A digital health intervention to support patients with chronic pain during prescription opioid tapering: a pilot randomised controlled trial

Introduction

Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support.

Objectives

We evaluated the feasibility, acceptability, and potential efficacy of a codesigned digital health intervention to support patients with chronic pain during voluntary prescription opioid tapering.

Methods

In a pilot randomised controlled trial, participants received a psychoeducational video and 28 days of text messages (2 SMS/day) in addition to their usual care (intervention) or usual care alone (control). The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy.

Results

Of 28 randomised participants, 26 completed the study (13 per group). Text message delivery was high (99.2%), but fidelity of video delivery was low (57.1%). Most participants rated the messages as useful, supportive, encouraging, and engaging; 78.5% would recommend the intervention to others; and 64.2% desired a longer intervention period. Tapering self-efficacy (Cohen d = 0.74) and pain self-efficacy (d = 0.41) were higher, and pain intensity (d = 0.65) and affective interference (d = 0.45) were lower in the intervention group at week 4.

Conclusion

First evidence supports the feasibility, acceptability, and potentially efficacy of a psychoeducational video and SMS text messaging intervention to support patients with chronic pain during voluntary prescription opioid tapering. Definitive trials with longer intervention duration are warranted.

Management of pain in cancer patients- lessons from practices during the COVID-19: a qualitative study of cancer care providers' perspectives

BACKGROUND

The ongoing COVID-19 pandemic has impacted health systems globally and affected managing many chronic conditions, including cancer. This study aimed to explore the perceptions of multi-disciplinary cancer care providers on how cancer pain management was affected by the COVID-19 pandemic.

METHODS

Participants were eligible if they were cancer care providers of any specialty and discipline from two tertiary hospitals in Australia. Data were collected using semi-structured interviews to explore cancer care providers' perspectives on cancer pain management within COVID-19. Thematic analysis of interview transcripts used an integrated approach that started with inductive coding before coding deductively against a behaviour framework called the COM-B Model, which proposes that 'capability', 'motivation' and 'opportunity' are requisites for any behaviour.

RESULTS

Twenty-three providers participated. Five themes were developed and interpreted from the analysis of data, namely: "Telehealth enables remote access to cancer pain management but also created a digital divide", "Access to cancer pain management in the community is compromised due to the pandemic", "COVID-19 negatively impacts hospital resource allocation", "Patients were required to trade off cancer pain management against other health priorities" and "Hospital restrictions result in decreased social and psychological support for patients with cancer pain".

CONCLUSIONS

The landscape of cancer pain management in the Australian health system underwent substantial shifts during the COVID-19 pandemic, with lasting impacts. Cancer care providers perceived the pandemic to have significant adverse effects on pain management across multiple levels, with repercussions for patients experiencing cancer-related pain. A more adaptive health system model needs to be established in the future to accommodate vulnerable cancer patients.

Text messaging intervention to support patients with chronic pain during prescription opioid tapering: protocol for a double-blind randomised controlled trial

INTRODUCTION

Increases in pain and interference with quality of life is a common concern among people with chronic non-cancer pain (CNCP) who are tapering opioid medications. Research indicates that access to social and psychological support for pain self-management may help people to reduce their opioid dose without increasing pain and interference. This study evaluates the efficacy of a text messaging intervention designed to provide people with CNCP with social and psychological support for pain self-management while tapering long-term opioid therapy (LTOT) under the guidance of their prescriber.

METHODS AND ANALYSIS

A double-blind randomised controlled trial will be conducted. Patients with CNCP (n=74) who are tapering LTOT will be enrolled from across Australia. Participants will continue with their usual care while tapering LTOT under the supervision of their prescribing physician. They will randomly receive either a psychoeducational video and supportive text messaging (two Short Message Service (SMS) per day) for 12 weeks or the video only. The primary outcome is the pain intensity and interference assessed by the Pain, Enjoyment of Life and General Activity scale. Secondary outcomes include mood, self-efficacy, pain cognitions, opioid dose reduction, withdrawal symptoms, and acceptability, feasibility, and safety of the intervention. Participants will complete questionnaires at baseline and then every 4 weeks for 12 weeks and will be interviewed at week 12. This trial will provide evidence for the efficacy of a text messaging intervention to support patients with CNCP who are tapering LTOT. If proven to be efficacious and safe, this low-cost intervention can be implemented at scale.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings.

TRIAL REGISTRATION NUMBER

ACTRN12622001423707.

A digital health intervention to support patients with chronic pain during prescription opioid tapering: a pilot randomised controlled trial

Introduction

Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support.

Objectives

We evaluated the feasibility, acceptability, and potential efficacy of a co-designed psycho-educational video and SMS text messaging intervention to support patients with chronic pain during prescription opioid tapering.

Methods

A pilot randomised controlled trial was conducted. In addition to their usual care, participants in the intervention group received a psycho-educational video and 28 days of text messages (two SMS/day). The control group received usual care. The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy.

Results

Of 28 randomised participants, 26 completed the study (13 in each group). Text message delivery was 99.2% successful. Most participants rated the messages as useful, supportive, encouraging, and engaging, 78.5% would recommend the intervention to others, and 64% desired a longer intervention period. Tapering self-efficacy (Cohen's d = 0.74) and pain self-efficacy (d = 0.41) were higher and pain intensity (d = 0.65) and affective interference (d = 0.45) lower in the intervention group at week 4.

Conclusions

It is feasible, acceptable, and potentially efficacious to support patients with chronic pain during prescription opioid tapering with a psycho-educational video and SMS text messaging intervention. A definitive trial has been initiated to test a 12-week intervention.

Prevalence and management of chronic nonmalignant pain in palliative care populations: A systematic review

OBJECTIVES

To investigate the prevalence and current approaches to clinical management of chronic nonmalignant pain in patients referred to palliative care services.

METHODS

A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered with PROSPERO (CRD42021205432). Six databases were searched on 25 August 2020 and again on 11 July 2022: PubMed and Ovid MEDLINE, Elsevier Scopus, PsychINFO, the Cochrane Library, and CINAHL. Search included prevalence or intervention studies with patients who had chronic nonmalignant pain and were referred to palliative care services. Screening was undertaken independently by 2 reviewers.

RESULTS

The searches returned 417 titles; subsequent screening identified 5 eligible studies, 4 from the USA and 1 from Hong Kong, including 2 cohort and 3 cross-sectional studies. Sample sizes ranged from 137 to 323, with a total of 1,056 patients. The prevalence of chronic nonmalignant pain ranged from 14% to 34% across different palliative care settings. There was significant crossover of pain types; 54% of patients with chronic no-malignant pain had additional cancer-related pain or cancer treatment-related pain. Opioids were used to manage stand-alone chronic nonmalignant pain for 39% of patients compared to 58% with mixed chronic nonmalignant pain and other pain diagnoses.

SIGNIFICANCE OF RESULTS

Five studies have documented the prevalence of chronic nonmalignant pain of 14-34% in palliative care. Further research including prevalence and treatment studies would provide clearer evidence for best practice management of chronic nonmalignant pain in the palliative care setting.

Tolerability and Efficacy of a 10:25 Preparation of Δ9-Tetrahydrocannabinol and Cannabidiol for Treatment of Chronic Back or Neck Pain: A Multiple-Dose Escalation Study

Introduction

The aim was to demonstrate the safety and tolerability of cannabidiol (CBD) with Δ9-THC in patients with moderate to severe chronic back or neck pain unresponsive to over-the-counter non-opioid analgesics.

Methods

This was a non-randomized, single-arm, open-label study. Participants received escalating doses of an oromucosal-administered combination containing 10 mg/mL of Δ9-THC, 25 mg/mL of CBD. On day 1, patients received once-daily 0.5 mL Cybis® 10:25 (5 mg Δ9-THC plus 12.5 mg CBD daily), escalated at days 8, 15, and 22 to 0.5 mL twice-daily (bd) (10 mg Δ9-THC plus 25 mg CBD daily), 1.0 mL bd (20 mg Δ9-THC plus 50 mg CBD daily), and 1.5 mL bd (30 mg Δ9-THC plus 75 mg CBD daily), respectively. The primary outcome was safety and tolerability, with secondary objectives including pharmacokinetic and efficacy outcomes.

Results

28 patients were enrolled in the study. Their median age was 63.3 years, and half were female. The median history of neck/back pain was 10 years. The pharmacokinetics following single doses of 0.5 mL were variable; however, there were dose-dependent increases in trough levels of CBD and Δ9-THC. Cybis® 10:25 was well tolerated, with the majority of adverse events of mild severity. The most common adverse events were nausea, vomiting, fatigue, dizziness, headache, paresthesia, and anxiety. There were dose-dependent improvements in numerical pain rating scores (p < 0.001), with clinically significant reductions in pain at 1.0 mL bd and 1.5 mL bd doses (28.8% and 34.1% reductions, respectively, p < 0.001). Depressive symptoms and stress had dose-dependent reductions (p = 0.0182, p < 0.01, respectively).

Conclusion

In patients with chronic neck/back pain, CBD and Δ9-THC are well tolerated and doses of 1.0 mL bd and 1.5 mL bd showed clinically significant reductions in pain compared to baseline pain scores.

Evaluating acceptability and feasibility of a mobile health intervention to improve self-efficacy in prescription opioid tapering in patients with chronic pain: protocol for a pilot randomised, single-blind, controlled trial

INTRODUCTION

Opioid medications are no longer recommended as long-term therapy for chronic non-cancer pain, and many patients are advised to reduce or discontinue opioid medications. Many patients report difficulties in tapering opioid medications, necessitating supporting interventions. This protocol describes a pilot randomised controlled trial (RCT) to investigate the acceptability, feasibility and potential efficacy of a mobile health intervention to improve the opioid tapering self-efficacy of patients with chronic non-cancer pain.

METHODS AND ANALYSIS

The trial will be a single-blind (clinician, data collector and statistician-blinded) pilot RCT with two parallel arms. Forty adult patients with chronic non-cancer pain who are voluntarily reducing their prescribed opioid medications under medical guidance will be recruited from two tertiary pain clinics (Start date 25 August 2021). Participants will be randomly assigned to an intervention or control group. Both groups will receive usual care, including multidisciplinary pain management. In addition to usual care, the intervention group will receive a short informational and testimonial video about opioid tapering and will receive two specifically text messages per day for 28 days. The intervention is codesigned with patients and clinicians to provide evidence-based informational, motivational and emotional support to patients with chronic pain to taper opioid medications. Feasibility of the intervention and a future definitive RCT will be evaluated by measuring patient acceptability, delivery of the intervention, rates and reasons of exclusions and drop-outs, completion rates and missing data in the study questionnaires, and obtaining estimates for sample size determination. Potential efficacy will be evaluated by comparing changes in opioid tapering self-efficacy between the two groups.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings.

TRIAL REGISTRATION NUMBER

ACTRN12621000795897.

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

OBJECTIVE

To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.

DESIGN

Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Original research in English. Case reports and cross sectional studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).

RESULTS

Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05).

CONCLUSIONS

Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.

REVIEW REGISTRATION

PROSPERO CRD42020140943.

Pharmacologic Management of Persistent Pain in Cancer Survivors

Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges  associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered.

mHealth Interventions to Support Prescription Opioid Tapering in Patients With Chronic Pain: Qualitative Study of Patients' Perspectives

BACKGROUND

Patients with chronic pain who are tapering prescription opioids report a need for greater support for coping with symptoms of pain and withdrawal. Mobile health (mHealth) technologies (SMS text messaging- or app-based) have the potential to provide patients with educational, emotional, and motivational support for opioid tapering beyond what is offered by their health care provider. However, it is not known whether patients with chronic pain who are tapering opioids would be willing or able to engage with technology-based support.

OBJECTIVE

This study aims to examine patients' use of mobile technologies in health care, interest in using mHealth support, preferences for the form and content of mHealth support, and potential barriers to and facilitators of engagement with mHealth support for opioid tapering.

METHODS

A total of 21 patients (11 women and 10 men; age range 29-83 years) with chronic noncancer pain on long-term opioid therapy who had recently initiated a voluntary opioid taper were recruited from primary and tertiary care clinics in metropolitan and regional Australia for a larger study of patients' experiences of opioid tapering. Participants had been taking prescription opioids for a mean duration of 13 (SD 9.6; range 0.25-30) years at the time of the study. Survey items characterized participants' typical mobile phone use and level of interest in mobile technology-based support for opioid tapering. Semistructured interviews further explored patients' use of mobile technologies and their interest in, preferences for, and perspectives on potential barriers to and facilitators of engagement with mHealth support for opioid tapering. Two researchers collaborated to conduct a thematic analysis of the interview data.

RESULTS

All participants reported owning and using a mobile phone, and most (17/21, 81%) participants reported using mobile apps. The majority of participants expressed interest in SMS text messaging-based (17/21, 81%) and app-based (15/21, 71%) support for opioid tapering. Participants expected that messages delivering both informational and socioemotional support would be helpful. Participants expected that access to technology, mobile reception, internet connectivity, vision impairment, and low self-efficacy for using apps may be barriers to user engagement. Patients expected that continuity of care from their health care provider, flexible message dosing, responsivity, and familiarity with pain self-management strategies would increase user engagement.

CONCLUSIONS

The results of this study indicate that patients with chronic noncancer pain may be willing to engage with SMS text messaging-based and app-based mHealth interventions to support opioid tapering. However, the feasibility and acceptability of these interventions may depend on how patients' preferences for functionality, content, and design are addressed.

Deprescribing long-term opioid therapy in patients with chronic pain

Proposed regulatory changes will limit the access to opioids by Australian patients with chronic pain, many of whom are under the care of consultant physicians. This review summarises points of consensus on opioid deprescribing that emerged from the interaction of an expert panel and the audience at a symposium on the topic held in Sydney in 2019. Each of these consensus points speaks to the need for an individualised, patient-centred approach. In other words, 'treat the patient, not the pill count'.

Transition from acute to chronic pain: where cells, systems and society meet

Current treatments for chronic pain are often ineffective. At the same as searching for novel therapeutics, there is growing interest in preventing acute pain becoming chronic. While the field is still in its infancy, its knowledge base is increasingly expanding. Certainly, biomedical factors, for example, the type of tissue damage, are important but they are often not modifiable. Psychosocial risk factors (e.g., thoughts and beliefs about pain, mood, social support, workplace problems) are modifiable. There is an increasing body of research that cognitive behavioral therapy can prevent transition. Internet-based delivery of cognitive behavioral therapy improves access. Clinicians need to be aware that they may inadvertently promote pain chronification in their patients by what they say and do.

Time for change: an experimental investigation of chronic pain patients' emotional and attitudinal responses to simulated opioid-tapering advice

Clinicians report reluctance to deliver opioid-tapering advice to patients with chronic pain, in part due to concerns that patients will be angry and dissatisfied. An experiment was conducted to examine chronic pain patients' emotional and attitudinal responses to simulated opioid-tapering advice. Patients scheduled for an initial assessment at a tertiary pain clinic and currently taking opioid medications for pain (N = 196) were randomly assigned to view video footage of a standardized patient receiving 1 of 3 forms of treatment advice: (1) stay on current medication (2) change to a different pain medication, or (3) taper off pain medications and participate in a CBT-based pain self-management program. Participants reported how positive/enthusiastic, anxious/worried, and angry/irritable they felt in response to the simulated treatment advice, and how satisfied with and willing they would be to accept and follow the advice. Participants expressed more positive emotional and attitudinal responses to simulated opioid-tapering advice than to simulated opioid-maintenance advice. Furthermore, participants' responses to simulated opioid-tapering and opioid-change advice were not significantly different, suggesting that participants responded positively to the prospect of change in treatment strategy. Additional analyses revealed that participants with a longer history of chronic pain and opioid use responded less positively to simulated opioid-tapering advice. The results of this study contribute to our understanding of factors that may shape chronic pain patients' responses to opioid-tapering advice and suggest that patients may respond more positively to opioid-tapering advice if it is presented together with an alternative treatment approach.

Transition from acute to chronic pain after surgery

Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse, and overdose-related deaths. Deaths from prescription opioids have more than quadrupled in the USA since 1999, and this pattern is now occurring globally. Inappropriate opioid prescribing after surgery, particularly after discharge, is a major cause of this problem. Chronic postsurgical pain, occurring in approximately 10% of patients who have surgery, typically begins as acute postoperative pain that is difficult to control, but soon transitions into a persistent pain condition with neuropathic features that are unresponsive to opioids. Research into how and why this transition occurs has led to a stronger appreciation of opioid-induced hyperalgesia, use of more effective and safer opioid-sparing analgesic regimens, and non-pharmacological interventions for pain management. This Series provides an overview of the epidemiology and societal effect, basic science, and current recommendations for managing persistent postsurgical pain. We discuss the advances in the prevention of this transitional pain state, with the aim to promote safer analgesic regimens to better manage patients with acute and chronic pain.

Choose Your Words Wisely: The Impact of Message Framing on Patients' Responses to Treatment Advice

Other people's words can have a powerful influence on how we interpret our environment, what we expect and experience, what we value, how we feel, what we choose, and how we behave. Placebo (and nocebo) effects are a dramatic example of this. The way in which healthcare professionals discuss, describe, and inform patients about the characteristic effects of a given disease and it prevention, diagnosis and treatment influence patients' feelings and expectations which in turn affects their psychobiological responses to, and subjective experiences and outcomes of the disease and its treatment effects. The effect of clinicians' words on patients' responses to treatments and procedures, both active and inert or sham is nothing less than incredible. The way in which information about treatment effects is delivered to patients can even reverse the clinically proven effects of an active treatment, or increase the adverse effects of it. In this chapter, we begin by presenting the data on the impact of message framing on affect and expectations of health care in experimental situations followed by the evidence that indicates how various patient, disease and clinician related factors modify framing effects in the clinic. Finally we discuss how framing effects affect clinical practice. They can be leveraged to enhance placebo effects and minimize nocebo effects. They can provide strategies to assist shared-decision making in the face of complex uncertainty. Going forward, automation of health care and artificial intelligence may change the delivery of health care but patients will continue to be humans seeking health gains while avoiding health losses and how the information is presented will always be susceptible to framing effects.

The Tri-Institutional Pain Registry-Analysis of Outpatient Pain Management at a Specialized Cancer Center

Objectives

The Outpatient Pain Clinics at Memorial Sloan Kettering Cancer Center participated in developing a pain registry to gain insight on the referral and management of cancer pain as related to demographic information, cancer history, prescription records, and interventional pain procedures stored in the institutional database.

Methods

Five cohorts (subsets of one another) were defined and compared to describe demographics and differences in management and outcomes by age, race, sex, and cancer type. Clinic patients were compared with the entire institution to determine factors associated with better pain relief and reduced side effects.

Results

A small percentage were referred to a pain specialist. A total of 1,043 patients completed 3,544 surveys. Compared with the institution, there were higher proportions of patients age 51 to 60 years, nonwhites, and patients with thoracic, abdominal, and head and neck cancers. Medical management controlled pain with three drug categories in 40% of visits. Short-acting opioids were the only category that statistically provided good pain relief with fewer side effects. Pain scores were improved with increasing opioid dose. Management differed by sex, age, and race; women consistently had lower doses of opioids, poorer pain control, more side effects, and were prescribed a greater variety of medications.

Conclusions

A limited set of medications was required to manage most patients in the clinic, supporting the continued place of opioids and the World Health Organization analgesic ladder in managing cancer pain. Women may need a more nuanced approach for obtaining the best balance of pain relief and side effects.

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

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.

Patient-Reported Outcomes and Opioid Use by Outpatient Cancer Patients

The Memorial Sloan Kettering Pain Registry contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,534 chronic pain cancer patients who were seen at outpatient pain service clinics. Average pain intensity (Brief Pain Inventory) was reported as mild by 24.6% of patients, moderate by 41.5%, and severe by 33.9%. The patient's report of average percent pain relief and health state (EuroQOL 5 dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Eighty-six percent of patients received an opioid at 1 or more clinic encounters. Regression analysis revealed that male sex or being younger (65 years of age or younger) was associated with a greater likelihood of an opioid ordered. Male sex nearly doubled the likelihood of a higher dose being ordered than female sex. Bivariate analysis found that patients receiving opioids reported significantly more pain relief than no-opioid patients. However, patients receiving opioids had higher pain interference scores, lower index of health state, and more physical distress than no-opioid patients Our results identify the need to consider opioid use and dosage when attempting to understand patient-reported outcomes (PROs) and factors affecting pain management.

PERSPECTIVE

This report describes the results of the analyses of PROs and patient-related electronic health record data collected under standard of care from cancer patients at outpatient pain management clinics of Anesthesiology and Palliative Care at the Memorial Sloan Kettering Cancer Center. Consideration of sex and age as predictors of opioid use is critical in attempting to understand PROs and their relationship to pain management.

Automatic referral to standardize palliative care access: an international Delphi survey

PURPOSE

Palliative care referral is primarily based on clinician judgment, contributing to highly variable access. Standardized criteria to trigger automatic referral have been proposed, but it remains unclear how best to apply them in practice. We conducted a Delphi study of international experts to identify a consensus for the use of standardized criteria to trigger automatic referral.

METHODS

Sixty international experts stated their level of agreement for 14 statements regarding the use of clinician-based referral and automatic referral over two Delphi rounds. A consensus was defined as an agreement of ≥70% a priori.

RESULTS

The response rate was 59/60 (98%) for the first round and 56/60 (93%) for the second round. Twenty-six (43%), 19 (32%), and 11 (18%) respondents were from North America, Asia/Australia, and Europe, respectively. The panel reached consensus that outpatient palliative care referral should be based on both automatic referral and clinician-based referral (agreement = 86%). Only 18% felt that referral should be clinician-based alone, and only 7% agreed that referral should be based on automatic referral only. There was consensus that automatic referral criteria may increase the number of referrals (agreement = 98%), facilitate earlier palliative care access, and help administrators to set benchmarks for quality improvement (agreement = 86%).

CONCLUSIONS

Our panelists favored the combination of automatic referral to augment clinician-based referral. This integrated referral framework may inform policy and program development.

Referral criteria for outpatient specialty palliative cancer care: an international consensus

Although outpatient specialty palliative-care clinics improve outcomes, there is no consensus on who should be referred or the optimal timing for referral. In response to this issue, we did a Delphi study to develop consensus on a list of criteria for referral of patients with advanced cancer at secondary or tertiary care hospitals to outpatient palliative care. 60 international experts (26 from North America, 19 from Asia and Australia, and 11 from Europe) on palliative cancer care rated 39 needs-based criteria and 22 time-based criteria in three iterative rounds. Nearly all experts responded in each round. Consensus was defined by an a-priori agreement of 70% or more. Panellists reached consensus on 11 major criteria for referral: severe physical symptoms, severe emotional symptoms, request for hastened death, spiritual or existential crisis, assistance with decision making or care planning, patient request for referral, delirium, spinal cord compression, brain or leptomeningeal metastases, within 3 months of advanced cancer diagnosis for patients with median survival of 1 year or less, and progressive disease despite second-line therapy. Consensus was also reached on 36 minor criteria for specialist palliative-care referral. These criteria, if validated, could provide guidance for identification of patients suitable for outpatient specialty palliative care.

Internet search query analysis can be used to demonstrate the rapidly increasing public awareness of palliative care in the USA

BACKGROUND

A lack of public awareness of palliative care (PC) has been identified as one of the main barriers to appropriate PC access. Internet search query analysis is a novel methodology, which has been effectively used in surveillance of infectious diseases, and can be used to monitor public awareness of health-related topics.

OBJECTIVES

We aimed to demonstrate the utility of internet search query analysis to evaluate changes in public awareness of PC in the USA between 2005 and 2015.

METHODS

Google Trends provides a referenced score for the popularity of a search term, for defined regions over defined time periods. The popularity of the search term 'palliative care' was measured monthly between 1/1/2005 and 31/12/2015 in the USA and in the UK.

RESULTS

Results were analysed using independent t-tests and joinpoint analysis. The mean monthly popularity of the search term increased between 2008-2009 (p<0.001), 2011-2012 (p<0.001), 2013-2014 (p=0.004) and 2014-2015 (p=0.002) in the USA. Joinpoint analysis was used to evaluate the monthly percentage change (MPC) in the popularity of the search term. In the USA, the MPC increase was 0.6%/month (p<0.05); in the UK the MPC of 0.05% was non-significant.

DISCUSSION

Although internet search query surveillance is a novel methodology, it is freely accessible and has significant potential to monitor health-seeking behaviour among the public. PC is rapidly growing in the USA, and the rapidly increasing public awareness of PC as demonstrated in this study, in comparison with the UK, where PC is relatively well established is encouraging in increasingly ensuring appropriate PC access for all.

Internet search query analysis can be used to demonstrate the rapidly increasing public awareness of palliative care in the USA

BACKGROUND

A lack of public awareness of palliative care (PC) has been identified as one of the main barriers to appropriate PC access. Internet search query analysis is a novel methodology, which has been effectively used in surveillance of infectious diseases, and can be used to monitor public awareness of health-related topics.

OBJECTIVES

We aimed to demonstrate the utility of internet search query analysis to evaluate changes in public awareness of PC in the USA between 2005 and 2015.

METHODS

Google Trends provides a referenced score for the popularity of a search term, for defined regions over defined time periods. The popularity of the search term 'palliative care' was measured monthly between 1/1/2005 and 31/12/2015 in the USA and in the UK.

RESULTS

Results were analysed using independent t-tests and joinpoint analysis. The mean monthly popularity of the search term increased between 2008-2009 (p<0.001), 2011-2012 (p<0.001), 2013-2014 (p=0.004) and 2014-2015 (p=0.002) in the USA. Joinpoint analysis was used to evaluate the monthly percentage change (MPC) in the popularity of the search term. In the USA, the MPC increase was 0.6%/month (p<0.05); in the UK the MPC of 0.05% was non-significant.

DISCUSSION

Although internet search query surveillance is a novel methodology, it is freely accessible and has significant potential to monitor health-seeking behaviour among the public. PC is rapidly growing in the USA, and the rapidly increasing public awareness of PC as demonstrated in this study, in comparison with the UK, where PC is relatively well established is encouraging in increasingly ensuring appropriate PC access for all.

Bisphosphonate-induced hypocalcemia associated with vitamin D deficiency in a patient with advanced cancer

A case is presented of symptomatic hypocalcemia following treatment with bisphosphonates. This patient also had deficiency of 25 hydroxyvitamin D that was unrecognized. The use of bisphosphonates in cancer is increasing, not only in the treatment of hypercalcemia, but also for bone pain and to decrease the risk of skeletal morbidity in metastatic breast cancer, multiple myeloma, and Paget’s disease in normocalcemic patients. The patient was probably vitamin D deficient because of a combination of poor oral intake, inadequate sunlight exposure, and the development of renal failure. However, despite receiving both parenteral and oral calcium therapy, the serum calcium remained low until the replacement of vitamin D. With increasing use of bisphosphonate therapy in malignant disease, we believe that an assessment of vitamin D status, calcium intake, renal function, phosphate, magnesium, and albumin should be undertaken prior to initiating therapy in most palliative care patients.

The efficacy and side effects of continuous infusion intravenous morphine (CIVM) for pain and symptoms due to advanced cancer

Morphine is the strong opioid of choice in the management of moderate-to-severe chronic cancer pain. The preferred route of administration is oral, in individually titrated doses, regularly scheduled around the clock. We conducted a retrospective study of continuous intravenous morphine (CIVM) in a palliative medicine program in 107 consecutive patients. The results suggest CIVM is an effective, safe, and versatile method of morphine administration when used with a defined protocol. Efficacy was similar to that obtained by others with intravenous morphine sulfate and also for oral morphine. Safety was suggested by the low incidence of dose-limiting side effects, most of which responded to dose reduction. Particularly noteworthy was the flexibility of CIVM with dose reduction in 20 percent.

Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline

PURPOSE

To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors.

METHODS

An ASCO-convened expert panel conducted a systematic literature search of studies investigating chronic pain management in cancer survivors. Outcomes of interest included symptom relief, pain intensity, quality of life, functional outcomes, adverse events, misuse or diversion, and risk assessment or mitigation.

RESULTS

A total of 63 studies met eligibility criteria and compose the evidentiary basis for the recommendations. Studies tended to be heterogeneous in terms of quality, size, and populations. Primary outcomes also varied across the studies, and in most cases, were not directly comparable because of different outcomes, measurements, and instruments used at different time points. Because of a paucity of high-quality evidence, many recommendations are based on expert consensus.

RECOMMENDATIONS

Clinicians should screen for pain at each encounter. Recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain should be evaluated, treated, and monitored. Clinicians should determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. Systemic nonopioid analgesics and adjuvant analgesics may be prescribed to relieve chronic pain and/or to improve function. Clinicians may prescribe a trial of opioids in carefully selected patients with cancer who do not respond to more conservative management and who continue to experience distress or functional impairment. Risks of adverse effects of opioids should be assessed. Clinicians should clearly understand terminology such as tolerance, dependence, abuse, and addiction as it relates to the use of opioids and should incorporate universal precautions to minimize abuse, addiction, and adverse consequences. Additional information is available at www.asco.org/chronic-pain-guideline and www.asco.org/guidelineswiki.

A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses

BACKGROUND

Palliative care has emerged as care that specifically aims to address gaps inherent in disease-centered approaches in order to enhance care quality in serious illness, both for patients and families and for health care systems. Late palliative care for patients with serious illness mitigates benefits to patients, families, and health care systems. Efforts have been made by investigators to define the impact of earlier palliative care interventions on patient, family and health care systems outcomes. We conducted a systematic review of randomized trials of outpatient and home palliative care, two locations where earlier palliative care do occur, to examine the evidence for palliative care benefits.

METHODS

Various terms were used; the search was performed in PubMed. From this search randomized trials were selected from 62 references derive from this search which appeared to be primary studies. Hand searches were done on references. Fifteen randomized control trials of outpatient palliative care and 13 randomized control trials of palliative home care were collected and collated into tables. Seven systematic reviews obtained and outcomes summarized in a table.

RESULTS

Advantages to palliative care include improvement in certain symptoms such as depression, improved patient quality of life, reduced aggressive care at the end of life, increased advanced directives, reduced hospital length of stay and hospitalizations, improved caregiver burden and better maintenance of caregiver quality of life and reduction in the medical cost of care as well as patient and family satisfaction. There are randomized trials which demonstrate that symptoms and quality of life are not improved, and resource utilization and costs are not different from "usual" care. Seven systematic reviews of randomized trials came to similar conclusions.

DISCUSSION

Notable methodological issues account for differences in results. Definitions of "early" palliative care vastly differed. There were no descriptions of what was meant by "usual" care in the control arm. Study designs and procedures were frequently flawed. Populations were heterogeneous in many studies and imbalances between randomly-allocated occurred frequently. Direct patient care versus consultation only, played a role. The assumption that the same model of care was equally effective across different diseases was unsubstantiated. Attrition was on average 40% and blinding of individuals who assessed outcomes frequently not mentioned. Power calculations were infrequent. Intention to treat analysis was often not done. Current studies fell short of the goal of measuring all relevant factors to assessing costs-benefits, having largely ignored the cost to the patient and family and instead focused narrowly on patient medical costs.

CONCLUSIONS

Multiple studies have demonstrated several benefits to early outpatient palliative care for patients with newly diagnosed metastatic cancer. However, better designed and executed studies are needed to determine the best time to intervene and the best model of care.

External validation of the number of risk factors score in a palliative care outpatient clinic at a comprehensive cancer center

BACKGROUND

Prognostic tools are available to predict if terminally ill cancer patients have days or weeks to live. Tools for predicting the prognosis in ambulatory patients at an earlier stage are lacking. The Number of Risk Factors (NRF) score developed in ambulatory cancer patients receiving palliative radiation therapy may be suitable for this purpose but has not been tested in a palliative care setting.

OBJECTIVE

Our aim was to evaluate the prognostic accuracy of the NRF score in patients referred to a palliative care outpatient clinic at a comprehensive cancer center.

METHODS

We conducted a retrospective chart review of NRF scores and survival in 300 consecutive, newly referred patients. Measurements included primary cancer type, extent of disease, Karnofsky Performance Scale (KPS) score, and survival duration after first visit. One point was allocated each for cancer other than breast cancer, metastases other than bone, and low KPS score.

RESULTS

Of 300 patients, 236 (79%) had advanced disease. Of those 236, 212 (90%) had a cancer other than breast cancer, 180 (76%) had metastatic disease in sites other than bone, and 64 (27%) had a KPS score <70%. During the 2-year follow-up, 221 (94%) patients died, with overall median survival of 4.9 months (95% confidence interval, 3.9-6.1 months). NRF scores of 0 to 1, 2, and 3 split the sample into subgroups with highly significantly different survival among the groups, with medians 9.0, 4.6, and 2.1 months, respectively (Wilcoxon test χ(2)=43.9, degrees of freedom [df] 2, p<0.0001). A simple parametric model was fit to determine the probability of subgroup members surviving to a certain number of months.

CONCLUSIONS

In cancer patients referred to palliative care earlier in their disease trajectory, the NRF score may be a useful prognostic tool. Further validation in other palliative care populations is needed.

Treating nausea and vomiting in palliative care: a review

Nausea and vomiting are portrayed in the specialist palliative care literature as common and distressing symptoms affecting the majority of patients with advanced cancer and other life-limiting illnesses. However, recent surveys indicate that these symptoms may be less common and bothersome than has previously been reported. The standard palliative care approach to the assessment and treatment of nausea and vomiting is based on determining the cause and then relating this back to the "emetic pathway" before prescribing drugs such as dopamine antagonists, antihistamines, and anticholinergic agents which block neurotransmitters at different sites along the pathway. However, the evidence base for the effectiveness of this approach is meager, and may be in part because relevance of the neuropharmacology of the emetic pathway to palliative care patients is limited. Many palliative care patients are over the age of 65 years, making these agents difficult to use. Greater awareness of drug interactions and QT(c) prolongation are emerging concerns for all age groups. The selective serotonin receptor antagonists are the safest antiemetics, but are not used first-line in many countries because there is very little scientific rationale or clinical evidence to support their use outside the licensed indications. Cannabinoids may have an increasing role. Advances in interventional gastroenterology are increasing the options for nonpharmacological management. Despite these emerging issues, the approach to nausea and vomiting developed within palliative medicine over the past 40 years remains relevant. It advocates careful clinical evaluation of the symptom and the person suffering it, and an understanding of the clinical pharmacology of medicines that are available for palliating them.

Chronic pain management in cancer survivors

The problem of pain in cancer survivors is attracting increased attention. Although comprehensive information about the prevalence of persistent pain in the cancer survivor population is currently lacking, it is known to depend on the type of cancer, comorbid conditions, and the initial pain management. Epidemiologic studies generally categorize pain in patients with cancer as either pain directly caused by the neoplastic process or related phenomena, pain occurring as a complication of anticancer treatment, or pain unrelated to the neoplastic process, caused by debility or concurrent disorders. This article focuses on pain syndromes in cancer survivors and the safe use of opioid therapy in this population when its ongoing use is part of the pain management plan. The use of physical therapy, rehabilitation therapy, and cognitive behavioral therapy, which are all extremely important aspects of pain management in the cancer survivor, are briefly mentioned.

Ongoing controversies in the pharmacological management of cancer pain

Pain management remains a problem in advanced cancer. Despite the ready availability of effective analgesia and good evidence to support the prescription of medications, concerns continue over the safety of this practice. The aim of the present paper was to review often-raised questions when considering the use of opioids, especially in cancer pain, to ascertain the levels of evidence that already exist to support opioid-prescribing practice and to identify areas where further research is needed.

Predicting survival in patients with advanced disease

Prognostication is an important clinical skill for all clinicians, particularly those clinicians working with patients with advanced cancer. However, doctors can be hesitant about prognosticating without a fundamental understanding of how to formulate a prognosis more accurately and how to communicate the information with honesty and compassion. Irrespective of the underlying type of malignancy, most patients with advanced cancer experience a prolonged period of gradual decline (months/years) before a short phase of accelerated decline in the last month or two. The main indicators of this final phase are poor performance status, weight loss, symptoms such as anorexia, breathlessness or confusion and abnormalities on laboratory parameters (e.g. high white cell count, lymphopaenia, hyopalbuminaemia, elevated lactate dehydrogenase or C-reactive protein). The clinical estimate of survival remains a powerful independent prognostic indicator, often enhanced by experience, but research has only begun to understand the different biases affecting clinicians' estimates. More recent research has shown probabilistic predictions to be more accurate than temporal predictions. Simple, reliable and valid prognostic tools have been developed in recent years that can be used readily at the bedside of terminally ill cancer patients. The greatest accuracy occurs with the use of a combination of subjective prognostic judgements and objective validated tools. Communicating survival predictions is an important part of cancer care and guidelines exist for improving delivery of such information. Important cultural differences may influence communication strategies and should be recognised in clinical encounters. More well-designed studies of prognosis and its impact on decision making are needed. The benefits and limitations of prognostication should be considered in many clinical decisions.

Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review

Many health professionals (HPs) express discomfort at having to broach the topic of prognosis, including limited life expectancy, and may withhold information or not disclose prognosis. A systematic review was conducted of 46 studies relating to truth-telling in discussing prognosis with patients with progressive, advanced life-limiting illnesses and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO and Cochrane Register of Controlled Trials) up to November 2004, with handsearching of studies, as well as inclusion of studies satisfying selection criteria reported in 2005 by the authors. The reference lists of identified studies were hand-searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Results showed that although the majority of HPs believed that patients and caregivers should be told the truth about the prognosis, in practice, many either avoid discussing the topic or withhold information. Reasons include perceived lack of training, stress, no time to attend to the patient's emotional needs, fear of a negative impact on the patient, uncertainty about prognostication, requests from family members to withhold information and a feeling of inadequacy or hopelessness regarding the unavailability of further curative treatment. Studies suggest that patients can discuss the topic without it having a negative impact on them. Differences and similarities in findings from different cultures are explored.

Discrepant perceptions about end-of-life communication: a systematic review

Little research has compared the perceptions of health professionals (HPs), patients, and caregivers about the communication of prognostic information. The objectives of this literature review were to determine 1) patient and caregiver perceptions of levels of information received about prognosis and end-of-life (EoL) issues regarding a life-limiting illness; 2) patient perceptions of and factors related to their understanding and awareness of prognosis; 3) HPs' perceptions of patients' wishes about disclosure of prognosis and factors related to their decision whether to disclose; and 4) concordance between HPs and patients/caregivers regarding the information given by HPs about prognostic and EoL issues. Relevant studies meeting the inclusion criteria were identified by searching computerized databases (MEDLINE, EMBASE, CINAHL, PsychINFO, Cochrane Register of Controlled Trials [Central]) up to November 2004. The reference lists of identified studies were hand searched for further relevant studies. Inclusion criteria were studies of any design evaluating communication of prognostic information that included adult patients with an advanced, life-limiting illness; their caregivers; and qualified HPs. Fifty-one studies were identified. There was a large discrepancy between patients/caregivers and HPs regarding the amount of information they believed had been given. Patients' understanding and awareness of information received conflicted with the HPs' perceptions of patients' understanding and awareness of the information that had been given. HPs tended to underestimate patients' need for information and overestimate patients' understanding and awareness of their prognosis and EoL issues. HPs need to repeatedly check patients' understanding and preferences for information.

A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information

Evidence-based recommendations concerning how to discuss dying, life expectancy, and likely future symptoms with patients with a limited life expectancy and their families are lacking. The aim of this systematic review was to review studies regarding prognostic/end-of-life communication with adult patients in the advanced stages of a life-limiting illness and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases up to November 2004. One hundred twenty-three studies met the criteria for the full review, and 46 articles reported on patient/caregiver preferences for content, style, and timing of information. The majority of the research was descriptive. Although there were individual differences, patients/caregivers in general had high levels of information need at all stages of the disease process regarding the illness itself, likely future symptoms and their management, and life expectancy and information about clinical treatment options. Patient and caregiver information needs showed a tendency to diverge as the illness progressed, with caregivers needing more and patients wanting less information. Patients and caregivers preferred a trusted health professional who showed empathy and honesty, encouraged questions, and clarified each individual's information needs and level of understanding. In general, most patients/caregivers wanted at least some discussion of these topics at the time of diagnosis of an advanced, progressive, life-limiting illness, or shortly after. However, they wanted to negotiate the content and extent of this information.

The adverse effects of morphine: a prospective survey of common symptoms during repeated dosing for chronic cancer pain

Little information is available about the incidence, prevalence, or severity of morphine side effects during repeated individualized dosing for chronic cancer pain, although it has been widely used in this way for more than 30 years. The authors' aim was to describe the prevalence of symptoms possibly attributable to morphine side effects in a convenience sample of patients with pain due to advanced cancer. They used a prospective survey of inpatients and outpatients on regularly dosed morphine, with a questionnaire administered weekly for 4 weeks. Forty-two of 56 eligible patients completed at least the first questionnaire, with 30 completing all 4. Dry mouth was the most common symptom reported (point prevalence, 95%); this was often moderate to severe in intensity (57%) and was the most persistent symptom (period prevalence, 20%). Sedation and constipation were frequent (point prevalence, 88%) and was often moderate or severe at some point (55% and 62%, respectively) but had low period prevalence. Nausea was reported by less than half the patients. Myoclonus was common (point prevalence, 83%) but was usually mild and not persistent. Total daily morphine dose had little impact on side-effect patterns. Constipation, dysphoria, myoclonus, nausea, and sedation were more likely to be severe following dose increases. In conclusion, although constipation, nausea, and sedation are well described as side effects of morphine administration, others such as dry mouth and myoclonus appear to be underestimated. Validated patient-based measures of opioid side effects are needed.

Palliative and shared care concepts in patients with advanced colorectal cancer

Approximately 50% of patients with colorectal cancer (CRC) will eventually die of metastatic disease. Effective palliative management can be used within a shared care model in CRC to provide optimum symptom control, psychological well-being and maintenance of quality of life for patients, their families and carers, including bereavement support. Maintenance of realistic hope and early goal setting are equally important in end-of-life discussions with patients and families. Palliative care should be incorporated early in the course of the illness, concurrent with disease-modifying therapies. Within shared care, the palliative medicine specialist, surgeon and other members of the multidisciplinary team can each bring their own expertise to provide a patient-centred approach. A case is presented that incorporates some of these principles and exemplifies the benefits of contemporary palliative care for patients with advanced CRC.

Prognostic factors in advanced cancer patients: evidence-based clinical recommendations--a study by the Steering Committee of the European Association for Palliative Care

PURPOSE

To offer evidence-based clinical recommendations concerning prognosis in advanced cancer patients.

METHODS

A Working Group of the Research Network of the European Association for Palliative Care identified clinically significant topics, reviewed the studies, and assigned the level of evidence. A formal meta-analysis was not feasible because of the heterogeneity of published studies and the lack of minimal standards in reporting results. A systematic electronic literature search within the main available medical literature databases was performed for each of the following four areas identified: clinical prediction of survival (CPS), biologic factors, clinical signs and symptoms and psychosocial variables, and prognostic scores. Only studies on patients with advanced cancer and survival < or = 90 days were included.

RESULTS

A total of 38 studies were evaluated. Level A evidence-based recommendations of prognostic correlation could be formulated for CPS (albeit with a series of limitations of which clinicians must be aware) and prognostic scores. Recommendations on the use of other prognostic factors, such as performance status, symptoms associated with cancer anorexia-cachexia syndrome (weight loss, anorexia, dysphagia, and xerostomia), dyspnea, delirium, and some biologic factors (leukocytosis, lymphocytopenia, and C-reactive protein), reached level B.

CONCLUSION

Prognostication of life expectancy is a significant clinical commitment for clinicians involved in oncology and palliative care. More accurate prognostication is feasible and can be achieved by combining clinical experience and evidence from the literature. Using and communicating prognostic information should be part of a multidisciplinary palliative care approach.

Clinical predictors of survival in advanced cancer

Prognostication is one of the three cardinal clinical skills. Although it has been undervalued by modern medicine compared with diagnostics and therapeutics, poor prognostication can have dire consequences for the patient with advanced cancer, almost as serious as the wrong diagnosis or treatment. Oncologists relying on their subjective judgment for predicting survival often will be inaccurate, usually as too optimistic, which may result in overly aggressive cancer treatment. Actuarial judgment, based on assessment of statistically derived key factors, has the potential to improve prognostic accuracy. These factors in patients with advanced cancer differ from those in patients with newly diagnosed disease; they include performance status, symptoms of the cancer cachexia syndrome, and patient-rated quality of life, rather than tumor size, tumor grade, or extent of disease. Laboratory markers such as leukocytosis or lymphopenia also appear to be useful. Novel markers include acute phase reactants (C-reactive protein, vitamin B12) and cytokines that may provide more objective evidence of survival prospects. Prognostic indices, nomograms, and web-based tools are in development for the advanced cancer population. Identifying the clinical markers predicting for short-term survival in patients with advanced cancer is important to help form the basis for teaching prognostication skills to physicians.

Neurotoxicity from chronic opioid therapy after successful palliative treatment for painful bone metastases

A 64-year-old man with severe bone pain secondary to pathological fracture of a vertebra required large doses of morphine to obtain pain relief. After receiving effective palliative anti-tumor treatment, he developed chronic opioid neurotoxicity. We postulate that the gradual reduction in pain over a period of time precipitated the development of toxicity that presented as cognitive failure. Delayed opioid toxicity is a potential consequence of effective disease-modifying therapies that needs to be recognized and treated appropriately when it occurs. The increasing use of community-based palliative care after hospitalization means that the community practitioner also needs to be aware of the development of chronic opioid toxicity at home. Optimal timing for going back down the ladder of opioid doses, after reduction of the noxious stimulus, requires clinicians to recognize different types of symptoms and signs and to consider the effect of other treatments and time on the noxious stimulus. A suggested protocol warrants consideration as a means of improving clinical practice; however, it requires prospective evaluation in the clinical setting.

Systematic review of the efficacy of antiemetics in the treatment of nausea in patients with far-advanced cancer

OBJECTIVES

To systematically review studies of antiemetics used in the treatment of nausea in patients with far-advanced cancer.

DATA SOURCES

Randomized controlled trials (RCT) and uncontrolled studies identified by electronic and hand searching.

REVIEW METHODS

Identified studies were appraised for quality and effect size.

RESULTS

Of 21 studies included, 2 were systematic reviews, 7 were RCT and 12 were uncontrolled studies or case series. Differences in interventions and outcomes amongst the RCT precluded any quantitative data synthesis and all seven studies were prone to bias. Whereas uncontrolled studies indicated a high response rate to standard regimens (75-93% for both nausea and vomiting), RCT showed much lower response rates to these agents (23-36% for nausea, 18-52% for vomiting). The two methods of antiemetic choice (choice based either on the inferred mechanism or empirical) were equally effective. There is reasonably strong evidence for the use of metoclopramide in cancer-associated dyspepsia and steroids in malignant bowel obstruction. There was conflicting evidence about the efficacy of serotonin antagonists compared with standard treatments (e.g. metoclopramide, dopamine antagonists and dexamethasone). There was little or no evidence of the efficacy of some commonly used and seemingly effective drugs such as haloperidol, cyclizine, and methotrimeprazine.

CONCLUSION

Evidence supporting the existing consensus-based guidelines for management of nausea and vomiting in advanced cancer is sparse. Current approaches to treatment based on the neuropharmacology of the emetic pathway may be inappropriate in this setting. Well-designed studies of the impact of "standard" management and novel agents on nausea and vomiting in palliative populations are needed.

Asking questions can help: development and preliminary evaluation of a question prompt list for palliative care patients

Question prompt lists (QPLs) have been shown to be an inexpensive and effective communication tool for patients in oncology consultations. We aimed to develop and pilot a QPL for palliative care (PC) patients. In order to identify suitable questions for inclusion in the QPL, we conducted focus groups and individual interviews with 19 patients, 24 carers and 22 PC health professionals. A further 21 health professionals reviewed the draft document. The draft QPL was piloted in 23 patients. In total, 112 questions were identified and grouped into eight categories. All participants felt that the QPL, in booklet form, could be a useful tool. Out of 23 patients in the pilot study, 22 agreed that the QPL was helpful, contained useful questions, was easy to understand and would be useful in the future. State anxiety (STAI) decreased after receiving the booklet and seeing the doctor in 16 out of 19 patients (overall anxiety decreased by a median of 8, IQR 1-13). Participants in the pilot study endorsed the inclusion of end-of-life issues in the QPL, despite some reservations expressed about this by health professionals in the individual interviews. We have identified a specific QPL that might facilitate useful dialogue between PC patients and their doctor. The QPL has strong support from patients, their carers and relevant health professionals.

A systematic review of physicians' survival predictions in terminally ill cancer patients

OBJECTIVE

To systematically review the accuracy of physicians' clinical predictions of survival in terminally ill cancer patients.

DATA SOURCES

Cochrane Library, Medline (1996-2000), Embase, Current Contents, and Cancerlit databases as well as hand searching.

STUDY SELECTION

Studies were included if a physician's temporal clinical prediction of survival (CPS) and the actual survival (AS) for terminally ill cancer patients were available for statistical analysis. Study quality was assessed by using a critical appraisal tool produced by the local health authority.

DATA SYNTHESIS

Raw data were pooled and analysed with regression and other multivariate techniques.

RESULTS

17 published studies were identified; 12 met the inclusion criteria, and 8 were evaluable, providing 1563 individual prediction-survival dyads. CPS was generally overoptimistic (median CPS 42 days, median AS 29 days); it was correct to within one week in 25% of cases and overestimated survival by at least four weeks in 27%. The longer the CPS the greater the variability in AS. Although agreement between CPS and AS was poor (weighted kappa 0.36), the two were highly significantly associated after log transformation (Spearman rank correlation 0.60, P < 0.001). Consideration of performance status, symptoms, and use of steroids improved the accuracy of the CPS, although the additional value was small. Heterogeneity of the studies' results precluded a comprehensive meta-analysis.

CONCLUSIONS

Although clinicians consistently overestimate survival, their predictions are highly correlated with actual survival; the predictions have discriminatory ability even if they are miscalibrated. Clinicians caring for patients with terminal cancer need to be aware of their tendency to overestimate survival, as it may affect patients' prospects for achieving a good death. Accurate prognostication models incorporating clinical prediction of survival are needed.