Showing papers in "Supportive Care in Cancer in 2008"
TL;DR: In addition to the symptomatic experience of side effects, patients reported a considerable time burden for treatment, and it is important to consider supportive care strategies that may effectively reduce side effects and their associated treatment burden.
Abstract: Goals
To examine the prevalence of chemotherapy-or radiotherapy-associated side effects and related treatment burden, and correlates of fatigue and missed work days among cancer patients.
314 citations
TL;DR: Targeted HRQOL assessments for patients with malignant bone disease are currently under development and are discussed herein.
Abstract: Skeletal-related events (SREs) from malignant bone disease cause considerable morbidity and can dramatically reduce patients’ quality of life. Pathologic fractures often require surgical intervention and palliative radiotherapy. Thus, patients suffer impaired mobility, loss of functional independence, and diminished health-related quality of life (HRQOL). Bisphosphonates can delay the onset and reduce the incidence of SREs and have become the standard of care for the treatment of malignant bone disease; however, minimal information on the effects of bisphosphonate treatment on HRQOL is available. Targeted HRQOL assessments for patients with malignant bone disease are currently under development and are discussed herein.
184 citations
TL;DR: Medical schools and oncology training can teach communication skills and cultural competence, while fostering in all students and young doctors those attitudes of humility, empathy, curiosity, respect, sensitivity, and awareness that are needed to deliver effective and culturally sensitive cancer care.
Abstract: Cultural competence in oncology requires the acquisition of specific knowledge, clinical skills, and attitudes that facilitate effective cross-cultural negotiation in the clinical setting, thus, leading to improved therapeutic outcomes and decreased disparities in cancer care Cultural competence in oncology entails a basic knowledge of different cultural attitudes and practices of communication of the truth and of decision-making styles throughout the world Cultural competence always presupposes oncology professionals' awareness of their own cultural beliefs and values To be able to communicate with cancer patients in culturally sensitive ways, oncologists should have knowledge of the concept of culture in its complexity and of the risks of racism, classism, sexism, ageism, and stereotyping that must be avoided in clinical practice Oncologists should develop a sense of appreciation for differences in health care values, based on the recognition that no culture can claim hegemony over others and that cultures are evolving under their reciprocal influence on each other Medical schools and oncology training can teach communication skills and cultural competence, while fostering in all students and young doctors those attitudes of humility, empathy, curiosity, respect, sensitivity, and awareness that are needed to deliver effective and culturally sensitive cancer care
183 citations
TL;DR: It was found that patients reporting TSCs more often reported: previous smell changes, less responsibility for cooking, concurrent medication, higher educational levels, and being on sick leave.
Abstract: Purpose
This study explores the prevalence of self-reported taste and smell changes (TSCs) during chemotherapy and relationships between TSCs and demographic and clinical factors.
180 citations
TL;DR: Supportive care needs and preferences among young adult cancer patients and off-treatment survivors are examined to serve as recommendations as to when and to whom to target delivery of supportive care services.
Abstract: Background Young adulthood is a time of increased vulnerability to stress and presents young adult cancer patients and off-treatment survivors with major developmental challenges above and beyond those faced by their peers. The intent of this study was to examine supportive care needs and preferences among young adult cancer patients. Methods Two hundred and seventeen young adults aged 18–40 years and diagnosed with cancer between the ages of 15–35 completed an online survey. Adapted from prior research on young adult survivors of childhood cancer, questions assessed the extent to which subjects had utilized various information and supportive care services and/or expressed a desire to use those services either now or in the past. Results While young adult patients demonstrate a high demand for information and assistance regarding diet and nutrition, exercise, fertility options, complementary and alternative services and assistance with health insurance, 40–50% of patients report that these needs are unmet. More than 50% of respondents who indicated a need or desire for camp programs and retreats, counseling or guidance related to sexuality, counseling for family members, infertility treatment and adoption services, transportation assistance, child care and alcohol or drug abuse counseling also indicated that these needs were unmet. Younger respondents (18–29 years olds) were significantly more likely to indicate unmet needs for the supportive care services assessed here. Conclusion Findings serve as recommendations as to when and to whom to target delivery of supportive care services.
168 citations
TL;DR: This study did not meet its accrual goal of 170 patients, mainly because women were reluctant to take additional medication in general and methylphenidate in particular, and there were no trends to suggest that d-MPH, taken concurrently with adjuvant chemotherapy, improves quality of life or fatigue.
Abstract: Women who receive adjuvant chemotherapy for breast cancer develop fatigue, and a subset reports cognitive impairment. Methylphenidate is reported to improve fatigue and to decrease cognitive impairment in other populations. Women were randomised early during their chemotherapy to receive d-methylphenidate (d-MPH), a form of methylphenidate, or an identical appearing placebo. All participants took placebo for one cycle to ensure compliance and then study medication until completion of chemotherapy. Subjects were assessed at baseline, end of chemotherapy and at ∼6 months follow-up with the High Sensitivity Cognitive Screen (HSCS) and the Hopkins Verbal Learning Test-Revised (HVLT-R). They also completed the self-report Functional Assessment of Cancer Therapy-General (FACT-G) and FACT-F (F = fatigue) questionnaires, evaluating quality of life and fatigue. A total of 57 evaluable women were randomised: 29 to d-MPH and 28 to placebo; the study did not meet its accrual goal of 170 patients, mainly because women were reluctant to take additional medication in general and methylphenidate in particular. Groups were well matched for age (median, 50 years) and education. d-MPH and placebo were well tolerated. There were no significant differences between the randomised groups in classification of cognitive function by HSCS or in summed FACT-F fatigue scores (the primary endpoints of the study) at any of the assessments. There were also no differences in HLTV-R scores or quality of life. This study is underpowered, but there are no trends to suggest that d-MPH, taken concurrently with adjuvant chemotherapy, improves quality of life or fatigue.
167 citations
TL;DR: Quality of life was influenced by T classification, clinical stage, a higher radiation dose or the use of concomitant chemotherapy, but was independent of the interval since the end of radiotherapy.
Abstract: Introduction
Xerostomia is a common complication of radiotherapy for head and neck cancer because irreparable damage is caused to the salivary glands if they are included in the radiation fields. The aim of the study was to evaluate the degree of xerostomia in survivors of head and neck cancer and to determine its impact on quality of life.
164 citations
TL;DR: Curative doses of RT for head and neck cancer result in trismus in a high percentage of patients, independent of other treatment modalities, and has a negative impact on quality of life in this population.
Abstract: To determine the incidence of trismus in patients who had previously received curative doses of radiation therapy (RT) for head and neck cancer. In addition, we assessed if trismus was associated with quality of life deficits and radiation toxicity. Between February, 2005 and December, 2006, 40 patients with histologically confirmed head and neck cancer who had received curative doses of RT to the area(s) of the masticatory muscles and/or the ligaments of the temporomandibular joint (TMJ) were enrolled in this study. Differences in trismus incidence were compared between cancer treatment modalities [i.e., RT vs RT/chemotherapy (CT) and conventional RT vs intensity modulated RT]. Quality of life (QOL) was measured by using four questions from the EORTC QLQ-C30 that address pain and difficulty opening the jaw. Scores regarding impaired eating as a result of decreased range of motion of the mouth were derived from the Modified Common Toxicity Criteria (CTCAE Version 3.0). Trismus was identified in 45% of subjects who had received curative doses of RT. No differences were noted in the incidence of trismus between RT and RT/CT or between conventional RT and intensity modulated RT (IMRT). Those with trismus demonstrated more QOL deficits than the non-trismus group. Curative doses of RT for head and neck cancer result in trismus in a high percentage of patients, independent of other treatment modalities. Trismus has a negative impact on quality of life in this population.
155 citations
TL;DR: Allogeneic HSCT patients present for transplantation with low symptom distress yet experience multiple symptoms and high symptom distress after HSCT conditioning, which can guide management strategies and improve HRQL.
Abstract: Goals of work
Despite advances in allogeneic hematopoietic stem cell transplantation (HSCT), post-transplant complications are common, and patients’ symptom experience has not been well documented.
153 citations
TL;DR: The meaning-making intervention is presented as one concrete approach to address the normative distress associated with the search for meaning within the context of cancer.
Abstract: Introduction
Despite modern advances that have led to improved prognoses and symptom management, a cancer diagnosis continues to evoke images of pain, suffering, and death.
150 citations
TL;DR: Preliminary research is promising, there remains a significant amount of research to be done on the role of PA in PC survivors, and future research would benefit from larger samples using randomized controlled trial methodology.
Abstract: Introduction
We reviewed physical activity (PA) studies in prostate cancer (PC) survivors investigating (a) the effects of PA on health outcomes, (b) the prevalence of PA, and (c) the determinants of PA
TL;DR: Improved management of cancer cachexia may require a multimodal approach by a multi-disciplinary team and is best commenced earlier rather than later, as well as the use of oral nutritional supplementation, which is preferable to parenteral nutrition in the majority of cases.
Abstract: Introduction
Malnutrition has since long been known to be associated with adverse outcomes in cancer patients. The wasting in cancer cachexia involves loss of muscle and fat and reflects a catabolic metabolism induced by an abnormal host response to tumour presence and/or tumour factors. Patients with cancer cachexia frequently develop a chronic negative energy and protein balance driven by a combination of reduced food intake and metabolic change. Thus, alterations in both energy intake and components of energy expenditure may contribute to progressive weight loss. Increased resting energy expenditure related to the systemic inflammatory response is common and a sustained hypermetabolism over a long period of disease progression can make a large contribution to negative energy balance and wasting if not compensated for by an increase in energy intake. Hypermetabolism and diminished energy intake due to anorexia may thus constitute a vicious circle in the development of cancer cachexia.
TL;DR: Communication of pessimistic information to patients with advanced cancer increases the likelihood that patients will report concordant prognostic estimates, and communication of optimistic information does not have any direct effect.
Abstract: Goals of work
Advanced cancer patients’ perceptions of prognosis, which are often overly optimistic compared to oncologist estimates, influence treatment preferences. The predictors of patients’ perceptions and the effect of oncologist communication on patient understanding are unclear. This study was designed to identify the communication factors that influence patient–oncologist concordance about chance of cure.
TL;DR: Patients who used the Internet to find information about cancer felt themselves to be better informed about their disease, and only 3% thought that consulting the Internet increased the frequency of visiting their doctor, whereas 20% felt that information from the Internet influenced the treatment decision made by their doctor.
Abstract: Objective
The objective of this study was to evaluate the extent of internet access and use and patient characteristics associated with internet use. We also aimed to study when and at which sites cancer patients search for information, the self-reported effect on health care use, and patients’ wishes with respect to future internet possibilities.
TL;DR: Results can support physicians in identifying patients most at risk of receiving impaired chemotherapy delivery who would benefit from suitable preventive measures, and remain serious problems in both breast cancer and lymphoma populations undergoing chemotherapy.
Abstract: Neutropenia is a life-threatening, dose-limiting toxicity of many chemotherapy regimens. The goals of this study were to assess the incidence and risk of chemotherapy-induced neutropenia, febrile neutropenia (FN) and dose limitations in breast cancer and lymphoma patients undergoing chemotherapy in Europe. Four hundred forty-four breast cancer and 305 lymphoma patients undergoing chemotherapy at 66 practices in five European countries participated in this prospective, observational study. Predictors of impaired chemotherapy delivery were investigated using a logistic regression model. In breast cancer, FN incidence was low (6%); however, grade 4 neutropenia was frequent (34%). Lymphoma patients experienced higher incidences of FN (non-Hodgkin lymphoma (NHL) 22%; Hodgkin lymphoma (HL) 15%) and grade 4 neutropenia (NHL 54%; HL 40%). For both diseases, FN and grade 4 neutropenia were associated with low relative dose intensity (RDI). Multivariate regression models indicated that first cycle FN, age ≥ 65 years and Eastern Co-operative Oncology Group > 1 were associated with low RDI in breast cancer and lymphoma, while colony-stimulating factor (CSF) primary prophylaxis appeared to be protective in lymphoma only. Primary CSF prophylaxis was provided to 9% of breast cancer, 28% of NHL and 19% of HL patients. Neutropenia and low RDI remain serious problems in both breast cancer and lymphoma populations undergoing chemotherapy. Several risk factors which can trigger reduced chemotherapy delivery were identified. These results can support physicians in identifying patients most at risk of receiving impaired chemotherapy delivery who would benefit from suitable preventive measures.
TL;DR: The Montreal Cognitive Assessment was well tolerated and provided additional information over the MMSE, justifying further validation studies of the MoCA in brain tumor patients.
Abstract: Detection of cognitive impairment in patients with brain metastases is important for both patient management and clinical trials The most commonly used cognitive screen, the Mini Mental State Examination (MMSE), though convenient, is not sensitive in these patients More sensitive tools are less convenient and, therefore, uncommonly used Therefore, a practical and sensitive tool is needed The Montreal Cognitive Assessment (MoCA) is a good candidate, shown to be sensitive in detecting mild cognitive impairment in the pre-dementia setting This study is the first to explore the MoCA in cancer patients and is aimed at determining the feasibility of administering the MoCA in brain tumor patients The secondary objective is to explore the relationship between MoCA and MMSE scores Forty patients with brain metastases being treated with whole brain radiotherapy were prospectively accrued from January to May 2007 All patients were administered both the MoCA and MMSE The MoCA was completed in 10 min in 88% of patients 92% of all the patients found the MoCA to be only mildly or not at all inconvenient Eighty percent of the patients were deemed cognitively impaired by the MoCA compared with 30% by the MMSE (p < 00001) Of the 28 patients with a normal MMSE, 71% had cognitive impairment according to the MoCA Overall, 50% of the patients had an abnormal MoCA, yet normal MMSE The MoCA was well tolerated and provided additional information over the MMSE, justifying further validation studies of the MoCA in brain tumor patients
TL;DR: Dermatological reactions associated with sunitinib occur frequently and evidence-based treatment recommendations are needed in order to maximize quality of life and optimize clinical outcome.
Abstract: The multikinase inhibitor sunitinib has enhanced the treatment of renal cell carcinoma and gastrointestinal stromal tumor through an improved clinical response with decreased systemic toxicities. However, sunitinib is frequently associated with dermatological adverse reactions. The physical and psychosocial impact of frequent dermatological toxicities can affect consistent antineoplastic therapy and quality of life. Dermatological adverse reaction information was compiled from Pfizer Medical Information and from abstracts from the 2007 American Society of Clinical Oncology annual meeting, Prostate Cancer Symposium, and Gastrointestinal Cancers Symposium. Published clinical trials of sunitinib in MEDLINE, Cochrane Library, Cochrane Controlled Trials Register, and EMBASE Drugs and Pharmacology databases were also included. Information was accessed on or before June 30, 2007. In the pooled analysis, all-grade hand–foot skin reaction occurred in 19% of patients (5% grades 3–4), skin discoloration in 28% (0% grades 3–4), dry skin in 16% (1% grades 3–4), skin rash in 13% (1% grades 3–4), dermatitis in 8% (2% grades 3–4), hair color changes in 10% (0% grades 3–4), alopecia in 6% (0% grades 3–4), and phototoxicity in <0.1%. Dermatological reactions associated with sunitinib occur frequently. Evidence-based treatment recommendations are needed in order to maximize quality of life and optimize clinical outcome.
TL;DR: The data suggest that, while vomiting is well controlled, nausea remains a significant problem in practice, and optimal management of CINV is yet to be achieved.
Abstract: Objective
The aim of the study was to assess levels of chemotherapy-induced nausea and vomiting (CINV) in routine practice.
TL;DR: At a population level, SPCS were associated with meaningful improvements in short-term (“unmet needs”) and long-term caregiver-defined outcomes.
Abstract: Goals of work
The goal of this study was to evaluate, at a population level, the association between specialized palliative care services (SPCS) and short- and long-term caregiver outcomes.
TL;DR: TS levels mitigated the impact of high FOR on lower levels of QOL, and patients who reported lower TS and greater FOR endorsed significantly lower levelsof QOL compared to other patients in the sample.
Abstract: Fear of cancer recurrence (FOR) is common in prostate cancer patients, but little research has examined the impact of FOR on quality of life (QOL) or the mechanism by which these fears become intensified. The objective of this study was to examine treatment satisfaction (TS) as a moderator of the relationship between FOR and QOL. Data were drawn from the CaPSURE™ database, a 12,000-man national observational prostate cancer registry. Three hundred and thirty-three patients who underwent radical prostatectomy (RP) to treat their prostate cancer completed self-report measures. TS was measured 0–6 months post-RP with a nine-item scale developed for this study, FOR was measured 6–12 months post-RP with a previously validated five-item scale, and QOL was measured 12–18 months post-RP with the Short Form 36. After controlling for age, education, number of comorbid medical conditions, and cancer severity, lower FOR (B = −0.12, p < 0.0001), higher TS (B = 0.09, p < 0.001), and the interaction of TS × FOR (B = 0.87, p < 0.05) significantly predicted higher mental health QOL scores. Furthermore, lower FOR (B = −0.08, p < 0.01), and the interaction of TS × FOR (B = −1.11, p < 0.01) significantly predicted higher physical health QOL scores. TS levels mitigated the impact of high FOR on lower levels of QOL. Specifically, patients who reported lower TS and greater FOR endorsed significantly lower levels of QOL compared to other patients in the sample.
TL;DR: Doppler myocardial imaging is focused on, a method which allows to sensitively measure myocardia function parameters like myocardian velocity, deformation, or deformation rate and which has been shown to reliably detect early abnormalities in both regional and globalMyocardial function in an early stage.
Abstract: With new anticancer therapies, many patients can have a long life expectancy. Treatment-related comorbidities become an issue for cancer survivors. Cardiac toxicity remains an important side effect of anticancer therapies. Myocardial dysfunction can become apparent early or long after end of therapy and may be irreversible. Detection of cardiac injury is crucial since it may facilitate early therapeutic measures. Traditionally, chemotherapy-induced cardiotoxicity has been detected by measuring changes in left ventricular ejection fraction. This parameter is, however, insensitive to subtle changes in myocardial function as they occur in early cardiotoxicity. This review will discuss conventional and modern cardiologic approaches of assessing myocardial function. It will focus on Doppler myocardial imaging, a method which allows to sensitively measure myocardial function parameters like myocardial velocity, deformation (strain), or deformation rate (strain rate) and which has been shown to reliably detect early abnormalities in both regional and global myocardial function in an early stage.Other newer echocardiographic function estimators are based on automated border detection algorithms and ultrasonic integrated backscatter analysis. A further technique to be discussed is dobutamine stress echocardiography. The use of new biomarkers like B-type natriuretic peptide and troponin and less often used imaging techniques like magnetic resonance imaging and computed tomography will also be mentioned.
TL;DR: Physical activity correlates and barriers among head and neck cancer patients showed that the strongest independent correlates of physical activity were social cognitive and treatment-related (i.e., symptom index).
Abstract: Purpose
Our study purpose was to determine physical activity correlates and barriers among head and neck cancer patients
TL;DR: This trial was unable to adequately test the ability of β-hydroxy β-methylbutyrate, glutamine, and arginine to reverse or prevent lean body mass wasting among cancer patients, but there was a strong trend towards an increased body mass among patients taking the Juven® compound using the secondary endpoint of AUC.
Abstract: Cancer cachexia is a common problem among advanced cancer patients. A mixture of β-hydroxyl β-methyl butyrate, glutamine, and arginine (HMB/Arg/Gln) previously showed activity for increasing lean body mass (LBM) among patients with cancer cachexia. Therefore a phase III trial was implemented to confirm this activity. Four hundred seventy-two advanced cancer patients with between 2% and 10% weight loss were randomized to a mixture of β-hydroxyl β-methyl butyrate, glutamine, and arginine or an isonitrogenous, isocaloric control mixture taken twice a day for 8 weeks. Lean body mass was estimated by bioimpedance and skin-fold measurements. Body plethysmography was used when available. Weight, the Schwartz Fatigue Scale, and the Spitzer Quality of Life Scale were also measured. Only 37% of the patients completed protocol treatment. The majority of the patient loss was because of patient preference (45% of enrolled patients). However, loss of power was not an issue because of the planned large target sample size. Based on an intention to treat analysis, there was no statistically significant difference in the 8-week lean body mass between the two arms. The secondary endpoints were also not significantly different between the arms. Based on the results of the area under the curve (AUC) analysis, patients receiving HMB/Arg/Gln had a strong trend higher LBM throughout the study as measured by both bioimpedance (p = 0.08) and skin-fold measurements (p = 0.08). Among the subset of patients receiving concurrent chemotherapy, there were again no significant differences in the endpoints. The secondary endpoints were also not significantly different between the arms. This trial was unable to adequately test the ability of β-hydroxy β-methylbutyrate, glutamine, and arginine to reverse or prevent lean body mass wasting among cancer patients. Possible contributing factors beyond the efficacy of the intervention were the inability of patients to complete an 8-week course of treatment and return in a timely fashion for follow-up assessment, and because the patients may have only had weight loss possible not related to cachexia, but other causes of weight loss, such as decreased appetite. However, there was a strong trend towards an increased body mass among patients taking the Juven® compound using the secondary endpoint of AUC.
TL;DR: Systemic opioids, administered orally or parenterally, can be used to manage dyspnea in cancer patients, and Nebulized morphine, prochlorperazine, and benzodiazepines are not recommended for the treatment of Dyspnea, and promethazine must not be used parentersally.
Abstract: The goal of the study is to evaluate the effectiveness of four drug classes (opioids, phenothiazines, benzodiazepines, and systemic corticosteroids) for relieving dyspnea experienced by advanced cancer patients. A systematic literature review was conducted to July 2006. Search sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, and the Cochrane Library. Four reviewers selected evidence using predefined criteria: controlled trials not limited to cancer and involving the specified drug classes for dyspnea treatment. Three systematic reviews, one with meta-analysis, two practice guidelines, and 28 controlled trials were identified. Most examined the effect of opioids, generally morphine, on dyspnea. Although the results of individual trials were mixed, the systematic review with meta-analysis detected a significant benefit for dyspnea with systemic opioids; two small placebo-controlled trials in cancer patients found systemic morphine reduced dyspnea, and dihydrocodeine also significantly reduced dyspnea in four placebo-controlled trials. Nebulized morphine was not effective in controlling dyspnea in any study or the meta-analysis. No controlled trials examined systemic corticosteroids in the treatment of cancer patients, and of the other non-opioid drugs examined, only oral promethazine, a phenothiazine, showed some benefit in the relief of dyspnea. Studies varied in methodological quality. Systemic opioids, administered orally or parenterally, can be used to manage dyspnea in cancer patients. Oral promethazine may also be used, as a second-line agent if systemic opioids cannot be used or in addition to systemic opioids. Nebulized morphine, prochlorperazine, and benzodiazepines are not recommended for the treatment of dyspnea, and promethazine must not be used parenterally.
TL;DR: It is indicated that patients receiving palliative therapy have a HHI score not significantly different from patients being treated for cure, and the hope deemed most important is also similar between groups.
Abstract: Goals
Hope is an important factor to consider when caring for cancer patients as a key component of coping with adversity. The aim of our study was to address the following questions: Is there a difference in level of hope between those patients being curatively and those palliatively treated, and how does this change over time? What are patients’ most important hopes? Better understanding of patients’ hopes may promote more effective patient-centered care.
TL;DR: It is suggested that mirtazapine is effective for resolving insomnia as well as anxiety and depressive symptoms in cancer patients, however, more systematic research, such as placebo-controlled studies, is needed.
Abstract: Goals of the work
This study aimed to compare the effectiveness of mirtazapine and imipramine on not only the distressing symptoms of cancer patients such as pain, nausea, vomiting, appetite loss, and sleep disturbances but also depressive and anxiety symptoms.
TL;DR: The educational DVD was considered highly acceptable by patients and was found to increase self-efficacy and reduce supportive care needs, and it is appropriate to give to patients before face-to-face chemotherapy education.
Abstract: Goals of work
Based on meta-analyses regarding the preparation of patients for potentially threatening medical procedures, a DVD, incorporating behavioral role modelling, was developed to prepare patients for chemotherapy and assist them to self-manage side effects. It was hypothesized that patients who watched the DVD (vs those who did not) would report (1) lower anxiety; (2) higher self-efficacy related to coping with treatment side effects; (3) fewer supportive care needs; and (4) higher satisfaction with information received. It was further hypothesized that these effects would be stronger in those perceiving their treatment intent to be curative rather than palliative.
TL;DR: There is considerable variation in the prescribing practices even within a single institution, with many patients receiving high dose of steroids for considerable periods of time and developing related side effects.
Abstract: To document the use of steroids and frequency of their side effects in patients with brain metastases. A survey of oncologists who manage patients with brain metastases was conducted to document steroid prescribing practice in our institution. In addition, a retrospective chart review of 88 patients treated with whole brain radiotherapy (WBRT), identified through the Palliative Radiation Oncology Program database, was conducted for a 6-month period to documents steroid doses prescribed, tapering schedules, and steroid side effects. Ninety percent of physicians responded to the survey. Forty-five percent routinely used dexamethasone 4 mg qid (16 mg/day). The others determined the dose of steroid according to the presence or absence of neurological symptoms. Sixty percent tapered the patient’s steroids over the 4 weeks following completion of WBRT. The most common side effects noted by physicians were: increased appetite or weight gain (46%), insomnia (24%), gastro-intestinal symptoms (20%). In the retrospective study, dexamethasone 4 mg qid was prescribed to 52% patients prior and during WBRT. Sixty-six percent of patients were instructed to taper dexamethasone after WBRT, but details were not provided. The most frequently documented steroid-related side effects were: increased appetite (32%), proximal muscle weakness (28%), and insomnia (21%). There is considerable variation in the prescribing practices even within a single institution, with many patients receiving high dose of steroids for considerable periods of time and developing related side effects. Strategies to reduce the amount and length of steroids may result in improved therapeutic ratio; we are currently accruing onto such a trial.
TL;DR: The PASQOC® questionnaire identified strengths and weaknesses of outpatient care for cancer patients by providing a comparison with other practices, and can help staff of individual practices to improve their performance.
Abstract: To examine how outpatient cancer patients assess their cancer care in private oncology practices and day hospitals, and to identify the extent to which staff meet the expectations of their patients. Private practices (n = 41) and day hospitals (n = 8) in Germany, including 16 “repeater” practices who had already participated in the 2002 Patient Satisfaction and Quality in Oncological Care (PASQOC)® survey. n = 4,615 patients with cancer. Diagnoses: 25% breast cancer, 21% colorectal cancer, 12% haematologic malignancies, 11% lymphomas; mean age 63.5 years; 57% female; n = 1,639 patients from repeater practices. The 2004 PASQOC® questionnaire contained 63 problem-oriented items which covered 15 different dimensions of care. Practice staff invited their patients to participate and surveys were mailed to all sampled patients. For statistical analysis, the problem frequency (PF) was calculated for each item. Of 5,600 patients who received the questionnaire, 4,615 replied (response rate: 82%). The best results were obtained for the dimensions “further support in daily life” (3% PF), “nurses” (5% PF), and “physician-patient-relationship” (8% PF). Potential for improvement was most pronounced for “handling of side effects” (39% PF), “partnership and shared decision making” (30% PF), “side effects” (30% PF) and “communication with other patients” (26% PF). Considerable differences in PFs between practices were observed. Mean results from the 16 repeater practices revealed only few changes compared to the 2002 PASQOC® survey, although some practices had greatly improved their performance. The PASQOC® questionnaire identified strengths and weaknesses of outpatient care for cancer patients. By providing a comparison with other practices, PASQOC® can help staff of individual practices to improve their performance.
TL;DR: The MASCC risk index is both feasible and safe when used in standard clinical practice to guide the management ofFebrile neutropenia in patients with solid tumours and lymphomas.
Abstract: Febrile neutropenia (FN) represents a spectrum of severity in which low-risk patients can be defined using the Multinational Association for Supportive Care in Cancer (MASCC) risk index. However, despite publication in 2000, there remains limited published literature to date to support the use of MASCC risk assessment in routine clinical practice and eligibility for early hospital discharge. In this study, we present our experience with the routine use of the MASCC risk index to determine the management of FN in our institution. Patients treated for solid tumours or lymphomas with low-risk FN (MASCC score ≥21) were eligible for oral antibiotics (ciprofloxacin plus either co-amoxiclav or doxycycline) and for early hospital discharge irrespective of first or subsequent episode. The primary outcome was rate of resolution of FN without serious medical complications (SMC). Secondary outcomes were the “success” of antibiotic therapy without treatment modifications, duration of hospitalisation and rate of readmissions. A total of 100 FN episodes occurring in 83 patients were treated over a 6-month period. Ninety of these episodes were low-risk (90%), of which 75 received oral antibiotics (83.3%) and 3 (3.3%) experienced SMC, and the success rate was 94.5% [95% confidence interval (CI) 89.6–99.3%] in low-risk episodes. The median duration of hospitalisation was 2.5 days (25th centile: 1.0 day; 75th centile: 5.0 days) in low-risk compared to 6.5 days (25th centile: 5.3 days; 75th centile: 9.3 days) in high-risk episodes (p = 0.003); 2 days for low-risk episodes treated with oral antibiotics compared to 4 days for low-risk receiving intravenous antibiotics (p = 0.015). Positive predictive value for the MASCC index was 96.7% (95% CI 95.0–98.6%). The MASCC risk index is both feasible and safe when used in standard clinical practice to guide the management of FN in patients with solid tumours and lymphomas. Patients predicted to have low risk can be managed safely with oral antibiotics and early hospital discharge.