Symptom distress in patients attending an outpatient palliative radiotherapy clinic

Patients with advanced cancer are often polysymptomatic. Different symptoms occur with varying frequency, intensity, and impact. Despite the high prevalence of symptoms in this population, reports of symptomatology in palliative outpatients have been limited. We report the symptom distress in metastatic cancer patients attending an outpatient palliative radiotherapy clinic. Patients referred for palliative radiotherapy for symptom control to the Rapid Response Radiotherapy Program (RRRP) were asked to rate symptom distress using the Edmonton Symptom Assessment Scale (ESAS) at the time of initial consultation. Patient demographics, cancer history, disease status, and analgesic consumption during the previous 24 hours were recorded. Between January 1999 and January 2002, 1,296 patients were seen at the RRRP and consented to participate in the study. Mean symptom distress rates ranged from 1.41 to 5.04. Fatigue, poor sense of well-being, pain, and poor appetite were the highest scored symptoms consecutively. Patients with poorer performance status (KPS < or = 60) had significantly higher symptom distress scores for all nine symptoms (P < 0.001). We conclude that the symptoms of metastatic cancer, including pain, fatigue, depression, anxiety, drowsiness, poor appetite, and sense of well-being, are common among patients attending outpatient palliative clinics. Symptom assessment tools, such as the ESAS, allow for the identification of symptoms and their severity. The appropriate regimen for management of pain and symptoms in metastatic cancer patients can then be planned.     

Fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic as screened by the Edmonton Symptom Assessment System

Introduction

Advanced cancer patients present with a variety of physical and psychological symptoms. Fatigue is one such symptom which reduces overall quality of life and is difficult to manage. The purpose of this study was to report the presence, severity, and correlating factors of fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic.

Materials/methods

Patients referred to the Rapid Response Radiotherapy Program between January 1999 and October 2009 completed the Edmonton Symptom Assessment System (ESAS) prior to consultation. Demographic information including age, Karnofsky Performance Status (KPS), gender, and primary cancer sites were collected. Ordinal logistic regression analysis was conducted to determine relationships between demographic information, other ESAS items, and levels of fatigue. Multivariate ordinal logistic regression analysis was used to determine the most significant predictors of fatigue. A p value of <0.05 was considered statistically significant.

Results

A total of 1,397 patients completed the ESAS prior to consultation. Median age was 68?years (range, 21–95), median KPS was 60 (range, 10–100), and slightly more males completed the ESAS (53.0%). Common primary cancers were of the lung (35.8%), breast (20.7%), and prostate (17.7%). Only 179 (12.8%) patients reported no fatigue; the majority of patients reported moderate (31.8%) or severe (34.4%) fatigue. A low KPS (p?<?0.0001), being female (p?=?0.0056), or being referred for bone metastases (p?=?0.0185) significantly correlated with higher levels of fatigue. Patients with a genitourinary primary cancer (p?=?0.0078) and/or referred for malignant spinal cord compression (p?=?0.0004) reported less fatigue. All other ESAS items were significantly related to fatigue. The most significant predictors of fatigue were pain (p?<?0.0001, odds ratio (OR)?=?1.07), nausea (p?=?0.0010, OR?=?1.10), depression (p?<?0.0001, OR?=?1.10), drowsiness (p?<?0.0001, OR?=?1.33), dyspnea (p?=?0.0003, OR?=?1.08), and overall well-being (p?<?0.0001, OR?=?1.19).

Conclusion

Moderate fatigue was reported in over 66% of our advanced cancer patients prior to radiotherapy. Since radiotherapy inherently causes fatigue, proactive and multidisciplinary management is required for these patients. Similar rates of fatigue severity, in lengthier, fatigue-specific tools, suggest that the ESAS may be a good tool for screening the advanced cancer population.     

A nurse- and pharmacist-led treatment advice clinic for patients attending an HIV outpatient clinic

AIM: This paper is a report of a study to map care pathways, examine the approach of different treatment advisors and explore the acceptability of a nurse- and pharmacist-led treatment advice clinic in order to aid decision-making for the future development and evaluation of the clinic. BACKGROUND: High levels of adherence to antiretroviral drugs are a prerequisite for a successful and durable virological and immunological response to HIV. Treatment guidelines acknowledge that adherence is a process, not a single event, and that adherence support must be integrated into clinical follow-up for all patients receiving these drugs. METHOD: Data were collected between September 2004 and January 2005 through 17 consultation observations and 10 patient interviews in a specialist treatment advice clinic located within a central London HIV outpatient clinic providing care for over 2200 patients, of whom more than 1300 are taking highly active antiretroviral therapy. FINDINGS: The nurses and pharmacist had similar consultation approaches, although follow-up care varied in extent. Benefits of the clinic approach included permitting patients to observe real tablets, tailoring regimens to lifestyles and telephone follow-up. These factors, particularly telephone support, were perceived by patients to assist with adherence. CONCLUSION: The role of telephone support, perceived to assist with initial adherence, requires further investigation. Future work is also needed to explore the health economics of this approach and to determine the actual impact of the clinic on clinical and adherence outcomes.     

Comparing baseline symptom severity and demographics over two time periods in an outpatient palliative radiotherapy clinic

Purpose

The primary objective of this study was to compare the symptom severity in two different patient populations assessed in an outpatient palliative radiotherapy clinic over two time periods spanning 10?years. The secondary objective was to assess any changes in the baseline demographics of these patients.

Methods

Data were collected from 1999 to 2009. Upon initial presentation to the clinic, the Edmonton Symptom Assessment Scale (ESAS) was administered to patients to capture symptom severity. This validated assessment tool asks patients to score their level of pain, tiredness, nausea, depression, anxiety, drowsiness, loss of appetite, well-being, and dyspnea on an 11-point Likert scale. Differences between the two patient groups were assessed using chi-squared analysis and Wilcoxon rank–sum tests. A p value of <0.05 was considered significant.

Results

A total of 1,439 patients completed the ESAS from 1999 to 2009. Patients were divided into two time periods 1999–2002 (n?=?689) and 2006–2009 (n?=?750). Pain, depression, nausea, fatigue, anxiety, drowsiness, and dyspnea were significantly better in 2006–2009 (p?<?0.0001). Loss of appetite was not statistically different between the two time periods (p?=?0.236). Significantly more patients with genitourinary cancers (p?=?0.03) or a referral for a mass (p?<?0.0001) were seen in 2006–2009. More patients with breast cancer (p?=?0.04) and bone pain (p?=?0.0002) were seen in 1999–2002. The median age was significantly higher (70?years vs. 68?years, p?=?0.03) for patients seen in 2006–2009. No significant differences were seen in performance status or gender between the two groups.

Conclusion

There have been statistically significant lower scores in the severity of the majority of symptoms as scored by the latter patient cohort; however, whether this difference in magnitude is clinically significant is debatable. The reason for referral and demographics in patients sent for palliative radiotherapy has changed over a 10-year period. This may be a reflection of the changes in systemic therapies and improvements in supportive care for patients with advanced cancer.     

The development of an interdisciplinary outpatient clinic in specialist palliative care

The interdisciplinary team approach is essential in the assessment and management of the palliative care of patients and their families. An innovative approach has been developed to allow the interdisciplinary team to see patients and their families in an outpatient clinic setting. This has allowed an improved assessment and has demonstrated to patients that a wider approach is undertaken. These interdisciplinary outpatient clinics have been audited and appear to be effective, and acceptable to patients and families.     

The palliative performance scale: examining its inter-rater reliability in an outpatient palliative radiation oncology clinic

Introduction  The Palliative Performance Scale (PPS) was developed by the Victoria Hospice Society in 1996 to modernize the Karnofsky Performance Scale. Currently, it is being used to measure palliative patient performance status in a variety of settings. Despite its widespread use, only one study has examined the inter-rater reliability of the PPS. Purpose  To examine the inter-rater reliability of the PPS in measuring performance status in patients seen in an outpatient palliative radiation oncology clinic Methods  Performance status for 102 consecutive patients was assessed by an oncologist (MD), a radiation therapist (RT), and a research assistant (RA) in the Rapid Response Radiotherapy Program at the Odette Cancer Centre in Toronto, Ontario, Canada. Raters’ scores were analyzed for correlation and compared to evaluate the inter-rater reliability of the PPS tool. Results  Excellent correlation was found between the scores rated by the MD and RA (r = 0.86); good correlation was observed between scores rated by the MD and RT (r = 0.69) and the RT and RA (r = 0.77). Scores between all three raters, as well as between rater pairs, were also found to have good reliability as measured by the Chronbach’s alpha coefficient. Significant results were obtained for the range of PPS scores in which the majority of our patients fell: 40–80%. Conclusion  PPS was shown to have good overall inter-rater reliability in an outpatient palliative setting, but more research is needed to establish the validity and reliability of the tool in a variety of different palliative settings.     

多学科协作癌痛整合门诊的实施与管理

目的 探讨专科医院多学科协作癌痛整合门诊的运营管理模式，为解决“看病难”问题提供参考。方法 同济大学附属上海市肺科医院于2013年起构建癌痛整合门诊一站式多学科协作诊疗模式，由肺内科医师、麻醉师、临床药师、疼痛专科护士兼国家二级心理咨询师组成，通过绿色通道实现癌痛问题的快速检查、诊断及解决；并建立个人档案，登记“疼痛筛查表”，由疼痛专科护士每周电话随访实施疼痛跟踪管理和延续护理。通过调查2018-2021年就诊于癌痛整合门诊的308例患者，了解其就医体验并评价癌痛门诊实施效果。结果 患者就医体验总体满意度为96.4%；认为一次性达到就医目的者占88.3%、认为诊治及时合理者占87.3%、认为居家康复护理指导及时者占78.6%;53.9%的患者认为门诊费用价格适中。结论 与目前分科精细化的诊疗模式相比，多学科癌痛整合门诊为患者提供了一站式的便捷快速诊疗服务，可有效解决看病难的问题，提升了患者的就医满意度，值得临床推广。     

Development of an outpatient oncology symptom management clinic

The Symptom Management Clinic (SMC) at University Hospital in Cincinnati, OH, was established to meet identified needs of patients with cancer seen in an outpatient setting. The initial step in the formation of the SMC consisted of the development of a business plan and the presentation of that business plan to the hospital administration. The development of clinic procedures using the creation of a guideline for pain management as an example is presented, as are medication reconciliation and patient teaching. Implications for clinical practice include the essential nature of collaborative relationships among medical oncologists, nursing, pharmacy, and administrative staff members. Interdisciplinary collaboration among the staff of the SMC facilitated referral to appropriate services within the institution and community.     

Prevalence of HLA-B27 in patients with back pain attending a pain clinic.

101 patients presenting to a pain clinic with low back pain were tested for HLA-B27 status. Eight (7.9%) of the patients were positive for HLA-B27. This prevalence is similar to that recorded in the general population and suggests that few patients referred to our clinic with back pain have undiagnosed spondyloarthropathies.     

Communication with referring physicians in a palliative radiotherapy clinic

Goals The rapid response radiotherapy program (RRRP) at Toronto-Sunnybrook Regional Cancer Center (TSRCC) provides quick access to palliative radiotherapy for patients with a life expectancy of less than 12 months. Patients then return to their referring physician for continued oncologic management. After the initial RRRP consultation, we fax an interim consultation report to the referring physician. The purpose of this study was to assess how useful referring physicians perceive this interim report and whether this report needs to be modified to meet their information needs.Methods Physicians who referred patients to the RRRP and who were faxed an interim consultation report were identified over a 4-month period. These physicians were then faxed a questionnaire that asked how useful the interim report was in patient management, about their satisfaction with the information provided, to critique the report format, and whether the RRRP physician and nurse were easily accessible by telephone.Main results Forty physicians referred patients to the RRRP clinic over the 4-month study period. The response rate to our survey was 58% (23/40). The vast majority of physicians (95%) stated that the interim consultation report was useful in patient management. They felt that treatment details were adequately discussed in the report. The report format was perceived to be clear and concise. Referring physicians wished to be informed about any medication changes. RRRP physicians and nurse were perceived to be easily accessible by telephone if needed.Conclusions Results showed that referring physicians found the faxed interim consultation report useful in patient management. Suggestions were made on how to improve the report, and they will be used to further enhance physician communication and ultimately patient care.     

Strategic procedures in founding a pain outpatient clinic

After 3 years of clinical work the first experiences in founding a pain outpatient clinic shall be reported. Meanwhile we treat about 150 patients every 3 months with more than 300 contacts. Patients suffer from headache, back pain, neuropathic,rheumatic and other pain states, but not cancer pain. Therapy lasts for 18 to 24 months. The different procedures presented as follows are performed with regard to lawful structures and orders. Difficulties consist of logistic transfer, financial problems and professional occupations, so that criteria for real interdisciplinarity are not yet fulfilled.