Patterns of self-reported symptoms in pancreatic cancer patients receiving chemoradiation

Pancreatic cancer is a lethal disease characterized by multiple disease-related symptoms. Chemoradiation therapy is a standard of treatment for locally advanced pancreatic cancer. Although shown to prolong survival, there is little information about treatment-related symptoms or the palliative benefits of chemoradiation. We assessed symptoms of patients with locally advanced pancreatic cancer receiving chemoradiation to determine the prevalence, and co-occurrence, of symptoms and to identify the extent to which symptoms interfered with function. Forty-eight patients were treated with chemoradiation on a Phase I protocol. Patients received radiotherapy (50.4 Gy in 28 fractions), capecitabine (median dose 825 mg/m(2) twice daily), and bevacizumab (2.5-10 mg/kg). Symptom severity and its interference with function were prospectively assessed (at presentation, during, and after chemoradiation) in 43 consenting patients using the M.D. Anderson Symptom Inventory. Results showed that 95% of patients reported at least one of the 13 symptoms assessed at presentation. The most commonly reported symptoms of moderate to severe (>or=5 on a 0-10 scale) intensity at presentation were lack of appetite (24%), pain (19%), fatigue (19%), and sleep disturbance (10%). We observed an increase in patients reporting moderate to severe fatigue, nausea, and sleep disturbance during chemoradiation. McNemar tests for paired binary observations showed the proportion of patients reporting moderate to severe symptoms significantly (P<0.001) decreased after chemoradiation at 94 days follow-up (lack of appetite=7%, pain=7%, fatigue=13%, sleep disturbance=7%). This study demonstrates the feasibility and usefulness of symptom assessment in chemoradiation protocols. Future studies with larger cohorts are needed to further characterize multiple symptoms associated with chemoradiation.     

English Proficiency, Knowledge, and Receipt of HPV Vaccine in Vietnamese-American Women

Cervical cancer is one of the most important disease burdens experienced by Vietnamese-American women. Human papillomavirus (HPV) is the etiological agent in almost all cases of cervical cancer. We surveyed Vietnamese-American women to determine receipt of HPV vaccine and assessed if limited English proficiency and knowledge related to HPV vaccine were associated with HPV vaccine uptake. Of the 113 Vietnamese-American women who participated in the study, 58 % (n = 68) was born in Vietnam. The mean years of residency in the United States was 12.75 years. Only 16 (14 %) reported receiving HPV vaccine and 11 (9 %) reported receiving all three shots. Thirteen women responded that they are not at all likely to receive HPV vaccine. Of the whole sample, 47 % (n = 53) reported proficiency in spoken and written English. English proficiency was significantly associated with receipt of HPV vaccine (OR = 4.4; confidence interval (95 % CI) = 1.2; 16.50; p = 0.03). Of the knowledge items, 70 % (n = 79) responded correctly that HPV increases the risk for cervical cancer. However, as many as 60 % responded incorrectly, that HPV infection can be cured with medication. The item, “People infected with HPV can be cured with medication,” was the most important variable associated with receipt of HPV vaccine. Specifically, those with correct response were 3.8 times more likely to report receiving the HPV vaccine (OR = 3.8; 95 % CI = 1.1; 13.5; p = 0.04). Important public health needs are the development and evaluation of educational programs on HPV and cervical cancer that are designed for Vietnamese-American women.     

Designing and implementing a COPD discharge care bundle

National surveys have revealed significant differences in patient outcomes following admission to hospital with acute exacerbation of COPD which are likely to be due to variations in care. We developed a care bundle, comprising a short list of evidence-based practices to be implemented prior to discharge for all patients admitted with this condition, based on a review of national guidelines and other relevant literature, expert opinion and patient consultation. Implementation was then piloted using action research methodologies with patient input. Actively involving staff was vital to ensure that the changes introduced were understood and the process followed. Implementation of a care bundle has the potential to produce a dramatic improvement in compliance with optimum health care practice.     

Symptom clusters of pain, depressed mood, and fatigue in lung cancer: assessing the role of cytokine genes

Purpose

Symptom clusters, the multiple, co-occurring symptoms experienced by cancer patients, are debilitating and affects quality of life. We assessed if a panel of immune-response genes may underlie the co-occurrence of severe pain, depressed mood, and fatigue and help identify patients with severe versus non-severe symptom clusters.

Methods

Symptoms were assessed at presentation, prior to cancer treatment in 599 newly diagnosed lung cancer patients. We applied cluster analyses to determine the patients with severe versus non-severe symptom clusters of pain, depressed mood, and fatigue.

Results

Two homogenous clusters were identified. One hundred sixteen patients (19 %) comprised the severe symptom cluster, reporting high intensity of pain, depressed mood, and fatigue and 183 (30 %) patients reported low intensity of these symptoms. Using Bayesian model averaging methodology, we found that of the 55 single nucleotide polymorphisms assessed, an additive effect of mutant alleles in endothelial nitric oxide synthase (-1474 T/A) (posterior probability of inclusion (PPI)?=?0.78, odds ratio (OR)?=?0.54, 95 % credible interval (CI)?=?(0.31, 0.93)); IL1B T-31C (PPI?=?0.72, OR?=?0.55, 95 % CI?=?(0.31, 0.97)); TNFR2 Met¹⁹⁶Arg (PPI?=?0.70, OR?=?1.85, 95 % CI?=?(1.03, 3.36)); PTGS2 exon 10+837T?>?C (PPI?=?0.69, OR?=?0.54, 95 % CI?=?(0.28, 0.99)); and IL10RB Lys⁴⁷Glu (PPI?=?0.68; OR?=?1.74; 95 % CI?=?(1.04, 2.92)) were predictive for symptom clusters.

Conclusions

Genetic polymorphisms may facilitate identification of high-risk patients and development of individualized symptom therapies.     

Impact of a Palliative Care Consultation Team on Cancer-Related Symptoms in Advanced Cancer Patients Referred to an Outpatient Supportive Care Clinic

ContextPatients with advanced cancer may develop severe physical and psychosocial symptoms. There are limited data on the impact of an outpatient palliative consultation (PC) team on cancer-related symptoms.ObjectivesTo study the impact of the PC on symptoms in patients with advanced cancer receiving outpatient palliative care.MethodsFour hundred six consecutive patients referred to a supportive care outpatient center (OPC) from January 2006 to June 2007 with complete Edmonton Symptom Assessment Scale (0–10 scale) at the initial and follow-up visits were reviewed. Patient characteristics, change of symptoms at follow-up visit, and response rate were analyzed. Using logistic regression models, the predictors of improvement of pain and fatigue were assessed.ResultsMedian age was 59 years; 53% were female. Median interval between visits was 15 days. Mean scores at baseline and follow-up visits were fatigue 6.8 and 5.3 (P < 0.0001), pain 5.3 and 4.1 (P < 0.0001), depression 3.2 and 2.5 (P < 0.0001), anxiety 3.7 and 2.8 (P < 0.0001), dyspnea 2.7 and 2.5 (P = 0.05), sleep 5 and 4 (P < 0.0001), and well-being 5.2 and 4.4 (P < 0.0001). Dyspnea (odds ratio and P-value, 0.90, 0.03), nausea (0.92, 0.06), and depression (0.91, 0.04) were associated with improvement in fatigue; drowsiness (1.10, 0.04), and feeling of well-being (0.87, 0.02) were associated with improvement in pain.ConclusionThe initial consult by PC achieved significant symptom improvement in patients receiving treatment in the OPC. Further prospective studies are needed.     

Status of cancer pain in Hanoi, Vietnam: A hospital-wide survey in a tertiary cancer treatment center

Little is known about the prevalence of cancer pain in many developing countries. We report a hospital-wide survey of pain in a tertiary cancer center in Hanoi, Vietnam. All inpatients and outpatients age 18 years or older were approached for participation in the study. Data were collected using the Brief Pain Inventory. Results showed a 70% response rate. Prevalence of moderate to severe pain was 50% (89/178), with 23% reporting severe ratings of pain at its "worst" and 33% reporting severe impairment in their ability to work due to pain. Only 1% and 40% reported total and partial pain relief from medications, respectively. This study is among the first to provide a representative view of pain in a tertiary cancer treatment center in Hanoi, Vietnam. The findings provide empirical support for the need for better programmatic efforts to improve relief of cancer pain in developing countries, including Vietnam.     

Discharge or admit? Emergency department management of incidental pulmonary embolism in patients with cancer: a retrospective study

Background

Hospitalization and early anticoagulation therapy remain standard care for patients who present to the emergency department (ED) with pulmonary embolism (PE). For PEs discovered incidentally, however, optimal therapeutic strategies are less clear—and all the more so when the patient has cancer, which is associated with a hypercoagulable state that exacerbates the threat of PE.

Methods

We conducted a retrospective review of a historical cohort of patients with cancer and incidental PE who were referred for assessment to the ED in an institution whose standard of care is outpatient treatment of selected patients and use of low-molecular-weight heparin for anticoagulation. Eligible patients had received a diagnosis of incidental PE upon routine contrast enhanced chest CT for cancer staging. Survival data was collected at 30 days and 90 days from the date of ED presentation and at the end of the study.

Results

We identified 193 patients, 135 (70%) of whom were discharged and 58 (30%) of whom were admitted to the hospital. The 30-day survival rate was 92% overall, 99% for the discharged patients and 76% for admitted patients. Almost all (189 patients, 98%) commenced anticoagulation therapy in the ED; 170 (90%) of these received low-molecular-weight heparin. Patients with saddle pulmonary artery incidental PEs were more likely to die within 30 days (43%) than were those with main or lobar (11%), segmental (6%), or subsegmental (5%) incidental PEs. In multivariate analysis, Charlson comorbidity index (age unadjusted), hypoxemia, and incidental PE location (P?=?0.004, relative risk 33.5 (95% CI 3.1–357.4, comparing saddle versus subsegmental PE) were significantly associated with 30-day survival. Age, comorbidity, race, cancer stage, tachycardia, hypoxemia, and incidental PE location were significantly associated with hospital admission.

Conclusions

Selected cancer patients presenting to the ED with incidental PE can be treated with low-molecular-weight heparin anticoagulation and safely discharged. Avoidance of unnecessary hospitalization may decrease in-hospital infections and death, reduce healthcare costs, and improve patient quality of life. Because the natural history and optimal management of this condition is not well described, information supporting the creation of straightforward evidence-based practice guidelines for ED teams treating this specialized patient population is needed.

     

Early referral to supportive care specialists for symptom burden in lung cancer patients: a comparison of non-Hispanic whites, Hispanics, and non-Hispanic blacks

BACKGROUND:

Effective management of symptoms in cancer patients requires early intervention. This study assessed whether the timing of referral to the Supportive Care Center (SCC) and symptom burden outcome varied by race or ethnicity in lung cancer patients who had been seen at a tertiary cancer center.

METHODS:

Non‐Hispanic white (n = 752), Hispanic (n = 111), and non‐Hispanic black (n = 117) patients with nonsmall cell lung cancer comprised this sample. Data on sociodemographic factors, stage of disease, comorbid conditions, and symptom severity (pain, depressed mood, fatigue) served as potential predictor variables.

RESULTS:

Whereas the mean time (15 months; median = 7 months) from initial presentation at the cancer center to referral to the SCC did not vary by race or ethnicity, we found that Hispanics and non‐Hispanic blacks had higher symptom burden when they first presented at the cancer center than non‐Hispanic whites. Severe pain, depressed mood, and fatigue were significant predictors for early referral (<7 months) of non‐Hispanic whites, but only severe fatigue (P <.05) was predictive of early referral for Hispanics and non‐Hispanic blacks. Furthermore, while the proportion of non‐Hispanic white patients reporting severe pain, depressed mood, and fatigue significantly decreased (P <.001) at first follow‐up visit after referral to the SCC; among Hispanics, improvement was only observed for depressed mood. No improvement in any of these symptoms was observed for non‐Hispanic blacks.

CONCLUSIONS:

Whereas the timing of referral to supportive services did not vary by race, disparities in symptom burden outcomes persisted. Additional studies are needed to validate our findings. Cancer 2012;. © 2011 American Cancer Society.