Treatment of terminal cancer pain in Finland. A questionnaire survey

A questionnaire concerning current practice in the treatment of cancer pain was sent to 783 Finnish physicians. This study is based on the replies from 421 physicians who stated that they at least sometimes see cancer patients. Three simulated patient cases were presented in the questionnaire, and the adequacy of the treatment suggestions was evaluated. The results indicated that drugs predominate in the treatment of cancer pain. The suggested doses of narcotic analgesics were well below the minimum effective daily doses. As many as half of the physicians failed to use the therapeutic modalities correctly, irrespective of the frequency of their seeing cancer patients. Education in effective pain treatment should therefore be intensified to ascertain that all physicians involved in clinical practice have satisfactory knowledge of the treatment of cancer pain.     

居家癌痛患者镇痛治疗现状及影响因素分析

目的了解居家癌痛患者镇痛治疗现况并分析影响因素,为制定干预措施缓解或减轻居家癌痛患者疼痛程度提供依据。方法选择在某三甲医院镇痛门诊治疗的居家癌痛患者158例,采用自制癌痛信息调查表以电话随访方式进行6个月的跟踪随访,随访内容包括疼痛评分、疼痛性质、疼痛部位、用药情况、药物不良反应、门诊复诊等。结果居家癌痛患者疼痛控制程度总均分为5.93±1.62;不同性别、年龄、疼痛性质、疼痛部位、是否自行使用过镇痛药、药物不良反应类型及发生不良反应后应对方式的患者疼痛控制程度评分比较,差异有统计学意义（P〈0.05,P〈0.01）。结论居家癌痛患者镇痛效果不理想,疼痛未能得到良好的控制与多种因素相关。医务人员应深入社区、家庭,加强对癌痛规范化治疗的宣传,帮助患者居家期间规范用药,有效控制疼痛。     

终末期癌症患者自我报告安宁疗护照护质量问卷的编制及信效度检验

目的 编制、检验终末期癌症患者自我报告安宁疗护照护质量问卷,为评价照护质量提供适用性工具。方法 通过文献分析、小组讨论、德尔菲法、预调查形成问卷初稿;先后选取终末期癌症患者238例、254例进行问卷信效度检验与验证分析。结果 问卷包括5个维度共39个条目,探索性因子分析提取5个因子,累积方差贡献率为74.433%;验证性因子分析显示χ²/df=1.721,GFI=0.921,NFI=0.925,CFI=0.963,TLI=0.943,RMSEA=0.054。问卷总Cronbach′s α系数为0.950,折半信度为0.927,重测信度为0.830,内容效度指数为0.950。结论 该问卷具有良好的信效度,可用于评估终末期癌症患者安宁疗护照护质量。     

Treatment of breast cancer in medically underserved women: a review

Women at risk of being undertreated for breast cancer include women who are older, from minority groups, from lower socioeconomic backgrounds, and those without health insurance or insured by Medicaid. Recent reviews of the cancer care experience of medically underserved populations indicate that breast cancer care may be even less optimal for these populations than the majority of women. These are the same women who may experience difficulty obtaining access to medical care once they are diagnosed with breast cancer. Indirect proof of problems with access is manifested as higher recurrence rates of breast cancer and differences in breast cancer-specific survival among medically underserved women. Multiple factors have been shown to affect access to medical care, and therefore quality of care, including patient-level factors, provider-level factors, and health system factors. This article reviews the current state of these factors in explaining breast cancer care in medically underserved women.     

Treatment of neuropathic cancer pain with continuous intrathecal administration of S +-ketamine

The effective treatment of patients suffering from neuropathic cancer pain remains a clinical challenge. When patients experience either insufficient analgesia or problematic side-effects after opioid administration, intrathecal administration of morphine and other medications such as bupivacaine and clonidine may offer significant advantages. Additionally, ketamine, a non-competitive N-methyl-D-Aspartate-receptor antagonist is able to alter pain perception at the spinal level. Because of the potential neurotoxicity after neuraxial use of racemic ketamine, intrathecal administration of the preservative-free active compound, S (+)-ketamine may be a valuable alternative. In this paper, we present a patient with severe neuropathic cancer pain successfully treated by continuous intrathecal infusion of morphine, bupivacaine, clonidine and S (+)-ketamine. Moreover, quality of life measurements before and 3 weeks after the start of spinal treatment revealed an improvement in pain relief and a higher overall quality of life. No clinical signs of neurologic deficit were observed during spinal treatment with S (+)-ketamine. However, the continuous intrathecal administration of S (+)-ketamine should be considered as the last resort because there are no preclinical safety data with relevant concentrations on intrathecal use of S (+)-ketamine.     

居家癌痛患者镇痛治疗现状及影响因素分析

目的了解居家癌痛患者镇痛治疗现况并分析影响因素,为制定干预措施缓解或减轻居家癌痛患者疼痛程度提供依据。方法选择在某三甲医院镇痛门诊治疗的居家癌痛患者158例,采用自制癌痛信息调查表以电话随访方式进行6个月的跟踪随访,随访内容包括疼痛评分、疼痛性质、疼痛部位、用药情况、药物不良反应、门诊复诊等。结果居家癌痛患者疼痛控制程度总均分为5.93±1.62;不同性别、年龄、疼痛性质、疼痛部位、是否自行使用过镇痛药、药物不良反应类型及发生不良反应后应对方式的患者疼痛控制程度评分比较,差异有统计学意义(P0.05,P0.01)。结论居家癌痛患者镇痛效果不理想,疼痛未能得到良好的控制与多种因素相关。医务人员应深入社区、家庭,加强对癌痛规范化治疗的宣传,帮助患者居家期间规范用药,有效控制疼痛。     

Management of pain in the terminally ill

Pain is common in terminal illness. It is a multidimensional experience and requires an integrated approach for its management to be successful.     

Pancreatic cancer

Pancreatic cancer accounts for 3% of all cancers in the UK; 7000 new cases are diagnosed annually and a similar number die from the disease each year. It has an insidious onset and, as a result, presentation is usually late, with only about 10–20% of patients having disease amenable to surgical resection. Following resection, the median survival is 11–20 months and the 5-year survival is 7–25%. Patients with unresectable locally advanced disease have a median survival of 6–11 months, and those with metastatic disease have a median survival of 2–6 months. Accurate staging has a vital role in the management of pancreatic tumours now that non-surgical palliative options are available. Computed tomography is currently the imaging modality of choice for diagnosis and staging of pancreatic cancer. With recent advances in magnetic resonance imaging and endoscopic ultrasonography, it is now possible to improve the accuracy of preoperative staging, particularly with respect to local invasion and regional node involvement. Resection is the only treatment that offers the potential of cure; ideally, an R0 resection should be aimed for. Chemotherapy renders a survival advantage in the adjuvant setting, even in patients undergoing R1 resections. Palliative chemotherapy can improve survival by 10–15% and other palliative therapies are aimed at relieving jaundice, controlling pain, treating malabsorption and reversing cancer cachexia.     

家属对晚期肿瘤患者实施预立医疗照护计划态度的质性研究

目的 了解家属对晚期肿瘤患者实施预立医疗照护计划的态度,为姑息照护领域相关医疗决策的制定提供依据.方法 对17名晚期肿瘤患者家属进行深度访谈,采用现象学分析法分析资料.结果 家属对预立医疗照护计划的态度提炼出4个主题:如患者主动提出,自己愿意支持;预立医疗照护计划本意较好,但不忍患者面对;预立医疗照护计划本身存在一定缺陷,效果令人质疑;目前实施有难度,将来有望推广.家属对晚期肿瘤患者终末治疗的选择提炼出2个主题:不忍患者受苦,选择放弃抢救;进退两难,抢救为无奈之举.结论 晚期肿瘤患者家属在认可预立医疗照护计划的同时存在很多顾虑,知晓抢救的无效性但因外在压力和良心不安选择抢救;医护人员应做好家属健康教育,并协助家属与患者、家属与家属之间进行坦诚沟通,以推广预立医疗照护计划的理念.     

Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients

Background: Patients with chronic non-malignant pain (CNMP) conditions are known to report reduced health-related quality of life (HRQoL). The objective of this exploratory study was to compare HRQoL between patients admitted to a multidisciplinary pain centre, palliative cancer (PC) patients and national norms.
Methods: HRQoL data from 288 patients with CNMP admitted to the multidisciplinary pain centre at Trondheim University Hospital were compared with 434 patients with advanced cancer included in a trial of comprehensive palliative care in the hospital palliative medicine unit and national norms. HRQoL was assessed using the EORTC QLQ-C30. Age- and gender-adjusted norm data were calculated and compared between the two groups.
Results: Scores from both groups deviated from adjusted norm data on all scales, with poorer functioning and more symptoms. Compared with PC patients, CNMP patients reported a larger deviation (worse scores) on global quality of life, cognitive functioning, pain, sleep disturbances and financial difficulties. Deviations from norm data were similar for physical, social and emotional functioning, diarrhoea, dyspnoea and fatigue. PC patients reported worse scores on role functioning, nausea/vomiting, loss of appetite and constipation.
Conclusion: CNMP patients admitted to multidisciplinary pain centres report significantly reduced HRQoL, in addition to severe pain. They consider their HRQoL to be as poor as HRQoL reported from dying cancer patients and substantially poorer than national norms. Factors other than the biological severity of the disease seem to be of major importance for self-reported HRQoL.     

神经语言程序技术在肿瘤患者心理舒缓疗护中的应用

目的减轻肿瘤患者患病期间的心理痛苦,使之以积极的心态面对疾病与死亡。方法成立舒缓疗护中心,与专业心理咨询师合作采用神经语言程序技术对11例有心理咨询需求的中晚期肿瘤患者进行心理辅导,每次60~90min,间隔1周1次。结果11例患者经1~5次神经语言程序技术疗护,10例获得预期效果:2例达成愿望,在亲人的陪伴下安详离世;8例对待疾病的态度改变,积极配合治疗与保健,病情好转,遵医嘱出院继续门诊治疗。1例失败。结论运用神经语言程序技术对肿瘤患者进行心理疏导,可激发患者潜意识自动选择最佳的能力,克服负性情绪,以积极平静的心态面对疾病与死亡。     

腹腔镜手术后的疼痛治疗

腹腔镜手术后早期疼痛是一个值得重视的问题，其强度、时限存在很大个体差异。腹腔镜手术术后疼痛是由不同成分组成，引起疼痛的机制不尽相同，因此目前多主张采用多种方法联合治疗。     

Low doses of epidural ketamine or neostigmine, but not midazolam, improve morphine analgesia in epidural terminal cancer pain therapy

Study Objective: To examine analgesia and adverse effects of combination epidural pain therapy consisting of administration of morphine with either low dose of ketamine, neostigmine, or midazolam in terminal cancer pain patients.

Design: Randomized double-blind study.

Setting: Teaching hospital.

Patients: 48 terminal cancer patients suffering from chronic pain.

Interventions: Patients were randomized to one of four groups (n = 12). The concept of visual analog scale (VAS), which consisted of a 10-cm line with 0 equaling “no pain at all” and 10 equaling “the worst possible pain” was introduced. All patients were taking oral amitriptyline 50 mg at bedtime. Pain was initially treated with epidural morphine 2 mg twice daily (12-hr intervals) to maintain the VAS below 4/10. Afterwards, VAS scores ≥4/10 at any time were treated by adding the epidural study drug (2 ml), which was administered each morning, just after the 2-mg epidural morphine administration. The control group (CG) received 2 mg of epidural morphine (2 ml). The ketamine group (KG) received 0.2 mg/kg epidural ketamine (2 ml). The neostigmine group (NG) received 100 μg epidural neostigmine (2 ml). The midazolam group (MG) received 500 μg epidural midazolam (2 ml). Patients received the study drugs on a daily basis.

Measurements and Main Results: Duration of effective analgesia was measured as time from the study drug administration to the first patient’s VAS score ≥4/10 recorded in days. The groups were demographically the same. The VAS pain scores prior to the treatment were also similar among groups. Only the patients in the KG demonstrated lower VAS scores compared to the MG (p = 0.018). Time since the epidural study drug administration until patient complaint of pain VAS ≥4/10 was higher for both the KG and NG compared to the CG (KG > CG, p = 0.049; NG > CG; p = 0.0163). Only the KG used less epidural morphine compared to the CG during the period of study (25 days) (p = 0.003).

Conclusion: The association of either low-dose epidural ketamine or neostigmine (but not midazolam) to epidural morphine increased the duration of analgesia in the population studied (gt;20 days) compared to the CG and MG (8 to 10 days) when administered in the early stages of terminal cancer pain therapy, without increasing the incidence of adverse effects.     

Ten-year survey reveals differences in GP management of neck and back pain

Purpose

Clinical guidelines provide similar recommendations for the management of new neck pain and low back pain (LBP) but it is unclear if general practitioner’s (GP) care is similar. While GP’s management of LBP is well documented, little is known about GP’s management of neck pain. We aimed to describe GP’s management of new neck pain and compare this to GP’s management of new LBP in Australia between April 2000 and March 2010.

Methods

All GP–patient encounters for a new (i.e. first visit to any medical practitioner) neck pain or LBP problem were compared in terms of treatment delivered, referral patterns and requests for laboratory and imaging investigations.

Results

General practitioners in Australia have managed new neck pain and LBP problems at a rate of 3.1 and 5.8 per 1,000 GP–patient encounters, respectively. GP’s primarily utilised medications, in particular non-steroidal anti-inflammatory drugs, to manage new neck and LBP problems and referred approximately 25% of all patients for imaging. Patients with new neck pain are more frequently managed using physical treatments and were referred more often to allied health professionals and specialists. In comparison, patients with new LBP were managed more frequently with medication, advice, provision of a sickness certificate and ordering of pathology tests.

Conclusions

This is the first time GP management of a new episode of neck pain has been documented using a nationally representative sample and it is also the first time that the management of back and neck pain has been compared. Despite guidelines endorsing a similar approach for the management of new neck pain and LBP, in actual clinical practice Australian GPs manage these two conditions differently.     

基于医院的晚期癌症患者居家延伸服务的可行性研究

目的探讨对晚期癌症患者实施居家延伸服务的可行性及其效果。方法由医院专科医生、护士组成的疼痛专科护理小组与社区护士合作为居家癌痛患者提供居家延伸服务,为期6个月。评价患者对延伸护理服务的满意度及服务前后患者癌痛知识掌握程度。结果 2015年、2016年、2017年1~6月分别有42、81、27例患者完成居家延伸服务,满意度分别为78.6%、95.1%、96.3%。服务后晚期癌症患者癌痛知识掌握程度显著高于服务前(P<0.01)。结论通过居家延伸服务可有效提高晚期癌症患者的癌痛知识掌握度及服务满意度,具有可行性。     

癌症患者主要照顾者家庭尊严干预的研究进展

从家庭尊严干预的相关概念、实施方案及其应用效果进行综述,旨在提高医务人员对家庭尊严干预的意识,维护癌症患者的尊严,提高照顾者生活质量,改善癌症患者及照顾者的身心健康水平,为今后对癌症患者开展家庭尊严干预提供参考,以推动我国安宁疗护的发展。     

A surgeon's look at the treatment of cancer

Radical resection of cancer, such as radical mastectomy and abdominoperineal rectal resection, was developed in the last century. Wide‐field resection and lymph node dissection formed the basic tenets of these operations. Oesophagectomy, hepatectomy, pancreatectomy and other major resections followed. These surgical endeavours led to some spectacular cures, but also frequent postoperative deaths and complications. Advances in surgical technique and medical science have reduced the risk of surgery to an acceptable level. The last two decades have seen patients presenting with earlier and smaller cancers, prompting re‐examination of the basic tenets of oncological resection. Radiotherapy as an adjunct to surgery has reduced the need for wide radical resection of cancer of the breast, rectum and many other sites. Prospective randomized clinical trials have validated the safety of lesser scopes of surgical resection for breast cancer and cutaneous melanoma. The classical radical mastectomy is now seldom carried out. Simple wedge excision (so‐called ‘lumpectomy’) is now the most common operation for breast cancer. Wide radical resection continues to be advocated for cancer of the lung, oesophagus, stomach, and pancreas, but its benefit needs to be confirmed by similar controlled trials. Adjuvant chemotherapy given after resection of breast and colon cancer has proven survival benefit. Chemotherapy can also shrink some bulky, unresectable cancers, making them resectable. Advances in molecular biology have recently allowed the introduction of novel therapeutic agents which can abrogate the growth and progression of some cancers at the molecular level. Technological advances have enabled the development of minimally invasive cancer treatment techniques. Procedures such as radiosurgery, radiofrequency ablation, and video‐assisted endoscopic resections can achieve cancer control with minimized risk and morbidity. The new millennium will see continued evolution in the role of surgery in the treatment of cancer.