=0.005) were statistically significant. However, improvement in these symptoms and cytokine levels were not significantly different in the thalidomide group compared with the placebo group. None of the patients withdrew from the study because of toxicity of either thalidomide or placebo. CONCLUSIONS Based on the poor accrual rate and attrition observed in this study, it is important that future research on thalidomide as a treatment for cancer-related anorexia-cachexia symptoms (ACS) in patients with advanced cancer use less stringent entry criteria and less exhaustive outcome measures.
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Affiliation(s)
- Sriram Yennurajalingam
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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