未能切除胰腺癌患者术中NCPB的临床意义

目的 研究术中腹腔神经丛阻滞对无法切除胰腺癌患者的镇痛疗效及并发症。方法 41例患者经腹行直视下的腹腔神经丛阻滞，每人次注射无水酒精20－50ml，同时行胆肠转流或／和胃肠转流，部分患者行区域动脉化疗。结果 腹腔神经丛阻滞后6个月内或已死亡者中有32例患者疼痛完全缓解，4例明显减轻，5例无明显效果。38例术中出现血压下降，15例术后腹泻，结论 术中直视下经腹行无水酒精腹腔神经丛阻滞对缓解未能切除胰腺癌患者的疼痛具有明显的镇痛效果。     

腹腔神经丛阻滞术的应用进展

腹腔神经丛阻滞术（neurolytic celiac plexus block，NCPB）是缓解胰腺癌或其他恶性肿瘤所致上腹部及背部疼痛的有效方法。腹腔神经丛松解术是治疗上腹部癌痛的常规和有效方法，在缓解疼痛的同时减少了镇痛药物导致的不良反应，提高了患者的生存质量。本文对临床常用的腹腔神经丛阻滞术的方法学研究和进展进行综述。      

The Utility of Stereotactic Ablative Radiation Therapy for Palliation of Metastatic Pancreatic Adenocarcinoma

PurposeOur purpose was to report the outcome of stereotactic ablative radiation therapy (SABR) to the primary tumor for patients with metastatic pancreatic cancer.Methods and MaterialsWe examined the records of patients with metastatic pancreatic cancer treated with SABR to the primary tumor between 2002 and 2018. Toxicities were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.03. Pain intensity pre- and post-SABR was scored according to the Stanford Pain Scale as reported by the patient. Time-to-events were calculated from the date of end of SABR delivery.ResultsIn total, 27 patients were identified that met the inclusion criteria. Seventeen (63%) patients received single fraction SABR with a median dose of 25 Gy (range, 12.5-25), and 10 (37%) patients were treated in 5 fractions with a median dose of 33 Gy (range, 25-40). Before the start of SABR, 17 (63%) patients reported having abdominal pain, with a median intensity of 5 in the 0 to 10 pain scale (range, 1-9), 11 (41%) of them needing continuous opioid use. The median follow-up was 6 months (range, 0-18). Median overall survival was 7 months (95% confidence interval, 3-10), with a cumulative incidence of local failures at 1 year of 25% (95% confidence interval, 10-44). After SABR, there was a significant reduction in the mean intensity of pain (P = .01), and a 46% relative reduction in continuous opioid use. Only 2 patients (7%) presented a grade 3 toxicity that could be attributed to treatment.ConclusionsIn this small series, SABR was a safe and effective option for the local palliation of metastatic pancreatic cancer, with measurable improvements in abdominal pain and the need for opioids.     

Health-related quality of life results from the PRODIGE 5/ACCORD 17 randomised trial of FOLFOX versus fluorouracil–cisplatin regimen in oesophageal cancer

BackgroundA recent prospective randomised trial did not reveal significant differences in median progression-free survival between two chemoradiotherapy (CRT) regimens for inoperable non-metastatic oesophageal cancer patients. This secondary analysis aimed to describe the impact of CRT on health-related quality of life (HRQOL), physical functioning, dysphagia, fatigue and pain and to evaluate whether baseline HRQOL domains can predict overall survival.Patients and methodsA total of 267 patients were randomly assigned to receive with 50 Gy of radiotherapy in 25 fractions six cycles of FOLFOX or four cycles of fluorouracil and cisplatin on day 1. HRQOL was prospectively assessed using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire version 3.0 with the oesophageal cancer module (QLQ-OES18).ResultsBoth groups showed high baseline compliance. Subsequently, compliance reduced to 41% at the 6-month follow-up. Baseline HRQOL scores showed no statistical differences between treatment arms. During treatment, both groups exhibited lower physical and social functioning and increased fatigue and dyspnoea, although dysphagia moderately improved in the fluorouracil–cisplatin arm only (p = 0.047).During follow-up, HRQOL scores revealed no significant differences between chemotherapy regimens. Linear mixed model exhibited a treatment-by-time interaction effect for dysphagia (p = 0.017) with a greater decrease in dysphagia in the fluorouracil–cisplatin group. Time until definitive deterioration analysis showed no significant differences in global HRQOL, functional or main symptom domains. However, time until definitive deterioration was significantly longer for the fluorouracil and cisplatin arm compared with FOLFOX for appetite loss (p = 0.002), QLQ-OES-18 pain (p = 0.008), trouble swallowing saliva (p = 0.011) and trouble talking (p = 0.020).ConclusionAnalyses of HRQOL scores revealed no statistically significant differences between patients with inoperable non-metastatic oesophageal cancer treated by FOLFOX versus those treated with a fluorouracil–cisplatin regimen as part of definitive CRT.     

Long-term quality of life in inoperable non-small cell lung cancer patients treated with conventionally fractionated compared to hyperfractionated accelerated radiotherapy – Results of the randomized CHARTWEL trial

Background and purposeTo evaluate the quality of life (QoL) of patients with inoperable non-small cell lung cancer treated with conventionally fractionated radiotherapy (CF) vs. continuous hyperfractionated accelerated radiotherapy weekend-less (CHARTWEL).Material and methodsThe largest monocentric subgroup of the phase III CHARTWEL trial was analyzed up to three years after randomization. QoL was assessed with the European Organization for Research and Treatment of Cancer QoL Core Questionnaire (QLQ-C30) and lung cancer module (QLQ-LC13) and compared using linear mixed models. QoL interrelations with recurrence, metastasis, and death were explored by multi-state modeling.Results160 patients (98%) provided at least one QoL assessment. Average treatment differences of CF vs. CHARTWEL over three years were −5.4 points (95%CI [−13.6,2.8], p = 0.19) in global QoL, 11.9 ([2.8,21.0], p = 0.01) in fatigue, 13.4 ([3.5,23.3], p = 0.009) in pain, 10.5 ([1.3,19.6], p = 0.03) in dyspnea, and 5.2 ([−2.7,13.0], p = 0.19) in dysphagia. At 12 months, the probabilities of being disease-free with good, good or moderate, any global QoL, or alive were 5.1%, 20.3%, 34.2%, 54.4% under CF and 10.4%, 21.0%, 37.5%, 65.3% under CHARTWEL.ConclusionsOver three years, QoL was similar or more favorable under CHARTWEL compared to CF. Modeling QoL together with disease states provided additional insight into treatment comparisons.     

Palliative radiotherapy improves pain and reduces functional interference in patients with painful bone metastases: a quality assurance study

AimsTo characterise the effect of palliative radiotherapy treatment outcomes as evaluated by the Brief Pain Inventory within a radiotherapy clinic, as a quality assurance initiative.Materials and methodsTumour and treatment parameters of patients with painful bone metastases treated through a dedicated bone pain radiotherapy clinic have been prospectively recorded since 2002. One hundred and nine ambulatory patients provided pre- and post-treatment pain assessments at 4–6 weeks after palliative radiotherapy. The self-administered Brief Pain Inventory questionnaire was completed by patients during their visits. Changes in pain and seven-item functional interference scores were analysed.ResultsMost of the patients had prostate (n = 42) or breast (n = 42) cancer. The mean Karnofsky performance score was 70 before palliative radiation therapy. Sixty-eight per cent of patients were treated with a single fraction (6–8 Gy) and 25% received 20 Gy/five fractions. The overall response (reduction in worst pain by ≥2/10) was 72%. Sixty-one per cent of patients had stable or reduced consumption of opioid analgesics. A significant reduction for all seven functional interference items was seen after treatment, the greatest improvement being general activity (−2.4/10). There was significant correlation between pain reduction and improvement in functional interference.ConclusionThis quality assurance initiative showed that palliative radiotherapy reduced both pain and its interference on function among ambulatory patients with symptomatic bone metastases. The reduction in pain was correlated with reductions in functional interference. Clinical trials of palliative radiotherapy should provide data that allow an evaluation of various domains of chronic pain.     

Phase II,randomized, biomarker identification trial (MARK) for erlotinib in patients with advanced pancreatic carcinoma

BackgroundA prospective, randomized phase II study, with mandatory tumor sampling at current disease stage, aimed to identify biomarkers predictive of improved progression-free survival (PFS) in patients with pancreatic cancer treated with erlotinib.Patients and methodsPatients with histologically/cytologically confirmed, unresectable, locally advanced/metastatic pancreatic cancer, who had failed on or were unsuitable for first-line chemotherapy, underwent a tumor biopsy and were then randomized to receive once-daily erlotinib 150 mg or placebo. The primary end point was identification of biomarkers predicting improved PFS with erlotinib. Secondary end points included PFS, overall survival, response and toxicity.ResultsAt data cut-off, 207 patients were enrolled and analyzed. Prespecified biomarker analyses of EGFR protein expression, EGFR gene copy number/mutations/polymorphisms and KRAS mutations did not identify any subgroups with a detrimental effect or a strong benefit for PFS with erlotinib. In the primary analysis, the median PFS was 6.1 versus 5.9 weeks in the erlotinib and placebo arms, respectively [hazard ratio (HR) 0.83; 95% confidence interval (CI) 0.63–1.10; P = 0.1909]. However, observed baseline imbalances indicated worse prognosis in the erlotinib arm. After adjustment for baseline characteristics, a significant PFS benefit for erlotinib was observed (HR 0.68; 95% CI 0.50–0.91; P = 0.0102). Exploratory biomarker analyses showed patients with high baseline serum amphiregulin levels might benefit from erlotinib.ConclusionThis study in patients with inoperable pancreatic cancer did not identify any prespecified biomarkers predictive of PFS benefit with erlotinib. Exploratory analyses suggested high amphiregulin might predict PFS benefit from erlotinib.ClinicalTrials.gov numberNCT00674973.     

An international multicentre validation study of a pain classification system for cancer patients

PurposeThe study’s primary objective was to assess predictive validity of the Edmonton Classification System for Cancer Pain (ECS-CP) in a diverse international sample of advanced cancer patients. We hypothesised that patients with problematic pain syndromes would require more time to achieve stable pain control, more complicated analgesic regimens and higher opioid doses than patients with less complex pain syndromes.MethodsPatients with advanced cancer (n = 1100) were recruited from 11 palliative care sites in Canada, USA, Ireland, Israel, Australia and New Zealand (100 per site). Palliative care specialists completed the ECS-CP for each patient. Daily patient pain ratings, number of breakthrough pain doses, types of pain adjuvants and opioid consumption were recorded until study end-point (i.e. stable pain control, discharge and death).ResultsA pain syndrome was present in 944/1100 (86%). In univariate analysis, younger age, neuropathic pain, incident pain, psychological distress, addictive behaviour and initial pain intensity were significantly associated with more days to achieve stable pain control. In multivariate analysis, younger age, neuropathic pain, incident pain, psychological distress and pain intensity were independently associated with days to achieve stable pain control. Patients with neuropathic pain, incident pain, psychological distress or higher pain intensity required more adjuvants and higher final opioid doses; those with addictive behaviour required only higher final opioid doses. Cognitive deficit was associated with fewer days to stable pain control, lower final opioid doses and fewer pain adjuvants.ConclusionThe replication of previous findings suggests that the ECS-CP can predict pain complexity in a range of practice settings and countries.     

A randomized clinical trial of nerve block to manage end-stage pancreatic cancerous pain

Pain control is the most difficult puzzle in patients with terminal pancreatic cancerous pain. Many methods in clinical practice fail in 20?~?50 % of patients. The present study aims to explore the effect of nerve block on patients with end-stage pancreatic cancerous pain. In this study, 100 subjects with end-stage pancreatic cancerous pain were enrolled and randomly assigned into two groups: 68 in nerve block group (N) and 32 in sham group (S). One group was treated with nerve block and the other group with sham procedure as controls. The pain score (by visual analog scale (VAS)), pain duration, reduction of other analgesic medications, and quality of life (with questionnaire QLQ) were evaluated before and 3 months after interventions. Comparisons were performed between before and after intervention in nerve block group and sham group. The results indicated that compared with sham group, the subjects in nerve block group had significant reduction with pain score, pain duration, and other analgesic medications, as well as improvement of quality of life (P?<?0.05, respectively). In conclusion, nerve block is an effective method for treating patients with end-stage pancreatic cancerous pain.     

Pancreatic cancer risk after treatment of Hodgkin lymphoma

BackgroundAlthough elevated risks of pancreatic cancer have been observed in long-term survivors of Hodgkin lymphoma (HL), no prior study has assessed the risk of second pancreatic cancer in relation to radiation dose and specific chemotherapeutic agents.Patients and methodsWe conducted an international case–control study within a cohort of 19 882 HL survivors diagnosed from 1953 to 2003 including 36 cases and 70 matched controls.ResultsMedian ages at HL and pancreatic cancer diagnoses were 47 and 60.5 years, respectively; median time to pancreatic cancer was 19 years. Pancreatic cancer risk increased with increasing radiation dose to the pancreatic tumor location (P_trend = 0.005) and increasing number of alkylating agent (AA)-containing cycles of chemotherapy (P_trend = 0.008). The odds ratio (OR) for patients treated with both subdiaphragmatic radiation (≥10 Gy) and ≥6 AA-containing chemotherapy cycles (13 cases, 6 controls) compared with patients with neither treatment was 17.9 (95% confidence interval 3.5–158). The joint effect of these two treatments was significantly greater than additive (P = 0.041) and nonsignificantly greater than multiplicative (P = 0.29). Especially high risks were observed among patients receiving ≥8400 mg/m² of procarbazine with nitrogen mustard or ≥3900 mg/m² of cyclophosphamide.ConclusionOur study demonstrates for the first time that both radiotherapy and chemotherapy substantially increase pancreatic cancer risks among HL survivors treated in the past. These findings extend the range of nonhematologic cancers associated with chemotherapy and add to the evidence that the combination of radiotherapy and chemotherapy can lead to especially large risks.     

Fentanyl buccal soluble film (FBSF) for breakthrough pain in patients with cancer: a randomized,double-blind,placebo-controlled study

BackgroundFentanyl buccal soluble film (FBSF) has been developed as a treatment of breakthrough pain in opioid-tolerant patients with cancer. The objective of this study was to evaluate the efficacy of FBSF at doses of 200–1200 μg in the management of breakthrough pain in patients with cancer receiving ongoing opioid therapy.Patients and methodsThis was a multicenter, randomized, double-blind, placebo-controlled, multiple-crossover study that included opioid-tolerant adult patients with chronic cancer pain who experienced one to four daily episodes of breakthrough pain. The primary efficacy assessment was the sum of pain intensity differences at 30 min (SPID30) postdose.ResultsThe intent-to-treat population consisted of 80 patients with ≥1 post-baseline efficacy assessment. The least-squares mean (LSM ± SEM) of the SPID30 was significantly greater for FBSF-treated episodes of breakthrough pain than for placebo-treated episodes (47.9 ± 3.9 versus 38.1 ± 4.3; P = 0.004). There was statistical separation from placebo starting at 15 min up through 60 min (last time point assessed). There were no unexpected adverse events (AEs) or clinically significant safety findings.ConclusionsFBSF is an effective option for control of breakthrough pain in patients receiving ongoing opioid therapy. In this study, FBSF was well tolerated in the oral cavity, with no reports of treatment-related oral AEs.     

芬太尼贴剂用于老年癌痛患者的临床效果观察

目的：探讨老年癌痛患者使用芬太尼透皮贴剂的效果和安全性.方法：63例伴有中度疼痛的癌症晚期患者,年龄大于65岁且伴不同程度的进食困难.入组前使用过解热镇痛药、曲马多、弱阿片类、强痛定等中度镇痛药物,且疼痛不能缓解者.使用西安杨森生产的芬太尼透皮贴剂,初始剂量从2.5 mg开始,连续使用两周,评价治疗前后疼痛缓解程度,生活质量及出现的不良反应.结果：芬太尼透皮贴剂能有效缓解癌病,不良反应轻,改善和提高伴有中度疼痛的老年晚期癌症患者的生活质量.结论：老年癌痛患者使用芬太尼透皮帖剂安全有效.     

Analgesic effect of high intensity focused ultrasound in patients with advanced pancreatic cancer

Objective

The aim of this study was to evaluate the analgesic effect of high intensity focused ultrasound (HIFU) in patients with advanced pancreatic cancer.

Methods

A total of 106 patients with advanced pancreatic cancer accompanied by abdominal pain were treated by HIFU. Pain intensities and quantities of morphine consumption before and after treatment were observed and compared.

Results

The average pain intensities before treatment, and at d3, d7 after treatment were 5.80 ± 2.14, 2.73 ± 2.68, 2.45 ± 2.43 respectively (P < 0.01). Fifty-nine cases (55.7%) got to extremely effective, and 29 cases (27.4%) effective. Total efficient rate was 83.0 %. The average quantities of morphine consumption before and after treatment in the patients with grade III pain were 114.9 ± 132.5 mg, 16.8 ± 39.7 mg each person everyday respectively (P < 0.01).

Conclusion

HIFU can relieve pain suffered by patients with pancreatic cancer effectively. It is a new adjuvant treatment for pancreatic cancer pain.     

Decline in CA19-9 during chemotherapy predicts survival in four independent cohorts of patients with inoperable bile duct cancer

BackgroundCarbohydrate associated antigen (CA19-9) has been approved by the FDA as a biomarker for monitoring treatment effect in pancreatic cancer. However, the value of serum CA19-9 as a biomarker of response to chemotherapy in bile duct cancer is unclear. The aim of this study was to determine if a decline in CA19-9 (CA19-9 response) during chemotherapy is predictive of survival in patients with inoperable bile duct cancer.MethodsConsecutive patients with inoperable bile duct cancer treated at a University Hospital were retrospectively included in an investigational cohort (n = 212). Three validation cohorts were established including patients 1) participating in phase I/II trials at a Danish Hospital (n = 71), 2) identified retrospectively in a Canadian cohort (n = 196) and 3) randomized in the ABC-02 trial (n = 410). Patients with a baseline CA19-9 and at least one CA19-9 value measured 10-12 weeks after the start of chemotherapy were included. Multivariate Cox regression analyses were performed.ResultsPatients meeting the criteria to be included were 54 in the investigational cohort and 34, 68 and 148 in the three validation sets, respectively. Multivariate analysis included radiological response, performance status, bilirubin, gender, site of cancer, extend of disease, CA19-9 at baseline and age. A hazard ratio (HR) of 0.60 (95%CI: 0.44-0.80, p = 0.0005) for death in CA19-9 responders was reached in the investigational cohort. The predictive value of CA 19-9 response was confirmed in all three validation cohorts.ConclusionsCA19-9 response is a robust predictor of survival in patients with inoperable bile duct cancer in four independent data sets.     

A Review of the Impact of Neoadjuvant Chemotherapy on Breast Surgery Practice and Outcomes

IntroductionNeoadjuvant chemotherapy (NAC) is increasingly used in locally advanced breast cancer as it facilitates breast conserving surgery (BCS) and allows surgical treatment of patients considered inoperable at baseline. The aim of this study was to assess the trends in breast cancer management with regard to the administration of NAC and adjuvant chemotherapy and the effect this has on surgical practice, patient outcomes, and patterns of disease recurrence.Patients and MethodsPatients treated with chemotherapy from 2005 to 2014 were identified from a prospectively maintained database. Clinicopathologic details, timing of chemotherapy delivery, and surgical procedures carried out were analyzed.ResultsA total of 1619 patients were included in the study. The NAC group (n = 383) had a higher T stage (P < .001) and higher grade disease than the adjuvant group (P = .017). Luminal A breast cancer was less likely to be treated by NAC. The proportion of patients treated with NAC has increased from 12.1% in 2005 to 48.3% in 2014 (P < .001). There was an increase in the BCS rate over time (P = .002); however, a higher proportion of the neoadjuvant group (55.5%) underwent mastectomy. Timing of chemotherapy influenced the type of reconstructive procedure carried out (P = .003).ConclusionThe number of patients with breast cancer being treated with NAC is increasing, which is influencing the increasing rate of BCS, though mastectomy is still central to the surgical management of those in receipt of NAC.     

Efficacy of Kanglaite against radiotherapy-induced mucositis in head and neck cancer,a phase II trial

PurposeTo explore the potential protective effect of Kanglaite injection against radiotherapy-induced mucositis in patients with head and neck cancer.Patients and methodsThis was an open-label, single-arm, and phase II trial. The primary endpoint was the incidence of grade 3–4 radiation-induced mucositis. The secondary endpoints were hematological toxicity, non-hematological toxicity, nutritional status, and quality of life. All patients received 20 g Kanglaite daily concurrently with radiotherapy.ResultsThe data of 46 patients were available for analysis. The incidence rates of grade 3 mucositis, pain, dysphagia, and neutropenia were 10.9%, 2.2%, 10.9%, and 6.5%, respectively, while the incidence of grade 4 acute toxicities was zero. The rate of opioid use was 2.2%. Radiotherapy dose reduction was 2.2% and no irradiation field was modified. The nutritional supports were oro-enteral nutritional supplements (13.0%), TPN (10.9%), and feeding tubes (0%) during radiotherapy. After radiotherapy, 52.2% of patients lost weight, and the weight loss was <10%. The mean pain score in the QLQ-H&N35 and QLQ-C30 was <50. Patients had nearly normal physical, emotional, and cognitive functions.ConclusionsA low incidence of grade 3–4 radiation-induced mucositis and no severe acute toxic events, with favorable nutritional status and quality of life, were observed in cancer patients after Kanglaite injection. Our findings highlight the need for a prospective, multicenter, and randomized study to investigate the effect of Kanglaite injection on the reduction of radiation-induced mucositis in patients with head and neck cancer.     

Comorbidity, age and overall survival in patients with advanced pancreatic cancer - results from NCIC CTG PA.3: a phase III trial of gemcitabine plus erlotinib or placebo

BackgroundThe effect of comorbidity, age and performance status (PS) on treatment of advanced pancreatic cancer is poorly understood. We examined these factors as predictors of outcome in advanced pancreatic cancer patients treated with gemcitabine +/– erlotinib.Patients and methodsComorbidity was evaluated by two physicians using the Charlson Comorbidity Index (CCI) and correlated with clinical outcome data from the NCIC Clinical Trials Group (NCIC CTG) PA.3 clinical trial.ResultsFive hundred and sixty-nine patients were included; 47% were aged ⩾65 years old, 36% had comorbidity (CCI > 0). In multivariate analysis, neither age (p = 0.22) nor comorbidity (p = 0.21) was associated with overall survival. The baseline presence of better PS and lower pain intensity scores was associated with better overall survival (p < 0.0001 and p = 0.01, respectively). An improvement in survival with the addition of erlotinib therapy was seen in patients age <65 (adjusted hazard ratio (HR) 0.73, p = 0.01) or in the presence of comorbidity (adjusted HR 0.72, p = 0.03). However, neither age nor CCI score was predictive of erlotinib benefit after test for interaction. Patients treated with gemcitabine plus erlotinib who were ⩾65 years of age or those with comorbidity had a higher rate of infections ⩾grade 3.ConclusionLow baseline pain intensity and better PS were associated with improved overall survival, while age and comorbidity were not independent prognostic factors for patients treated with gemcitabine-based therapy.     

Health outcome priorities in older patients with head and neck cancer

ObjectivesOlder patients with head and neck cancer often have comorbidity, have reduced life-expectancy and await intensive treatment. For the decision-making process, knowledge of a patient's health outcome prioritization is of paramount importance. We aim to study the health outcome priorities of older patients with head and neck cancer, and to evaluate whether general health, markers of physical, cognitive, and social functioning, and quality of life are associated with health outcome prioritization.Materials and MethodsPatients aged ≥70 years with head and neck cancer received a Comprehensive Geriatric Assessment and their priorities were assessed using the Outcome Prioritization Tool (OPT). Distribution of first priority, and associations with general health, markers of physical, cognitive, and social functioning, and quality of life were evaluated using ANOVA or chi-square.ResultsOf the 201 included patients, the OPT was available in 170 patients. The majority prioritized maintaining independence (n = 91, 53.3%), followed by extending life (n = 58, 34.1%), reducing pain (n = 14, 8.2%), and reducing other symptoms (n = 7, 4.1%). Housing situation, Body Mass Index, presence of musculoskeletal diseases, and quality of life were significantly related to prioritization of health outcomes. Reducing pain or other symptoms was more often prioritized by patients who lived alone, had a history of musculoskeletal problems, or had poor perceived quality of life. Age, sex, comorbidity, and markers of physical and cognitive functioning were not associated with health prioritization.ConclusionMaintaining independence is most often prioritized by older patients with head and neck cancer. In addition, we found that health outcome priorities of older patients are only limited based on general and specific health characteristics. We suggest to systematically discuss patients' priorities in order to facilitate complex treatment decisions in older patients with cancer.     

Impact of Obesity on Quality of Life,Psychological Distress,and Coping on Patients with Colon Cancer

BackgroundDespite the causal relationship between obesity and colon cancer being firmly established, the effect of obesity on the course of cancer calls for further elucidation. The objective of this study was to assess differences in clinical‐pathological and psychosocial variables between obese and nonobese individuals with colon cancer.Materials and MethodsThis was a prospective, multicentric, observational study conducted from 2015–2018. The sample comprised patients with stage II–III, resected colon cancer about to initiate adjuvant chemotherapy with fluoropyrimidine in monotherapy or associated with oxaliplatin and grouped into nonobese (body mass index <30 kg/m²) or obese (≥30 kg/m²). Subjects completed questionnaires appraising quality of life (European Organization for Research and Treatment of Cancer Quality of Life Core questionnaire), coping (Mini‐Mental Adjustment to Cancer), psychological distress (Brief Symptom Inventory 18), perceived social support (Multidimensional Scale of Perceived Social Support), personality (Big Five Inventory 10), and pain (Brief Pain Inventory). Toxicity, chemotherapy compliance, 12‐month recurrence, and mortality rate data were recorded.ResultsSeventy‐nine of the 402 individuals recruited (19.7%) were obese. Obese subjects exhibited more comorbidities (≥2 comorbidities, 46.8% vs. 30.3%, p = .001) and expressed feeling slightly more postoperative pain (small size‐effect). There was more depression, greater helplessness, less perceived social support from friends, and greater extraversion among the obese versus nonobese subjects (all p < .04). The nonobese group treated with fluoropyrimidine and oxaliplatin suffered more grade 3–4 hematological toxicity (p = .035), whereas the obese had higher rates of treatment withdrawal (17.7% vs. 7.7%, p = .033) and more recurrences (10.1% vs. 3.7%, p = .025). No differences in sociodemographic, quality of life, or 12‐month survival variables were detected.ConclusionObesity appears to affect how people confront cancer, as well as their tolerance to oncological treatment and relapse.Implications for PracticeObesity is a causal factor and affects prognosis in colorectal cancer. Obese patients displayed more comorbidities, more pain after cancer surgery, worse coping, and more depression and perceived less social support than nonobese patients. Severe hematological toxicity was more frequent among nonobese patients, whereas rates of withdrawal from adjuvant chemotherapy were higher in the obese cohort, and during follow‐up, obese patients presented greater 12‐month recurrence rates. With the growing and maintained increase of obesity and the cancers associated with it, including colorectal cancer, the approach to these more fragile cases that have a worse prognosis must be adapted to improve outcomes.     

Evaluation of a Novel Multimodal Opioid-Free Postoperative Pain Management Pathway Following Robotic-Assisted Radical Prostatectomy: A Pilot Series in the Veteran Population

BackgroundVeterans have disproportionate risk of opioid misuse and abuse compared to the civilian population. Managing acute postoperative pain without opioids is of the utmost importance for the Veteran patient population. This pilot study evaluates a novel multimodal opioid-free pain control regimen by assessing postoperative pain in Veterans undergoing robotic-assisted radical prostatectomy (RARP).MethodsProspective data was collected from patients undergoing RARP at a Department of Veterans Affairs Medical Center. Patients in the opioid-cohort received tramadol, hydrocodone-acetaminophen, or oxycodone-acetaminophen postoperatively. The opioid-free novel multimodal approach consisted of 100 mg gabapentin TID, 15 mg ketorolac Q6 hours, and 1 mg scheduled IV acetaminophen Q6 hours. Pain scores were collected using a visual analogue pain scale on postoperative days 0 and 1.ResultsData was collected from 57 patients, 33 treated with opioids and 24 with the opioid-free pathway. There were no significant differences in demographics (P > .05) between cohorts. No significant differences were observed for preoperative and intraoperative variables (P > .05). Average postoperative day 0 pain scores for opioid-free (2.2 ± 3.1) and opioid treatments (3.1 ± 3.1) were not statistically different (P = .1321). Postoperative day 1 differences of average pain scores for opioid-free (0.9 ± 1.9) and opioid (1.6 ± 3.1) treatments were not statistically significant (P = .1647).ConclusionsThe novel multimodal opioid-free treatment in this study may be effectively utilized for postoperative pain during hospital recovery of Veterans undergoing RARP. Future directions include a randomized control clinical trial in the general population.