Should we treat pain in the elderly palliative care cancer patients differently?

Opioids are considered the cornerstone of pain management in palliative care. Available data suggest that older patients use different analgesics and lower opioid doses compared to younger patients. However, it has not been elucidated yet whether such dosing is associated with worse pain levels or shorter survival in the palliative care setting. We evaluated the relationship among pain scores, quality of life, opioid dose, and survival in palliative care cancer patients in a hospice setting. A total of 137 palliative care cancer patients were analyzed prospectively. We divided patients into two groups using the age of 65 as a cut-off value. Younger patients exhibited significantly higher pain ratings (5.14 vs. 3.59, p=0.01), although older patients used almost 20 mg less oral morphine equivalent (OME) on arrival (p=0.36) and 55 mg OME/day less during the last week (p=0.03). There were no differences in survival between the two groups (17.36 vs. 17.58 days). The elderly patients also used nonsteroidal analgesics less often and paracetamol more often. Hence, using lower opioid doses in older palliative care cancer patients does not result in worse pain rating, and could be a plausible approach for pain management in this patient group.

Smoking Cessation after a Cancer Diagnosis: A Cross-Sectional Analysis in the Setting of a Developing Country.

Since smoking accounts for around 30% of all cancer deaths, public health campaigns often focus on smoking cessation as a means of primary prevention. However, smoking after cancer diagnosis is also associated with a higher symptom burden and lower survival rate. As data regarding smoking cessation vary dramatically between different populations, we aimed to analyze smoking prevalence in cancer patients, smoking cessation after cancer diagnosis, and the factors associated with smoking cessation in the setting of a developing country. We performed a cross-sectional survey on 695 patients in two clinical hospital centers. After cancer diagnosis, 15.6% of cancer patients stopped smoking. Male gender, younger age, and smoking-related cancer were the main factors associated with greater smoking cessation (p < 0.05). A total of 96% of breast cancer patients continued to smoke after cancer diagnosis and, compared to lung and colorectal cancer patients, exhibited a lower reduction in the number of cigarettes smoked (p = 0.023). An alarming rate of smoking prevalence was recorded in younger patients (45.6% at the time of cancer diagnosis) suggesting a future rise in smoking-related cancers and complications. These results should guide anti-smoking public health campaigns in transitional countries with a critical focus on younger and breast cancer patients.

Differences between Transdermal Fentanyl and Buprenorphine in the Elderly Hospice Patients.

INTRODUCTION: Opioids are the most important drugs in treating pain in palliative care patients. Transdermal formulations are especially useful due to their noninvasive nature and minimal interference in daily life. However, studies have shown a controversial relationship of opioids to survival and a rise in deaths associated with the use of transdermal opioids. Although applying precise doses is paramount, we have no clear recommendations for the exact equianalgesic ratio for buprenorphine patch and no recommendation for the type of transdermal opioid to use in hospice. METHODS: We analyzed the differences between the transdermal fentanyl and buprenorphine group by analyzing patient characteristics and evaluating the differences in survival in hospice patients over the age of 65, from 2013 to 2017. RESULTS: A total of 292 patients (75.8%) used fentanyl patch and 93 (24.1%) were on buprenorphine patch. Patients had virtually the same characteristics in both groups. However, when using a 1:100 buprenorphine equianalgesic ratio, there were significant differences in initial and final doses, and it seems that a 1:80 conversion rate is more accurate for elderly hospice patients. Finally, there was no difference in survival between the two groups using transdermal opioids, with or without adjuvant analgesics. DISCUSSION: There were no differences in survival between the group using transdermal fentanyl and the group using buprenorphine in the elderly hospice population. Although adjuvant NSAIDs could be useful in the treatment of pain in terminal cancer, they do not affect survival or reduce the opioid doses, while a 1:80 equianalgesic ratio of buprenorphine might be the most appropriate in this population.

Do Physicians Underestimate Pain in Terminal Cancer Patients? A Prospective Study in a Hospice Setting.

OBJECTIVES: Unrelieved pain is present in a majority of terminal cancer patients. However, the treatment of pain in palliative and hospice care is affected by the lack of validated pain assessment. The goal of this study was to evaluate differences in pain evaluation between terminal cancer patients and physicians and evaluate the pain levels as a survival biomarker. MATERIALS AND METHODS: Patients were evaluated every 7 days for a total of 4 assessments. Physicians evaluated patients' pain on an numeric rating scale (NRS) scale after clinical examination, after which the patients completed NRS, Quality of Life Questionnaire Core 15 Pal (QLQ-C15-PAL), and Edmonton Symptom Assessment System (ESAS) questionnaires. RESULTS: On average, physicians minimally underestimated the pain level in patients (3.47 vs. 3.94 on an NRS scale). Pain was overestimated in 28% and underestimated in 46% of the patients. However, half of all underestimation was clinically meaningful, compared with 28% of the overestimation. For patients with an NRS score of ≥7, pain underestimation was both clinically and statistically significant (5.56 vs. 8.17). Pain ratings exhibited a very small correlation to survival (up to r=-0.22), limiting their use as a survival biomarker. DISCUSSION: Although physicians can accurately assess mild pain in terminal cancer patients in the hospice setting, the underestimation of pain is still clinically significant in almost a quarter of patients, and especially pronounced in patients with higher levels of pain and in female patients. Hence, validated pain assessment is a necessity in hospice care, with the choice of pain evaluation tool dependent on patient and physician preference.

Physical Exercise: An Evaluation of a New Clinical Biomarker of Survival in Hospice Patients.

PURPOSE: Survival analysis is an important issue in palliative care. However, there is a lack of quality clinical biomarkers for assessing survival, especially in bedridden patients. Recent research supports the benefit of physiotherapy in palliative care, as majority of hospice patients are able to perform physical therapy. We propose the hypothesis that the difference in activity during physical exercise can be used as a biomarker of survival in hospice care. METHODS: We examined 536 consecutive patients who performed physical exercises in our hospice from March 2013 to July 2017. Univariate, multivariate, and Kaplan-Meier analysis were performed to explore the association between the level of physical exercise activity and survival. RESULTS: Physical exercises were performed by almost 70% of our hospice patients. The patients who initially performed active exercises lived longer, on average, compared to patients who only managed passive exercises (15 days vs 6 days, hazard ratio 0.60, 0.49-0.74). Surprisingly, the difference in survival based on the level of physical activity remained consistent regardless of the patient performance score, emphasizing its usefulness as an independent survival biomarker in a hospice setting. This tool also gave us an option to recognize a significant proportion of bedridden patients performing active exercises (30%), previously unrecognized using standard performance scales, exhibiting longer survival compared to others with the same performance score. CONCLUSION: Patients' level of activity during physical exercises has the potential to be a valuable new clinical biomarker in palliative care, whether used individually or combined with commonly used performance scales.

Quality of Life in a Hospice: A Validation of the Croatian Version of the EORTC QLQ-C15-PAL.

PURPOSE: Quality of life is the cornerstone of palliative care, and assessing it requires validated and standardized questionnaires. However, the majority of questionnaires are not tested in a hospice setting. The purpose of this study is to evaluate the quality of life in a hospice using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 for Palliative Care (PAL) (EORTC QLQ-C15-PAL) questionnaire and validating it in Croatian language. METHODS: The study was conducted prospectively on 151 consecutive patients who were evaluated at the admittance to the hospice and after 7 days. Along with the EORTC QLQ-C15-PAL, both evaluations included the Edmonton Symptom Assessment System (ESAS) and the Palliative Performance Score (PPS) version 2. Cronbach α coefficient was used to test the reliability of multi-item scales, while construct and concurrent validity was tested using the Pearson correlation coefficients. Known-group validity was evaluated using the Student t test. RESULTS: Physical functioning, pain, and emotional functioning scales all exhibited high reliability on both assessments and met the criteria of Cronbach α ≥.70, while fatigue scale met the predetermined criteria in the follow-up assessment (α = .90). Adequate validity was also displayed, with the highest correlation coefficients between the EORTC QLQ-C15-PAL and ESAS scales recorded for the corresponding items. The EORTC QLQ-C15-PAL was also able to distinguish patients with different PPS scores, exhibiting excellent clinical validity. CONCLUSIONS: The EORTC QLQ-C15-PAL can be used successfully in Croatian palliative care. However, inevitable issues such as low retest percentage due to short survival and low physical functioning scores need to be acknowledged in further formulations of quality of life questionnaires specific to hospice care.