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Lorenz KA, Mickelsen J, Vallath N, Bhatnagar S, Spruyt O, Rabow M, Agar M, Dy SM, Anderson K, Deodhar J, Digamurti L, Palat G, Rayala S, Sunilkumar MM, Viswanath V, Warrier JJ, Gosh-Laskar S, Harman SM, Giannitrapani KF, Satija A, Pramesh CS, DeNatale M. The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative. J Pain Symptom Manage 2021; 61:190-197. [PMID: 32858163 PMCID: PMC7445485 DOI: 10.1016/j.jpainsymman.2020.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/06/2020] [Accepted: 08/20/2020] [Indexed: 11/28/2022]
Abstract
Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.
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Affiliation(s)
- Karl A Lorenz
- VA Palo Alto Healthcare System, Palo Alto, California, USA; Section of Palliative Care, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA.
| | | | - Nandini Vallath
- Division of Palliative Care, Tata Trusts Cancer Care Program, Mumbai, Maharashtra, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B. R. Ambedkar, IRCH, AIIMS, New Delhi, India
| | - Odette Spruyt
- Western Health Network, VCCC, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Rabow
- Division of Palliative Care, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Meera Agar
- Faculty of Health, Palliative Care, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Sydney M Dy
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA; Johns Hopkins School of Medicine, Lutherville, Maryland, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Jayita Deodhar
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Leela Digamurti
- Department of Palliative Care and Gynaecological Oncology, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Visakhapatnam, Andhra Pradesh, India
| | - Gayatri Palat
- Department of Medical Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
| | - Spandana Rayala
- Department of Medical Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
| | - M M Sunilkumar
- Trivandrum Institute of Palliative Sciences, Thiruvananthapuram, Kerala, India
| | - Vidya Viswanath
- Department of Palliative Care and Gynaecological Oncology, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Visakhapatnam, Andhra Pradesh, India
| | - Jyothi Jayan Warrier
- Department of Medical Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
| | - Sarbani Gosh-Laskar
- Division of Palliative Care, Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Stephanie M Harman
- Section of Palliative Care, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Karleen F Giannitrapani
- VA Palo Alto Healthcare System, Palo Alto, California, USA; Section of Palliative Care, Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Anchal Satija
- Department of Onco-Anaesthesia and Palliative Medicine, Dr B. R. Ambedkar, IRCH, AIIMS, New Delhi, India
| | - C S Pramesh
- Tata and the National Cancer Grid, Mumbai, India
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Drosdowsky A, Gough K, Grewal M, Dabscheck A, Tebbutt N, Philip J, Spruyt O, Michael M, Krishnasamy M. Does Care for Australians With Pancreatic Cancer Compare Favourably to a Consensus-Based Standard of Optimal Care? J Glob Oncol 2018. [DOI: 10.1200/jgo.18.58800] [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
Background: Pancreatic cancer has one of the lowest survival rates of all cancer types, with an incidence to mortality ratio approaching one. People with pancreatic cancer experience a rapid decline in health characterized by pain, nausea, fatigue and weight loss. For most people, the disease is detected at an advanced stage and the focus of treatment is palliative. In Victoria, Australia, knowledge regarding patterns of care for people with pancreatic cancer is out-of-date, but central to quality improvement initiatives targeting unwarranted variations in care and improvement in supports that are consistent with patient preferences. Aim: Our aim was to compare care received by patients with pancreatic cancer with a consensus-based standard representing optimal care to identify deviations from best practice and highlight processes that may improve the quality and safety of care provided. Methods: Eligible patients included those with pancreatic cancer, first treated in 2015, at one of three tertiary hospitals in Victoria, Australia. Once identified, dates and details of events indicated by the optimal care pathway were extracted from the medical record of each patient. Data were summarized using descriptive statistics and process maps: a visualization method that illuminates gaps, duplication, deviations from best practice and processes that may be amenable to improvement. Results: Thirty-two of 165 care pathways have been mapped to date. The nature and timing of care received appears highly variable. Only nine of 32 patients (28%) received all of their cancer care at a single institution; the remainder (n=23, 72%) received care in multiple tertiary and community facilities. Apart from four (13%) emergency presentations, referrals for specialist care came from general/primary practitioners (n=26, 81%). The timeframe for general/primary practitioner investigations ranged from one to 57 days. Once referred to a tertiary setting, most patients (n=23, 72%) were discussed at a multidisciplinary team meeting and received standard therapies. Only four had resectable disease. Nineteen patients (60%) had documented referrals to hospital- or community-based palliative care services. Where observed, deviations from the consensus-based standard tended to be related to the difficult nature of diagnosing pancreatic cancer, and determining appropriate care for patients with an advanced cancer with nonspecific symptoms. Conclusion: Process mapping provided a useful and efficient means of comparing care received with a consensus-based standard; however, the assessment of adherence to optimal timeframes and specific care events was complicated by missing data. Implications for quality improvement activities will be considered in the context of study limitations. We will also emphasize the importance of engaging patients and carers in setting improvement priorities.
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Affiliation(s)
| | - K. Gough
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - M. Grewal
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - A. Dabscheck
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - N. Tebbutt
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - J. Philip
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - O. Spruyt
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - M. Michael
- Peter MacCallum Cancer Centre, Melbourne, Australia
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Hardy J, Skerman H, Glare P, Philip J, Hudson P, Mitchell G, Martin P, Spruyt O, Currow D, Yates P. A randomized open-label study of guideline-driven antiemetic therapy versus single agent antiemetic therapy in patients with advanced cancer and nausea not related to anticancer treatment. BMC Cancer 2018; 18:510. [PMID: 29720113 PMCID: PMC5932901 DOI: 10.1186/s12885-018-4404-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 12/01/2017] [Accepted: 04/18/2018] [Indexed: 11/12/2022] Open
Abstract
Background Nausea/vomiting (N/V) not related to anti-cancer treatment is common in patients with advanced cancer. The standard approach to management is to define a dominant cause, and treat with an antiemetic selected through pathophysiologic knowledge of emetic pathways. High rates of N/V control have been reported using both etiology-based guideline-driven antiemetic regimens and an empiric approach using single agents in uncontrolled studies. These different approaches had never been formally compared. Methods This randomized, prospective, open label, dose-escalating study used readily available antiemetics in accordance with etiology-based guidelines or single agent therapy with haloperidol. Participants had a baseline average nausea score of ≥3/10. Response was defined as a ≥ 2/10 point reduction on a numerical rating scale of average nausea score with a final score < 3/10 at 72 h. Results Nausea scores and distress from nausea improved over time in the majority of the 185 patients randomized. For those who completed each treatment day, a greater response rate was seen in the guideline arm than the single agent arm at 24 h (49% vs 32%; p = 0.02), but not at 48 or 72 h. Response rates at 72 h in the intention to treat analysis were 49 and 53% respectively, with no significant difference between arms (0·04; 95% CI: -0·11, 0·19; p = 0·59). Over 80% of all participants reported an improved global impression of change. There were few adverse events worse than baseline in either arm. Conclusion An etiology-based, guideline-directed approach to antiemetic therapy may offer more rapid benefit, but is no better than single agent treatment with haloperidol at 72 h. Clinical trial registration Australian New Zealand Clinical Trials Registry: ANZCTRN12610000481077.
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Affiliation(s)
- Janet Hardy
- Mater Misericordiae Limited, Mater Research - University of Queensland, Raymond Terrace, Brisbane, QLD, 4101, Australia. .,Department Palliative and Supportive Care, Mater Health Services, Raymond Terrace, South Brisbane, QLD, 4101, Australia.
| | - Helen Skerman
- Institute of Health and Biomedical Innovation (IHBI), Faculty of Health, Queensland University of Technology, Level 7, Q Block, Kelvin Grove Campus, Brisbane, QLD, 4059, Australia
| | - Paul Glare
- Pain Management Research Institute, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia
| | - Jennifer Philip
- St Vincent's Hospital and the University of Melbourne, Fitzroy, VIC, 3065, Australia
| | - Peter Hudson
- St Vincent's Hospital & Collaborative Centre of The University of Melbourne, PO Box 2900, Fitzroy, VIC, 3065, Australia.,University of Melbourne, Melbourne, Australia
| | - Geoffrey Mitchell
- School of Medicine, The University of Queensland, QLD, Brisbane, 4072, Australia
| | - Peter Martin
- Barwon Health McKellar Centre, 45-95 Ballarat Rd, North Geelong, VIC, 3215, Australia
| | - Odette Spruyt
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - David Currow
- Faculty of Health, University of Technology, Sydney, Australia
| | - Patsy Yates
- Queensland University of Technology, VIC Park Rd, Kelvin Grove, QLD, 4059, Australia
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Wong A, Williams M, Milne D, Morris K, Lau P, Spruyt O, Fullerton S, McArthur G. Clinical and palliative care outcomes for patients of poor performance status treated with antiprogrammed death-1 monoclonal antibodies for advanced melanoma. Asia Pac J Clin Oncol 2017; 13:385-390. [DOI: 10.1111/ajco.12702] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 04/08/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Annie Wong
- Department of Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
| | - Molly Williams
- Department of Palliative Care; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Donna Milne
- Department of Cancer Experiences Research; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Kortnye Morris
- Department of Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Peter Lau
- Department of Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
| | - Odette Spruyt
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
- Department of Palliative Care; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Sonia Fullerton
- Department of Palliative Care; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Grant McArthur
- Department of Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
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Affiliation(s)
- Odette Spruyt
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Australia
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Affiliation(s)
- Annie Wong
- Peter MacCallum Cancer Centre, East Melbourne, Australia
| | | | - Odette Spruyt
- Peter MacCallum Cancer Centre, East Melbourne; and University of Melbourne, Parkville, Victoria, Australia
| | - Benjamin Brady
- Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Grant McArthur
- Peter MacCallum Cancer Centre, East Melbourne; and University of Melbourne, Parkville, Victoria, Australia
| | - Shahneen Sandhu
- Peter MacCallum Cancer Centre, East Melbourne; and University of Melbourne, Parkville, Victoria, Australia
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Sanderson C, Quinn SJ, Agar M, Chye R, Clark K, Doogue M, Fazekas B, Lee J, Lovell MR, Rowett D, Spruyt O, Currow DC. Pharmacovigilance in hospice/palliative care: net effect of pregabalin for neuropathic pain. BMJ Support Palliat Care 2016; 6:323-30. [PMID: 26908535 DOI: 10.1136/bmjspcare-2014-000825] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 02/02/2016] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Real-world effectiveness of many medications has been poorly researched, including in hospice/palliative care. Directly extrapolating findings from other clinical settings may not yield robust clinical advice. Pharmacovigilance studies provide an opportunity to understand better the net impact of medications. The study aimed to examine immediate and short-term benefits and harms of pregabalin in routine practice for neuropathic pain in hospice/palliative care. METHODS A consecutive cohort of 155 patients from 62 centres in 5 countries was started on pregabalin and studied prospectively. Data were collected at three time points: baseline; day 7 (immediate, short-term harms); ad hoc reports of any harms ≤21 days; and day 21 (short-term benefits). RESULTS Median dose for 155 patients at day 21 was 150 mg/24 h. Benefits were reported by 61 patients (39%), of whom 11 (7%) experienced complete pain resolution. Harms were reported by 51 (35%) patients at or before 7 days, the most frequent of which were somnolence, fatigue, cognitive disturbance and dizziness. 10 patients (6%) ceased pregabalin due to harms, but 82 patients (53%) were being treated at 21 days. In regression modelling, people with worse baseline pain derived more benefit (OR=8.5 (95% CI 2.5 to 28.68). CONCLUSIONS Pregabalin delivered benefit to many patients, with 4 of 10 experiencing pain reductions by 21 days. Harms, occurring in 1 in 3 patients, may be difficult to detect in clinical practice, as they mostly involve worsening of symptoms prevalent at baseline.
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Affiliation(s)
- Christine Sanderson
- Department of Palliative Medicine, Calvary Health Care Sydney, Sydney, New South Wales, Australia CareSearch, Flinders University, Adelaide, South Australia, Australia
| | - Stephen J Quinn
- Flinders Clinical Effectiveness, Flinders University, Adelaide, South Australia, Australia
| | - Meera Agar
- CareSearch, Flinders University, Adelaide, South Australia, Australia Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Palliative Care Services, Darlinghurst, New South Wales, Australia
| | - Katherine Clark
- Department of Palliative Care, Calvary Mater Hospital, Newcastle, New South Wales, Australia
| | - Matthew Doogue
- Clinical Pharmacologist & Endocrinologist University of Otago Christchurch & Canterbury District Health Board, Christchurch, New Zealand
| | - Belinda Fazekas
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Jessica Lee
- Department of Palliative Medicine, Concord Hospital, Sydney, New South Wales, Australia
| | - Melanie R Lovell
- Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Debra Rowett
- Drug and Therapeutic Information Services, Repatriation General Hospital, Daw Park, Adelaide, South Australia, Australia
| | - Odette Spruyt
- Pain and Palliative Care, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - David C Currow
- CareSearch, Flinders University, Adelaide, South Australia, Australia Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
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Mendis R, Soo WK, Zannino D, Michael N, Spruyt O. Multidisciplinary Prognostication Using the Palliative Prognostic Score in an Australian Cancer Center. Palliat Care 2015; 9:7-14. [PMID: 26309410 PMCID: PMC4524542 DOI: 10.4137/pcrt.s24411] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 02/04/2015] [Revised: 05/24/2015] [Accepted: 06/23/2015] [Indexed: 11/05/2022] Open
Abstract
CONTEXT Accurate prognostication is important in oncology and palliative care. A multidisciplinary approach to prognostication provides a novel approach, but its accuracy and application is poorly researched. In this study, we describe and analyze our experience of multidisciplinary prognostication in palliative care patients with cancer. OBJECTIVES To assess our accuracy of prognostication using multidisciplinary team prediction of survival (MTPS) alone and within the Palliative Prognostic (PaP) Score. METHODS This retrospective study included all new patients referred to a palliative care consultation service in a tertiary cancer center between January 2010 and December 2011. Initial assessment data for 421 inpatients and 223 outpatients were analyzed according to inpatient and outpatient groups to evaluate the accuracy of prognostication using MTPS alone and within the PaP score (MTPS-PaP) and their correlation with overall survival. RESULTS Inpatients with MTPS-PaP group A, B, and C had a median survival of 10.9, 3.4, and 0.7 weeks, respectively, and a 30-day survival probability of 81%, 40%, and 10%, respectively. Outpatients with MTPS-PaP group A and B had a median survival of 17.3 and 5.1 weeks, respectively, and a 30-day survival probability of 94% and 50%, respectively. MTPS overestimated survival by a factor of 1.5 for inpatients and 1.2 for outpatients. The MTPS-PaP score correlated better than MTPS alone with overall survival. CONCLUSION This study suggests that a multidisciplinary team approach to prognostication within routine clinical practice is possible and may substitute for single clinician prediction of survival within the PaP score without detracting from its accuracy. Multidisciplinary team prognostication can assist treating teams to recognize and articulate prognosis, facilitate treatment decisions, and plan end-of-life care appropriately. PaP was less useful in the outpatient setting, given the longer survival interval of the outpatient palliative care patient group.
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Affiliation(s)
- Ruwani Mendis
- Department of Pain & Palliative Care, Peter MacCallum Cancer Centre, VIC, Australia ; Austin Health, Department of Palliative Care, Studley Road, Heidelberg, VIC, Australia
| | - Wee-Kheng Soo
- Department of Pain & Palliative Care, Peter MacCallum Cancer Centre, VIC, Australia ; Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Diana Zannino
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, VIC, Australia
| | - Natasha Michael
- Department of Palliative Care, Cabrini Health, Prahran, VIC, Australia
| | - Odette Spruyt
- Department of Pain & Palliative Care, Peter MacCallum Cancer Centre, VIC, Australia
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McDonald JC, Spruyt O, Alhatem A. Control of intractable pruritus in a patient with cutaneous T-cell lymphoma using a continuous subcutaneous infusion of lidocaine. J Pain Symptom Manage 2015; 49:e1-3. [PMID: 25623922 DOI: 10.1016/j.jpainsymman.2014.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/09/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Julie Clare McDonald
- Department of Psychosocial Oncology and Palliative Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
| | - Odette Spruyt
- Pain and Palliative Care, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Albert Alhatem
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Hardy JR, Spruyt O, Quinn SJ, Devilee LR, Currow DC. Implementing practice change in chronic cancer pain management: clinician response to a phase III study of ketamine. Intern Med J 2015; 44:586-91. [PMID: 24720500 DOI: 10.1111/imj.12442] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 01/29/2014] [Accepted: 04/01/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND An adequately powered, double-blind, multisite, randomised controlled trial has shown no net clinical benefit for subcutaneous ketamine over placebo in the management of cancer pain refractory to combination opioid and co-analgesic therapy. The results of the trial were disseminated widely both nationally and internationally. AIM To determine whether the trial had impacted on clinical practice in Australasia. METHODS Members of the Australia and New Zealand Society of Palliative Medicine were sent an online ketamine utilisation survey. RESULTS A total of 123/392 clinicians responded (31% response rate). The majority of respondents had practised for more than 10 years in a metropolitan hospital setting. Ketamine had been prescribed by 91% of respondents, and 92% were aware of the trial. As a result, 65% of respondents had changed practice (17% no longer prescribed ketamine, 46% used less and 2% more). Thirty-five per cent had not changed practice. Reasons for change included belief in the results of the study, concerns over the toxicity reported or because there were alternatives for pain control. Of those who prescribed less, over 80% were more selective and would now only use the drug in certain clinical situations or pain types, or when all other medications had failed. CONCLUSIONS Although two-thirds of respondents reported practice change as a result of the randomised controlled trial, a minority remained convinced of the benefit of the drug from their own observations and would require additional evidence.
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Affiliation(s)
- J R Hardy
- Mater Health Services, Mater Research/University of Queensland, Brisbane, Queensland, Australia
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Sanderson C, Quinn SJ, Agar M, Chye R, Clark K, Doogue M, Fazekas B, Lee J, Lovell MR, Rowett D, Spruyt O, Currow DC. Pharmacovigilance in hospice/palliative care: net effect of gabapentin for neuropathic pain. BMJ Support Palliat Care 2014; 5:273-80. [PMID: 25324335 PMCID: PMC4552911 DOI: 10.1136/bmjspcare-2014-000699] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [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: 04/10/2014] [Accepted: 09/09/2014] [Indexed: 01/21/2023]
Abstract
Objective Hospice/palliative care patients may differ from better studied populations, and data from other populations cannot necessarily be extrapolated into hospice/palliative care clinical practice. Pharmacovigilance studies provide opportunities to understand the harms and benefits of medications in routine practice. Gabapentin, a γ-amino butyric acid analogue antiepileptic drug, is commonly prescribed for neuropathic pain in hospice/palliative care. Most of the evidence however relates to non-malignant, chronic pain syndromes (diabetic neuropathy, postherpetic neuralgia, central pain syndromes, fibromyalgia). The aim of this study was to quantify the immediate and short-term clinical benefits and harms of gabapentin in routine hospice/palliative care practice. Design Multisite, prospective, consecutive cohort. Population 127 patients, 114 of whom had cancer, who started gabapentin for neuropathic pain as part of routine clinical care. Settings 42 centres from seven countries. Data were collected at three time points—at baseline, at day 7 (and at any time; immediate and short-term harms) and at day 21 (clinical benefits). Results At day 21, the average dose of gabapentin for those still using it (n=68) was 653 mg/24 h (range 0–1800 mg) and 54 (42%) reported benefits, of whom 7 (6%) experienced complete pain resolution. Harms were reported in 39/127 (30%) patients at day 7, the most frequent of which were cognitive disturbance, somnolence, nausea and dizziness. Ten patients had their medication ceased due to harms. The presence of significant comorbidities, higher dose and increasing age increased the likelihood of harm. Conclusions Overall, 42% of people experienced benefit at a level that resulted in continued use at 21 days.
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Affiliation(s)
- Christine Sanderson
- Department of Palliative Medicine, Calvary Health Care, Sydney, New South Wales, Australia Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Stephen J Quinn
- Flinders Clinical Effectiveness, Flinders University, Adelaide, South Australia, Australia
| | - Meera Agar
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Palliative Care Services, Darlinghurst, New South Wales, Australia
| | - Katherine Clark
- Department of Palliative Care, Calvary Mater Hospital, Newcastle, New South Wales, Australia
| | - Matthew Doogue
- Christchurch & Canterbury District Health Board, University of Otago, Christchurch, New Zealand
| | - Belinda Fazekas
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Jessica Lee
- Department of Palliative Medicine, Concord Hospital, Sydney, New South Wales, Australia
| | - Melanie R Lovell
- Department of Palliative Care, Braeside Hospital, HammondCare, Sydney, New South Wales, Australia
| | - Debra Rowett
- Drug and Therapeutics Information Service, Repatriation General Hospital, Adelaide, Australia
| | - Odette Spruyt
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia Flinders Clinical Effectiveness, Flinders University, Adelaide, South Australia, Australia
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Spruyt O, Le BH, Philip J. Integrating new evidence about an old drug: authors' reply to Franco et al. and Bell et al. J Pain Symptom Manage 2014; 47:e4-5. [PMID: 24679556 DOI: 10.1016/j.jpainsymman.2014.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 01/06/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Odette Spruyt
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
| | - Brian H Le
- Department of Palliative and Supportive Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | - Jennifer Philip
- Centre for Palliative Care, St. Vincent's Hospital, Fitzroy, Victoria, Australia
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Le BHC, Mileshkin L, Doan K, Saward D, Spruyt O, Yoong J, Gunawardana D, Conron M, Philip J. Acceptability of early integration of palliative care in patients with incurable lung cancer. J Palliat Med 2014; 17:553-8. [PMID: 24588685 DOI: 10.1089/jpm.2013.0473] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Lung cancer remains the leading cause of cancer death, and it is known many affected will have significant palliative care needs. Evidence suggests that early involvement of palliative care can translate into improvements in quality of care, quality of life, and survival. However, routine early integration is yet to be embraced as standard of care for the majority of patients, and it is unclear what lung cancer clinicians continue to perceive as the barriers to this model of care. METHODS We performed a qualitative exploration of lung cancer clinicians' perceptions, focusing on current experiences of engaging with palliative care, perceptions of palliative care for patients with lung cancer, and views of barriers and benefits of referring to palliative care. RESULTS Focus group and targeted interviews were conducted with 28 clinicians, with four key emergent themes: 1) Competence/skill--with referrers needing to be confident in the quality and capability of palliative care provision; 2) Care Coordination--the need to ensure integrated care, with defined lines of responsibility and clear team communication; 3) Ease of referral--the need for ready access to a palliative care provider in the lung cancer clinic; and 4) Perceptions--concerns about loss of hope and fears of negative patient reaction. CONCLUSIONS Early and routine involvement of palliative care in patients with incurable lung cancer is acceptable to the majority of treating clinicians. To facilitate early integration of palliative care, palliative care providers need to become front-line team members who provide a high-quality service. Lung cancer clinicians need further education as to the role and benefits of early palliative care, and how best to introduce this.
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Affiliation(s)
- Brian H C Le
- 1 Department of Palliative Care, The Royal Melbourne Hospital , Parkville, Victoria, Australia
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Spruyt O, Le B, Philip J. Integrating new evidence about an old drug: growing pains as palliative medicine matures. J Pain Symptom Manage 2013; 46:e3-5. [PMID: 24176613 DOI: 10.1016/j.jpainsymman.2013.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 08/22/2013] [Indexed: 11/21/2022]
Affiliation(s)
- Odette Spruyt
- Pain and Palliative Care, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
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Sanderson C, Hardy J, Spruyt O, Currow DC. Placebo and nocebo effects in randomized controlled trials: the implications for research and practice. J Pain Symptom Manage 2013; 46:722-30. [PMID: 23523360 DOI: 10.1016/j.jpainsymman.2012.12.005] [Citation(s) in RCA: 25] [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: 07/17/2012] [Revised: 12/04/2012] [Accepted: 12/18/2012] [Indexed: 11/17/2022]
Abstract
Placebo and nocebo effects are known to contribute significantly to the response to symptom control, including analgesia. Clinical trial methodologies using placebo controls are designed to identify the magnitude of these effects in the research context. An adequately powered, randomized, double-blind, placebo-controlled trial of ketamine in cancer pain has recently been reported, which demonstrated no net clinical benefit for ketamine over and above that of placebo. Rates of placebo and nocebo responses were high. The setting of a clinical trial provides an opportunity to quantify the nonpharmacologic aspects of patient responses to analgesia, raising important clinical and ethical issues for practice. The findings of the ketamine study are analyzed in the context of a methodological discussion of placebo and nocebo effects, what is known about the biological and psychological bases for each of these, and their implications for a clinical trial design in the palliative care setting. Along with reviewing the use of ketamine after this negative trial, clinicians need to remain aware of the strength and significance of both placebo and nocebo responses in their own practices and the biopsychosocial complexity of why and how patients actually respond to pain management strategies. The results of this study strongly reinforce the importance of the therapeutic relationship and the context of care.
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Affiliation(s)
- Christine Sanderson
- Calvary Health Care Sydney, Kogarah, New South Wales, Australia; CareSearch, Flinders University, Bedford Park, South Australia, Australia.
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Spruyt O, Westerman D, Milner A, Bressel M, Wein S. A randomised, double-blind, placebo-controlled study to assess the safety and efficacy of methoxyflurane for procedural pain of a bone marrow biopsy. BMJ Support Palliat Care 2013; 4:342-8. [PMID: 24644183 DOI: 10.1136/bmjspcare-2013-000447] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
CONTEXT Pain during bone marrow biopsy (BMB) under local anaesthesia (LA) is reported in 70% of patients, of whom 35% rate the pain as severe. Pain is experienced during both the biopsy and the marrow aspiration. Many medical centres use conscious sedation involving benzodiazepines and/or opioids administered orally or intravenously for BMB analgesia. Methoxyflurane (MEOF) is self-administered by a handheld device (the Penthrox inhaler), which is licensed in Australia for the relief of pain associated with short surgical procedures. OBJECTIVES To evaluate the efficacy and safety of MEOF analgesia in patients with cancer undergoing BMB. METHODS Patients received LA plus either MEOF or placebo. The primary endpoint was worst pain intensity measured with the Numerical Rating Scale. Anxiety was assessed with the State Trait Anxiety Inventory (STAI-Y-1). Patients, operators and the research nurse rated global medication performance using a 5-point Likert scale. RESULTS Forty-nine of the 50 patients randomised to MEOF and 48 of the 50 patients randomised to placebo effectively received the allocated intervention. Mean±SD worst pain overall was 4.90±2.07 in MEOF group and 6.0±2.24 in placebo group (p=0.011). Worst pain during the aspiration was 3.3±2.0 in MEOF group and 5.0±2.4 in placebo group (p<0.001). 49% of patients treated with MEOF rated the medication as very good or excellent compared with 16.5% of the patients treated with placebo (p=0.005). 20.4% of patients treated with MEOF had an adverse event (AE) compared with 4.2% in the placebo arm (p=0.028). All AEs were grade 1. CONCLUSIONS MEOF was safe and performed better than placebo for analgesia in BMB procedures.
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Affiliation(s)
- Odette Spruyt
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David Westerman
- Department of Haematology, Peter MacCallum Cancer Centre/University of Melbourne, Melbourne, Victoria, Australia
| | - Alvin Milner
- Centre for Biostatistics & Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Mathias Bressel
- Centre for Biostatistics & Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Simon Wein
- Palliative Medicine, Davidoff Cancer Centre, Rabin Medical Centre, Petah-Tikva, Israel
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Michael N, Stepanov N, Spruyt O, Pollard A, Clayton J, O'Callaghan C. UNDERSTANDING HOW CANCER PATIENTS ACTUALISE, RELINQUISH, AND REJECT ADVANCE CARE PLANNING: IMPLICATIONS FOR PRACTICE. BMJ Support Palliat Care 2013. [DOI: 10.1136/bmjspcare-2013-000491.15] [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: 11/04/2022]
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Corbett CL, Johnstone M, Trauer JM, Spruyt O. Palliative Care and Hematological Malignancies: Increased Referrals at a Comprehensive Cancer Centre. J Palliat Med 2013; 16:537-41. [DOI: 10.1089/jpm.2012.0377] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [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)
| | - Martina Johnstone
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
| | | | - Odette Spruyt
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
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Affiliation(s)
- Janet Hardy
- Mater Health Services, Mater Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Steve Quinn
- Flinders University, Adelaide, South Australia, Australia
| | | | - Simon Eckermann
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Meera R. Agar
- Braeside (Hammond Care) and South West Sydney Local Health District, New South Wales, Australia
| | - Odette Spruyt
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Debra Rowett
- Flinders University, Adelaide, South Australia, Australia
| | - David Currow
- Flinders University, Adelaide, South Australia, Australia
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Hardy J, Quinn S, Fazekas B, Plummer J, Eckermann S, Agar M, Spruyt O, Rowett D, Currow DC. Randomized, double-blind, placebo-controlled study to assess the efficacy and toxicity of subcutaneous ketamine in the management of cancer pain. J Clin Oncol 2012; 30:3611-7. [PMID: 22965960 DOI: 10.1200/jco.2012.42.1081] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [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
PURPOSE The anesthetic ketamine is widely used for pain related to cancer, but the evidence to support its use in this setting is weak. This study aimed to determine whether ketamine is more effective than placebo when used in conjunction with opioids and standard adjuvant therapy in the management of chronic uncontrolled cancer pain. Ketamine would be considered of net benefit if it provided clinically relevant improvement in pain with limited breakthrough analgesia and acceptable toxicity. PATIENTS AND METHODS In this multisite, dose-escalation, double-blind, randomized, placebo-controlled phase III trial, ketamine or placebo was delivered subcutaneously over 3 to 5 days. RESULTS In all, 185 participants were included in the primary analysis. There was no significant difference between the proportion of positive outcomes (0.04; 95% CI, -0.10 to 0.18; P = .55) in the placebo and intervention arms (response rates, 27% [25 of 92] and 31% [29 of 93]). Pain type (nociceptive v neuropathic) was not a predictor of response. There was almost twice the incidence of adverse events worse than baseline in the ketamine group after day 1 (incidence rate ratio, 1.95; 95% CI, 1.46 to 2.61; P < .001) and throughout the study. Those receiving ketamine were more likely to experience a more severe grade of adverse event per day (odds ratio, 1.09; 95% CI, 1.00 to 1.18; P = .039). The number of patients needed to treat for one additional patient to have a positive outcome from ketamine was 25 (95% CI, six to ∞). The number needed to harm, because of toxicity-related withdrawal, was six (95% CI, four to 13). CONCLUSION Ketamine does not have net clinical benefit when used as an adjunct to opioids and standard coanalgesics in cancer pain.
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Affiliation(s)
- Janet Hardy
- Dept Palliative Care, Mater Adult Hospital, Raymond Terrace, South Brisbane, Queensland, Australia 4101.
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Currow DC, Hardy J, Quinn S, Fazekas B, Plummer J, Eckermann S, Agar M, Spruyt O, Debra R. A randomized, double-blind, placebo-controlled study to assess the efficacy and toxicity of subcutaneous ketamine in the management of cancer pain. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.2604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
2604 Background: The dissociative anaesthetic ketamine is widely used for cancer related pain. A Cochrane review concluded that insufficient evidence was available to support its use in this setting. Methods: This phase III, multisite, double-blind, dose escalation, placebo, randomised controlled study aimed to determine whether ketamine, delivered subcutaneously over three to five days is more effective than placebo, when used in conjunction with adjuvant therapy in the management of chronic uncontrolled cancer pain. Ketamine would be considered to be of net benefit if it provided a reduction in average pain scores by ≥2/10 points from baseline, with limited breakthrough analgesia and acceptable toxicity. Results: For the 185 participants, there was no significant difference between the proportion of positive outcomes (0.04 (-0.10, 0.18) p=0.55) in the placebo and intervention arms (response rates 27% (25/92) and 31% (29/93)). Pain type (nociceptive versus neuropathic) was not a predictor of response. There was almost twice the incidence of adverse events worse than baseline in the ketamine group after day 1 (IRR = 1.95 (1.46, 2.61), p<0.001) and throughout the study. Those receiving ketamine were more likely to experience a more severe grade of adverse event/day (OR=1.09 (1.00, 1.18), p=0.039). The number needed to treat for one additional patient to get a positive outcome from ketamine was 25 (6, ∞). The number needed to harm, because of toxicity-related withdrawal was 6 (4, 13). Conclusions: Ketamine does not have net clinical benefit when used as an adjunct to opioids and standard co-analgesics in cancer pain.
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Affiliation(s)
- David C. Currow
- Discipline and Palliative and Support Services, Flinders University, Adelaide, South Australia, Australia
| | - Odette Spruyt
- Pain and Palliative Care, Peter MacCallum Cancer Center, East Melbourne, Victoria, Australia
| | - Janet Hardy
- Palliative and Support Care, Mater Health Services, South Brisbane, Queensland, Australia
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Abstract
“If you want to travel quickly, go alone. But if you want to travel far, you must go together”. African proverb. The delivery of palliative care is often complex and always involves a group of people, the team, gathered around the patient and those who are close to them. Effective communication and functional responsive systems of care are essential if palliative care is to be delivered in a timely and competent way. Creating and fostering an effective team is one of the greatest challenges for providers of palliative care. Teams are organic and can be life giving or life sapping for their members.
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Affiliation(s)
- Odette Spruyt
- Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
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Currow P, Hardy J, Agar M, Sanderson C, Spruyt O, Eckermann S, Plummer J, Quinn S. 1225 POSTER A Randomised, Double-blind, Placebo Controlled, Multi-site Study of Subcutaneous Ketamine in the Management of Cancer Pain. Eur J Cancer 2011. [DOI: 10.1016/s0959-8049(11)70837-1] [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: 10/17/2022]
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Spruyt O, Westerman D, Lipshutt S, Wein S. 3058 POSTER Incident Pain in Patients Undergoing a Bone Marrow Biopsy Procedure: a Randomized, Double-blind, Single Centre, Placebo-controlled Study to Assess the Safety and Efficacy of Methoxyflurane. Eur J Cancer 2011. [DOI: 10.1016/s0959-8049(11)71131-5] [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: 12/01/2022]
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Spruyt O, Brennan F. Australasian Palliative Link International (APLI) Fosters Links in Palliative Care throughout the Asia-Pacific Region. J Palliat Med 2011; 14:988-9. [DOI: 10.1089/jpm.2011.9653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Odette Spruyt
- Pain and Palliative Care, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
| | - Frank Brennan
- Calvary Hospital, Kogarah, New South Wales, Australia
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Saward D, Spruyt O, Cook E, Pigott C. Communication towards the end-of-life: a novel way to enhance education. BMJ Support Palliat Care 2011. [DOI: 10.1136/bmjspcare-2011-000053.134] [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: 11/04/2022]
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Fainsinger RL, Nekolaichuk C, Lawlor P, Hagen N, Bercovitch M, Fisch M, Galloway L, Kaye G, Landman W, Spruyt O, Zhukovsky D, Bruera E, Hanson J. An international multicentre validation study of a pain classification system for cancer patients. Eur J Cancer 2010; 46:2896-904. [PMID: 20483589 DOI: 10.1016/j.ejca.2010.04.017] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 04/19/2010] [Indexed: 11/19/2022]
Abstract
PURPOSE The study's primary objective was to assess predictive validity of the Edmonton Classification System for Cancer Pain (ECS-CP) in a diverse international sample of advanced cancer patients. We hypothesised that patients with problematic pain syndromes would require more time to achieve stable pain control, more complicated analgesic regimens and higher opioid doses than patients with less complex pain syndromes. METHODS Patients with advanced cancer (n=1100) were recruited from 11 palliative care sites in Canada, USA, Ireland, Israel, Australia and New Zealand (100 per site). Palliative care specialists completed the ECS-CP for each patient. Daily patient pain ratings, number of breakthrough pain doses, types of pain adjuvants and opioid consumption were recorded until study end-point (i.e. stable pain control, discharge and death). RESULTS A pain syndrome was present in 944/1100 (86%). In univariate analysis, younger age, neuropathic pain, incident pain, psychological distress, addictive behaviour and initial pain intensity were significantly associated with more days to achieve stable pain control. In multivariate analysis, younger age, neuropathic pain, incident pain, psychological distress and pain intensity were independently associated with days to achieve stable pain control. Patients with neuropathic pain, incident pain, psychological distress or higher pain intensity required more adjuvants and higher final opioid doses; those with addictive behaviour required only higher final opioid doses. Cognitive deficit was associated with fewer days to stable pain control, lower final opioid doses and fewer pain adjuvants. CONCLUSION The replication of previous findings suggests that the ECS-CP can predict pain complexity in a range of practice settings and countries.
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Philip J, Gold M, Milner A, Di Iulio J, Miller B, Spruyt O. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J Pain Symptom Manage 2006; 32:541-50. [PMID: 17157756 DOI: 10.1016/j.jpainsymman.2006.06.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Revised: 06/19/2006] [Accepted: 06/24/2006] [Indexed: 10/23/2022]
Abstract
Dyspnea is a common symptom in palliative care. Despite this, there is uncertainty regarding the role of oxygen to treat the symptom in patients with advanced illness. This randomized, double-blind, crossover trial examined the effect of oxygen versus air on the relief of dyspnea in patients with advanced cancer. Following the blinded administration of air and oxygen via nasal prongs, 51 patients rated dyspnea and indicated preferences for the blinded treatments. On average, patients improved symptomatically with both air and oxygen, and there were no significant differences between the treatments. The subgroup of 17 hypoxic patients overall did not demonstrate a significant difference between air and oxygen, despite having improved oxygen saturations when administered oxygen. Hypoxia was corrected in 13 of 17 patients using the treatment dose of 4 L/min of oxygen. The experience of dyspnea is a complex, multifactorial phenomenon, with oxygen tension not correlating with the subjective experience. The administration of either air or oxygen via nasal prongs on average confers improvement of the symptom.
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Affiliation(s)
- Jennifer Philip
- Palliative Care Service, The Alfred Hospital, Melbourne, Australia.
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Bruera E, Sala R, Spruyt O, Palmer JL, Zhang T, Willey J. Nebulized versus subcutaneous morphine for patients with cancer dyspnea: a preliminary study. J Pain Symptom Manage 2005; 29:613-8. [PMID: 15963870 DOI: 10.1016/j.jpainsymman.2004.08.016] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2004] [Indexed: 11/29/2022]
Abstract
This study compared the effects of nebulized versus subcutaneous morphine on the intensity of dyspnea in cancer patients. Patients with a resting dyspnea intensity > or =3 on a 0-10 scale (0=no dyspnea, 10=worst possible dyspnea) who received regular oral or parenteral opioids were included. On day 1, patients received either subcutaneous (SC) morphine plus nebulized placebo or nebulized morphine plus SC placebo. On day 2, a crossover was made. Dyspnea intensity, side effects, and blinded preference of treatment were assessed. Eleven patients completed the study. Dyspnea decreased from a median of 5 (range, 3-8) to 3 (range, 0-7) after SC morphine (P=0.025) and from 4 (range, 3-9) to 2 (range, 0-9) after nebulized morphine (P=0.007). There was no significant difference in dyspnea intensity between nebulized and subcutaneous morphine at 60 minutes. Unfortunately, due to limited sample size, there was insufficient power to rule out a significant difference between both routes of administration. Nebulized morphine offered dyspnea relief similar to that of SC morphine. Larger randomized controlled trials in patients with both continuous dyspnea and earlier stages of dyspnea are justified.
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Affiliation(s)
- Eduardo Bruera
- The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Bruera E, Palmer JL, Bosnjak S, Rico MA, Moyano J, Sweeney C, Strasser F, Willey J, Bertolino M, Mathias C, Spruyt O, Fisch MJ. Methadone Versus Morphine As a First-Line Strong Opioid for Cancer Pain: A Randomized, Double-Blind Study. J Clin Oncol 2004; 22:185-92. [PMID: 14701781 DOI: 10.1200/jco.2004.03.172] [Citation(s) in RCA: 133] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To compare the effectiveness and side effects of methadone and morphine as first-line treatment with opioids for cancer pain. Patients and Methods Patients in international palliative care clinics with pain requiring initiation of strong opioids were randomly assigned to receive methadone (7.5 mg orally every 12 hours and 5 mg every 4 hours as needed) or morphine (15 mg sustained release every 12 hours and 5 mg every 4 hours as needed). The study duration was 4 weeks. Results A total of 103 patients were randomly assigned to treatment (49 in the methadone group and 54 in the morphine group). The groups had similar baseline scores for pain, sedation, nausea, confusion, and constipation. Patients receiving methadone had more opioid-related drop-outs (11 of 49; 22%) than those receiving morphine (three of 54; 6%; P = .019). The opioid escalation index at days 14 and 28 was similar between the two groups. More than three fourths of patients in each group reported a 20% or more reduction in pain intensity by day 8. The proportion of patients with a 20% or more improvement in pain at 4 weeks in the methadone group was 0.49 (95% CI, 0.34 to 0.64) and was similar in the morphine group (0.56; 95% CI, 0.41 to 0.70). The rates of patient-reported global benefit were nearly identical to the pain response rates and did not differ between the treatment groups. Conclusion Methadone did not produce superior analgesic efficiency or overall tolerability at 4 weeks compared with morphine as a first-line strong opioid for the treatment of cancer pain.
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Affiliation(s)
- Eduardo Bruera
- Department of Palliative Care & Rehabilitation Medicine (Unit 0008), the University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030-0049, USA.
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Affiliation(s)
- Odette Spruyt
- Oncologist Peter MacCallum Cancer InstituteMelbourneVIC
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Affiliation(s)
- D W Kissane
- Department of Medicine (St Vincent's), University of Melbourne, Vic
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Abstract
The aim of this paper is to describe the palliative care experience of Bangladeshi patients and carers in the Tower Hamlets area in the east of London. Semi-structured interviews were carried out in Sylheti, the Bengali dialect of this community, with bereaved primary carers of 18 patients (10 male, eight female) referred to an east London community palliative care team between 1986 and 1993. It was found that patients were young, with a mean age of males of 55 years (range 34-65) and females of 40 years (range 28-57). Communication difficulties were common. The fluency in English of patients was low, with reliance on family members, especially children, for translation. The diagnosis was known by all patients, but only 56% of carers agreed with disclosure. Team dissatisfaction with communication was recorded in 16 cases. Fourteen patients died in London; however, 13 were buried in Bangladesh. Carers often reported symptoms as poorly controlled. Pain was said to be severe for 14 patients, and pain control said to be poor in 11. Family and friends provided most support during the illness and bereavement. Serious financial difficulties occurred in nine families. General practitioners were involved actively in six cases. In conclusion, there are ethno-specific needs in this particular community, many of which arise from socio-economic factors, recent migration and religious beliefs, and which are highlighted by terminal illness.
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Affiliation(s)
- O Spruyt
- Peter MacCallum Cancer Institute, Victoria, Australia.
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Abstract
This study examines how frequently and for what indications sedatives are prescribed in a hospital support team and in a hospice. We also looked at the survival of sedated patients from the date of admission and from the start of sedation. Overall 26% of patients were prescribed sedatives in order to sedate them (31% at the hospice and 21% at the hospital) and 43% of patients were given sedatives for symptom control (67% at the hospice and 21% at the hospital). Sedated patients survived for a mean of 1.3 days after the start of sedation, and there was no detectable difference in survival from the date of admission between sedated and nonsedated patients.
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