Doing the hard work of learning: oncologists' enduring impressions of a year-long communication skills training program.

PURPOSE: Few studies have examined the long-term impact of communication skills training for oncologists. We developed a year-long communication skills curriculum for medical oncology fellows with the primary goals of fostering life-long learning of patient-centered communication skills and internalization of associated attitudes and beliefs. We engaged learners through reflection, narrative methods, and action methods, thereby creating a non-threatening, team-based environment. The purpose of the current study was to determine whether learners perceived that they had acquired enduring skills, attitudes, and knowledge years after they participated. METHODS: Former fellows completed an online cross-sectional survey from June to July 2019 that included demographic information, 21 items on a numerical scale, and 3 narrative prompts. Survey items pertained to 4 domains, including skills, attitudes, confidence with specific scenarios, and overall impressions. The numerical scale ranged from "strongly agree" = 1 to "strongly disagree" = 5. RESULTS: A total of 114 fellows, including 27 teaching assistants, participated in the communication skills training over 8 years. The average time between the end of the training program and completion of the survey was 5.2 years. The response rate was 68/114 (64%). Forty-one (60%, 95% CI: 49.3-73.8) fellows agreed or strongly agreed that the curriculum profoundly impacted their practice of medicine. Forty-three (64%, 95% CI: 51.5-75.5) fellows strongly agreed or agreed that they often found themselves informally sharing lessons they learned during the series. Overall average domain scores were 1.89 (SD = 0.84) for skills, 2.16 (0.79) for attitudes, 2.05 (0.81) for confidence with specific challenges, and 2.38 (0.94) for lasting impressions. Results were significantly more favorable for teaching assistants than for others. CONCLUSION: Engaging, interactive, safe, and learner-centered communication skills training has an enduring and favorable impact on oncologists' self-perceived skills, confidence with specific challenges, and attitudes.

The development of a nomogram to determine the frequency of elevated risk for non-medical opioid use in cancer patients.

OBJECTIVE: Non-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center. METHOD: 3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. "+risk" was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk. RESULTS: 731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. The C-index was 0.8. A nomogram was developed and can be accessed at https://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1. SIGNIFICANCE OF RESULTS: We established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.

Predicting the risk for aberrant opioid use behavior in patients receiving outpatient supportive care consultation at a comprehensive cancer center.

BACKGROUND: Opioid misuse is a growing crisis. Patients with cancer who are at risk of aberrant drug behaviors are frequently underdiagnosed. The primary objective of this study was to determine the frequency and factors predicting a risk for aberrant opioid and drug use behaviors (ADB) among patients who received an outpatient supportive care consultation at a comprehensive cancer center. In addition, the screening performance of the Cut Down-Annoyed-Guilty-Eye Opener (CAGE) questionnaire adapted to include drug use (CAGE-AID) was compared with that of the 14-item Screener and Opioid Assessment for Patients With Pain (SOAPP-14) tool as instruments for identifying patients at risk for ADB. METHODS: In total, 751 consecutive patients with cancer who were referred to a supportive care clinic were reviewed. Patients were eligible if they had diagnosis of cancer and had received opioids for pain for at least 1 week. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), the SOAPP-14, and the CAGE-AID. SOAPP scores ≥7 (SOAPP-positive) were used to identify patients who were at risk of ADB. RESULTS: Among the 729 of 751 (97%) evaluable consults, 143 (19.6%) were SOAPP-positive, and 73 (10.5%) were CAGE-AID-positive. Multivariate analysis revealed that the odds ratio of a positive SOAPP score was 2.3 for patients who had positive CAGE-AID scores (P < .0001), 2.08 for men (P = .0013), 1.10 per point for ESAS pain (P = .014), 1.13 per point for ESAS anxiety (P = .0015), and 1.09 per point for ESAS financial distress (P = .012). A CAGE-AID cutoff score of 1 in 4 had 43.3% sensitivity and 90.93% specificity for screening patients with a high risk of ADB. CONCLUSIONS: The current results indicate a high frequency of an elevated risk of ADB among patients with cancer. Men and patients who have anxiety, financial distress, and a prior history of alcoholism/illicit drug use are at increased risk of ADB.

Perception of Curability Among Advanced Cancer Patients: An International Collaborative Study.

BACKGROUND: There are limited data on illness understanding and perception of cure among advanced cancer patients around the world. The aim of the study was to determine the frequency and factors associated with inaccurate perception of curability among advanced cancer patients receiving palliative care across the globe. MATERIALS AND METHODS: Secondary analysis of a study to understand the core concepts in end-of-life care among advanced cancer patients receiving palliative care from 11 countries across the world. Advanced cancer patients were surveyed using a Patient Illness Understanding survey and Control Preference Scale. Descriptive statistics and multicovariate logistic regression analysis were performed. RESULTS: Fifty-five percent (763/1,390) of patients receiving palliative care inaccurately reported that their cancer is curable. The median age was 58, 55% were female, 59% were married or had a partner, 48% were Catholic, and 35% were college educated. Sixty-eight percent perceived that the goal of therapy was "to get rid of their cancer," and 47% perceived themselves as "seriously ill." Multicovariate logistic regression analysis shows that accurate perception of curability was associated with female gender (odds ratio [OR] 0.73, p = .027), higher education (OR 0.37, p < .0001), unemployment status (OR 0.69, p = .02), and being from France (OR 0.26, p < .0001) and South Africa (OR 0.52, p = .034); inaccurate perception of curability was associated with better Karnofsky performance status (OR 1.02 per point, p = .0005), and being from Philippines (OR 15.49, p < .0001), Jordan (OR 8.43, p < .0001), Brazil (OR 2.17, p = .0037), and India (OR 2.47, p = .039). CONCLUSION: Inaccurate perception of curability in advanced cancer patients is 55% and significantly differs by gender, education, performance status, employment status, and country of origin. Further studies are needed to develop strategies to reduce this misperception of curability in advanced cancer patients. IMPLICATIONS FOR PRACTICE: The findings of this study indicate that inaccurate perception of curability among advanced cancer patients is 55%. Inaccurate perception of curability significantly differs by gender, education, performance status, employment status, and country of origin. There is great need to facilitate improved patient-physician communication so as to improve health care outcomes and patient satisfaction.

Decisional control preferences among patients with advanced cancer: An international multicenter cross-sectional survey.

BACKGROUND: Understanding patients' decision control preferences is important in providing quality cancer care. Patients' decisional control preference can be either active (patients prefer to make decisions themselves), shared (collaborative between patient, their physician, and/or family), or passive (patients prefer that the decisions are made by either the physician and/or their family). AIM: To determine the frequency and predictors of passive decision control preferences among advanced cancer patients. We also determined the concordance between actual decision-making and decision control preferences and its association with patient satisfaction. DESIGN: In this cross-sectional survey of advanced cancer patients referred to palliative care across 11 countries, we evaluated sociodemographic variables, Control Preference Scale, and satisfaction with the decisions and care. RESULTS: A total of 1490 participants were evaluable. Shared, active, and passive decision control preferences were 33%, 44%, and 23%, respectively. Passive decision control preferences (odds ratio, p value) was more frequent in India (4.34, <0.001), Jordan (3.41, <0.001), and France (3.27, <0.001). Concordance between the actual decision-making and decision control preferences was highest in the United States ( k = 0.74) and lowest in Brazil (0.34). Passive decision control preference was significantly associated with (odds ratio per point, p value) better performance status (0.99/point, 0.017), higher education (0.64, 0.001), and country of origin (Brazil (0.26, <0.0001), Singapore (0.25, 0.0003), South Africa (0.32, 0.0002), and Jordan (2.33, 0.0037)). CONCLUSION: Passive decision control preferences were less common (23%) than shared and active decision control preference even among developing countries. Significant predictors of passive decision control preferences were performance status, education, and country of origin.

Creation of Minimum Standard Tool for Palliative Care in India and Self-evaluation of Palliative Care Programs Using It.

BACKGROUND: It is important to ensure that minimum standards for palliative care based on available resources are clearly defined and achieved. AIMS: (1) Creation of minimum National Standards for Palliative Care for India. (2) Development of a tool for self-evaluation of palliative care organizations. (3) Evaluation of the tool in India. In 2006, Pallium India assembled a working group at the national level to develop minimum standards. The standards were to be evaluated by palliative care services in the country. MATERIALS AND METHODS: The working group prepared a "standards" document, which had two parts - the first composed of eight "essential" components and the second, 22 "desirable" components. The working group sent the document to 86 hospice and palliative care providers nationwide, requesting them to self-evaluate their palliative care services based on the standards document, on a modified Likert scale. RESULTS: Forty-nine (57%) palliative care organizations responded, and their self-evaluation of services based on the standards tool was analyzed. The majority of the palliative care providers met most of the standards identified as essential by the working group. A variable percentage of organizations had satisfied the desirable components of the standards. CONCLUSIONS: We demonstrated that the "standards tool" could be applied effectively in practice for self-evaluation of quality of palliative care services.

Scheduled and Breakthrough Opioid Use for Cancer Pain in an Inpatient Setting at a Tertiary Cancer Hospital.

Background: Our aim was to examine the frequency and prescription pattern of breakthrough (BTO) and scheduled (SCH) opioids and their ratio (BTO/SCH ratio) of use, prior to and after referral to an inpatient supportive care consult (SCC) for cancer pain management (CPM). Methods and Materials: Patients admitted at the MD Anderson Cancer Center and referred to a SCC were retrospectively reviewed. Cancer patients receiving SCH and BTO opioids for ≥24 h were eligible for inclusion. Patient demographics and clinical characteristics, including the type and route of SCH and BTO opioids, daily opioid doses (MEDDs) of SCH and BTO, and BTO/SCH ratios were reviewed in patients seen prior to a SCC (pre-SCC) and during a SCC. A normal BTO ratio was defined as 0.5-0.2. Results: A total of 665/728 (91%) patients were evaluable. Median pain scores (p < 0.001), BTO MEDDs (p < 0.001), scheduled opioid MEDDs (p < 0.0001), and total MEDDs (p < 0.0001) were higher, but the median number of BTO doses was fewer (2 vs. 4, p < 0.001), among patients seen at SCC compared to pre-SCC. A BTO/SCH ratio over the recommended ratio (>0.2) was seen in 37.5% of patients. The BTO/SCH ratios in the pre-SCC and SCC groups were 0.10 (0.04, 0.21) and 0.17 (0.10, 0.30), respectively, p < 0.001. Hydromorphone and Morphine were the most common BTO and SCH opioids prescribed, respectively. Patients in the early supportive care group had higher pain scores and MEDDs. Conclusions: BTO/SCH ratios are frequently prescribed higher than the recommended dose. Daily pain scores, BTO MEDDs, scheduled opioid MEDDs, and total MEDDs were higher among the SCC group than the pre-SCC group, but the number of BTO doses/day was lower.

Frequency and Prediction of Burnout Among Physicians Who Completed Palliative Care Fellowship Training - A 10 Year Survey.

CONTEXT: Palliative Care (PC) physicians are vulnerable to burnout given the nature of practice. Reports suggest that burnout frequency is variable across different countries. OBJECTIVE: The main objective of our study was to determine knowledge, attitudes and frequency of burnout among Hospice and Palliative Medicine (HPM) Fellowship graduates trained at a comprehensive cancer center. METHODS: We conducted a survey to determine the knowledge, attitudes, and frequency of burnout in former fellows, consisting of the Maslach Burnout Inventory (MBI) and 41 custom questions. Palliative care fellows who trained at a Comprehensive Cancer Center from 2008 to 2018 were included in the survey. RESULTS: Eighty-four percent of the 52 eligible physicians completed surveys. Median age was 38 years, with 68% females. Seventy-seven percent practiced PC more than 50% of time. Median practice duration was four years, and 84% were board certified. Most common disease types treated were cancer (89%), cardiac (43%) and pulmonary (43%). Burnout rate was high at 52% (n=20). The median scores for emotional exhaustion were 25.5, depersonalization 9, and personal accomplishment 48. Female gender (P=0.07) and having administration as a component in the job description (P=0.044) were associated with risk of burnout. Clinical care setting, work hours/week, frequency of weekend calls, and size of team were not significantly associated with burnout. CONCLUSION: Burnout among former fellows trained in HPM between 2008 and 2018 is high. More research is needed to develop strategies to better prevent and manage burnout among HPM fellowship trained PC physicians.

Frequency of Burnout Among Palliative Care Physicians Participating in a Continuing Medical Education Course.

CONTEXT: Palliative care (PC) physicians are vulnerable for burnout given the nature of practice. The burnout frequency may be variable and reported between 24% and 38% across different countries. OBJECTIVE: The main objective of our study was to determine the frequency of burnout among PC physicians participating in PC continuing medical education course. METHODS: A survey including the Maslach Burnout Inventory-General along with 41 custom questions were administered to determine the frequency of burnout among physicians attending the 2018 Hospice and Palliative Medicine Board review course. RESULTS: Of 110 physicians, 91 (83%) completed the survey. The median age was 48 years with 65% being females, 81% married, 46% in community practice, 38% in practice for 6-15 years. PC was practiced ≥50% of the time by 62%, and 76% were doing clinical work. About 73 (80%) reported that PC is appreciated at their work, 58 (64%) reported insurance to be a burden, and 58 (64%) reported that the electronic medical record was a burden. About 82 (90%) felt optimistic about continuing PC in future. Maslach Burnout Inventory results suggest that 35 (38%) participants reported at least one symptom of burnout. Only being single/separated showed trend toward significance with burnout (P = 0.056). CONCLUSION: Burnout among PC physicians who attended a board review course was 38%. Being single/separated showed trend toward association with burnout. Physicians who choose to attend continuing medical education may have unique motivating characteristics allowing them to better cope with stress and avoid burnout.

Integration of a Mandatory Palliative Care Education Into Hematology-Oncology Fellowship Training in a Comprehensive Cancer Center: A Survey of Hematology Oncology Fellows.

PURPOSE: The primary aim of this study was to determine the attitudes and beliefs of hematology and medical oncology (HMO) fellows regarding palliative care (PC) after they completed a 4-week mandatory PC rotation. METHODS: The PC rotation included a 4-week standardized curriculum covering all PC domains. HMO fellows were provided educational materials and attended all didactic sessions. All had clinical rotation in an acute PC unit and an outpatient clinic. All HMO fellows from 2004 to 2017 were asked to complete a 32-item survey on oncology trainee perception of PC. RESULTS: Of 105 HMO fellows, 77 (73%) completed the survey. HMO fellows reported that PC rotation improved assessment and management of symptoms (98%); opioid prescription (89%), opioid rotation (78%), and identification of opioid adverse effects (87%); communication with patients and families (91%), including advance care planning discussion (88%) and do-not-resuscitate discussion (88%); and they reported comfort with discussing ethical issues (74%). Participants reported improvement in knowledge of symptom assessment and management (n = 76; 98%) as compared with efficacy in ethics (n = 57 [74%]; P = .0001) and for coping with stress of terminal illness (n = 45 [58%]; P = .0001). The PC rotation educational experience was considered either far better or better (53%) or the same (45%) as other oncology rotations. Most respondents (98%) would recommend PC rotations to other HMO fellows, and 95% felt rotation should be mandatory. CONCLUSION: HMO fellows reported PC rotation improved their attitudes and knowledge in all PC domains. PC rotation was considered better than other oncology rotations and should be mandatory.

Patterns of Opioid Prescription, Use, and Costs Among Patients With Advanced Cancer and Inpatient Palliative Care Between 2008 and 2014.

PURPOSE: An understanding of opioid prescription and cost patterns is important to optimize pain management for patients with advanced cancer. This study aimed to determine opioid prescription and cost patterns and to identify opioid prescription predictors in patients with advanced cancer who received inpatient palliative care (IPC). MATERIALS AND METHODS: We reviewed data from 807 consecutive patients with cancer who received IPC in each October from 2008 through 2014. Patient characteristics; opioid types; morphine equivalent daily dose (MEDD) in milligrams per day of scheduled opioids before, during, and after hospitalization; and in-admission opioid cost per patient were assessed. We determined symptom changes between baseline and follow-up palliative care visits and the in-admission opioid prescription predictors. RESULTS: A total of 714 (88%) of the 807 patients were evaluable. The median MEDD per patient decreased from 150 mg/d in 2008 to 83 mg/d in 2014 ( P < .001). The median opioid cost per patient decreased and then increased from $22.97 to $40.35 over the 7 years ( P = .03). The median MEDDs increased from IPC to discharge by 67% ( P < .001). The median Edmonton Symptom Assessment Scale pain improvement at follow-up was 1 ( P < .001). Younger patients with advanced cancer (odds ratio [OR[, 0.95; P < . 001) were prescribed higher preadmission MEDDs (OR, 1.01; P < .001) more often in the earlier study years (2014 v 2009: OR, 0.18 [ P = .004] v 0.30 [ P = .02]) and tended to use high MEDDs (> 75 mg/d) during hospitalization. CONCLUSION: The MEDD per person decreased from 2008 to 2014. The opioid cost per patient decreased from 2008 to 2011 and then increased from 2012 to 2014. Age, prescription year, and preadmission opioid doses were significantly associated with opioid doses prescribed to patients with advanced cancer who received IPC.

Characteristics, findings, and outcomes of palliative care inpatient consultations at a comprehensive cancer center.

PURPOSE: There is limited information available about the role and effect of a palliative care consultation service (mobile team, MT) in patient care. The purpose of this retrospective chart review was to determine the characteristics, findings, and outcomes of patients referred to MT in a comprehensive cancer center and to thereby gain information about its role in this setting. PATIENTS AND METHODS: The study group was 61 consecutive patients assessed by one MT during 2-month period. We reviewed their charts for information about demographic and disease features, reasons for consultation, findings, interventions, and outcomes. RESULTS: Patients were mainly referred by thoracic (n = 21; 34%), genitourinary (n = 10; 16%), and gynecology (n = 9; 15%) services. The majority of patients had metastatic disease (n = 56; 92%). Evaluation of pain was the main reason for the consultation (n = 47; 77%) followed by delirium (n = 10; 16%). The MT found a total of 449 symptoms (median 8 per patient), whereas the referring team had mentioned only 86 (1 symptom per patient) in their requests. Twenty patients (38%) screened positive for a history of alcoholism. The MT diagnosed delirium in 34 patients (56%) and frequently found features of opioid-induced side effects, such as sedation (n = 46; 75%), constipation (n = 43; 70%), and confusion (n = 34; 56%). Frequent MT interventions were: administration of neuroleptics (n = 33; 54%), opioid rotation (n = 30; 49%), and enema (n = 33; 54%). Seventeen patients (28%) showed symptoms improvement within 24 hours and 23 patients within 72 hours (38%). Twenty-five patients (41%) required transfer to the palliative care unit. CONCLUSIONS: The MT had a positive impact on these patients' care in terms of clinical findings and outcomes. Further investigations are warranted.

Patient Home Visits: Measuring Outcomes of a Community Model for Palliative Care Education.

BACKGROUND: Health care professionals may have limited exposure to home-based care. There is no published literature that has described the experiences and satisfaction of participation in patient home visits (PHV). OBJECTIVE: The objective of this article is to describe the characteristics of PHV, our approach, and evaluation by participants over a nine-year period. METHODS: We conducted a review of surveys completed by participants in PHV from 2005-2013. All participants anonymously completed the evaluation questionnaires at the end of PHVs. Different PHV assessment forms were used for the 2005-2010 and 2011-2013 time periods. RESULTS: A total of 34 PHVs were conducted with 106 patients and approximately 750 participants with a mean of 3 patients and 22 participants per PHV between 2005 and 2013. For 18 PHVs there are 317 surveys completed with 353 participants, making it a 90% response rate. Responding participants were physicians 125/543 (23%) and other professionals 418/543 (77%). In both time periods of 2005-2010 and 2011-2013 a survey with a 1 (completely agree) to 5 (completely disagree) scale was used. Agreeing that PHV was an effective teaching tool during 2005-2010 were 335/341 (98%); during 2011-2013, 191/202 (95%) agreed that PHV provided increased understanding and sharing of best practices in palliative care. CONCLUSIONS: PHV was perceived by participants as an effective way of providing interactive community education. A broad range of themes were addressed, and the participants reported high levels of learning in all domains of palliative care. There were no cases of patient or relative expression of distress as a result of PHV.

Percutaneous vertebroplasty--a technique to treat refractory spinal pain in the setting of advanced metastatic cancer: a case series.

We present three cases of severe movement-related spinal pain in patients with advanced metastatic carcinomas successfully treated with percutaneous vertebroplasty (PV). These patients had multi-symptom burden and progressive metastasis. Their movement-related pain was incapacitating and refractory to a variety of more conservative interventions. PV is a minimally invasive technique to stabilize vertebral compression fractures, thereby decreasing spinal pain in this setting. Its use in the setting of advanced cancer with severe movement-related pain has not been previously clarified in the palliative care literature. In summary, PV is a technique with a favorable risk: benefit ratio even in the setting of advanced metastatic cancer. The keys to successful utilization of PV in this patient population are careful patient assessment and selection as outlined in the report, in addition to an experienced care team approach.

Palliative medicine--part 2.

With the recent release of the report from The Institute of Medicine regarding terminal patients, palliative medicine could receive much needed attention among medical specialties in the form of improving education, advanced research, and improved reimbursements. Thus, we continue our two-part series on palliative medicine. In this section, we discuss the assessment and management of symptoms like constipation, nausea/vomiting, hypercalcemia, and hydration.

Reduction of cancer-related fatigue with dexamethasone: a double-blind, randomized, placebo-controlled trial in patients with advanced cancer.

PURPOSE: Cancer-related fatigue (CRF) is the most common symptom in patients with advanced cancer. The primary objective of this prospective, randomized, double-blind, placebo-controlled study was to compare the effect of dexamethasone and placebo on CRF. PATIENTS AND METHODS: Patients with advanced cancer with ≥ three CRF-related symptoms (ie, fatigue, pain, nausea, loss of appetite, depression, anxiety, or sleep disturbance) ≥ 4 of 10 on the Edmonton Symptom Assessment Scale (ESAS) were eligible. Patients were randomly assigned to either dexamethasone 4 mg or placebo orally twice per day for 14 days. The primary end point was change in the Functional Assessment of Chronic Illness-Fatigue (FACIT-F) subscale from baseline to day 15. Secondary outcomes included anorexia, anxiety, depression, and symptom distress scores. RESULTS: A total of 84 patients were evaluable (dexamethasone, 43; placebo, 41). Mean (± standard deviation) improvement in the FACIT-F subscale at day 15 was significantly higher in the dexamethasone than in the placebo group (9 [± 10.3] v 3.1 [± 9.59]; P = .008). The improvement in FACIT-F total quality-of-life scores was also significantly better for the dexamethasone group at day 15 (P = .03). The mean differences in the ESAS physical distress scores at day 15 were significantly better for the dexamethasone group (P = .013, respectively). No differences were observed for ESAS overall symptom distress (P = .22) or psychological distress score (P = .76). Frequency of adverse effects was not significantly different between groups (41 of 62 v 44 of 58; P = .14). CONCLUSION: Dexamethasone is more effective than placebo in improving CRF and quality of life in patients with advanced cancer.

Unrelieved pain and suffering in patients with advanced cancer.

Even with specialist-level palliative care, cancer pain can be difficult to treat especially when the pain is complicated by profound suffering. It is paramount to consider not only the patients' biochemical factors but also their psychosocial and spiritual/existential influences. A multidimensional approach with knowledge of the risk factors for poor pain control is important to prevent, detect, and manage risk factors for intractable pain, including psychosocial distress, addictive behavior, and delirium in patients with terminal cancer. We present 3 cases of patients with advanced cancer with intractable bone pain whose hospital courses were complicated by severe psychosocial distress and delirium. We also propose an algorithm of multidimensional approach to unrelieved pain and suffering in patients with advanced cancer.

Challenges associated with spinal opioid therapy for pain in patients with advanced cancer: a report of three cases.

Intraspinal opioid therapy has been increasingly used for the management of cancer pain refractory to traditional treatment. However, this approach may present challenges in patients with advanced cancer. Three cases are presented that highlight the challenges associated with using neuraxial analgesia to manage cancer pain that was felt to be "refractory" to conventional treatment. Before an invasive procedure, such as placement of a permanent intrathecal opioid delivery system, a rigorous assessment and treatment of total pain (physical, psychological, spiritual, social, and practical) by an interdisciplinary team would be prudent.

Characteristics and correlates of dyspnea in patients with advanced cancer.

BACKGROUND: Dyspnea is a very distressing symptom present in the vast majority of patients with advanced cancer. There are limited data on the characteristics and correlates of dyspnea in this population. The purpose of this study was to characterize dyspnea, explore the differences between breakthrough and continuous presentations, and to determine factors associated with its intensity. METHODS: Prospective observational study among 70 patients with dyspnea referred to a palliative care service. Dyspnea was assessed using the Edmonton Symptom Assessment System (ESAS, 0-10) and the Oxygen Cost Diagram (OCD). Oximetry, pulmonary function tests, Hospital Anxiety and Depression Scale (HADS), and a detailed systematic evaluation of daily characteristics of dyspnea were performed. Other symptoms were recorded using the ESAS. RESULTS: Of 30 patients, 70 (43%) were female, median age was 58 (range, 28-87), and the most frequent cancer diagnosis were lung (31/70; 44%) and urologic (15/70; 21%). Constant dyspnea occurred in 27 of 70 (39%) patients, with 14 of 70 (20%) presenting breakthrough episodes. Breakthrough-only dyspnea occurred in 43 of 70 (61%). The majority of patients with breakthrough episodes (39/57; 68%) presented fewer than 5 episodes daily, most frequently lasting for less than 10 minutes (50/57; 88%). In univariate analyses ESAS dyspnea was associated with fatigue (p < 0.0001), sleep (p = 0.002), anxiety (p = 0.006), depression (p = 0.01), sensation of well-being (p = 0.03), and with OCD (p = 0.001). In multivariate analysis, ESAS dyspnea was associated with fatigue (p = 0.001), forced expiratory volume (p = 0.004), pain (p = 0.01), and depression (p = 0.03). Dyspnea intensity significantly interfered with activities (general activity, p = 0.01, mood, p = 0.02, walking ability, p = 0.04, normal work p = 0.04, and enjoyment of life, p = 0.01). CONCLUSION: Dyspnea in patients with advanced cancer more frequently had breakthrough characteristics, was of very short duration, and interfered with daily activities.