Health care professionals' experiences of dealing with cancer cachexia.

BACKGROUND: Cancer cachexia (CC) is a debilitating syndrome severely impacting patients' quality of life and survivorship. We aimed to investigate the health care professionals' (HCPs') experiences of dealing with CC. METHODS: Survey questions entailed definitions and guidelines, importance of CC management, clinician confidence and involvement, screening and assessment, interventions, psychosocial and food aspects. The online survey was disseminated through Australian and New Zealand palliative care, oncology, allied health and nursing organisations. Frequencies were reported using descriptive statistics accounting for response rates. Associations were examined between variables using Fisher's exact and Pearson's chi-square tests. RESULTS: Over 90% of the respondents (n = 192) were medical doctors or nurses. Over 85% of the respondents were not aware of any guidelines, with 83% considering ≥ 10% weight loss from baseline indicative of CC. CC management was considered important by 77% of HCPs, and 55% indicated that it was part of their clinical role to assess and treat CC. In contrast, 56% of respondents were not confident about managing CC, and 93% believed formal training in CC would benefit their clinical practice. Although formal screening tools were generally not used (79%), 75% of respondents asked patients about specific symptoms. Antiemetics (80%) and nutritional counselling (86%) were most prescribed or recommended interventions, respectively. CONCLUSION: This study underlines the deficiencies in knowledge and training of CC which has implications for patients' function, well-being and survival. HCP training and a structured approach to CC management is advocated for optimal and continued patient care.

A review of the content and psychometric properties of cancer-related fatigue (CRF) measures used to assess fatigue in intervention studies.

PURPOSE: Cancer-related fatigue (CRF) is a common and debilitating consequence of cancer and its treatment. Numerous supportive care interventions have been developed to alleviate CRF; however, the diversity of outcome measures used to assess CRF limits comparability of findings. We aimed to evaluate the content and psychometric properties of measures used to assess CRF in interventions targeting fatigue, to inform the selection of suitable measures in future research. METHODS: Included measures were identified from a systematic review of interventions targeting CRF. General characteristics of each measure were extracted, and item content was assessed against domains specified by the National Comprehensive Cancer Network (NCCN) definition of CRF. Psychometric properties were evaluated against COnsensus-based Standards for the selection of heath Measurement INstruments (COSMIN) criteria. RESULTS: Of 54 measures identified, 25 met inclusion criteria. Seventeen were fatigue-specific and eight a fatigue subscale or single item within a broader measure. Only 14 (56%) were specifically developed for cancer populations. Content coverage according to the NCCN CRF definition ranged from 0 to 75%. Evidence for fulfilment of COSMIN criteria in cancer populations ranged from 0 to 93%, with only five measures meeting > 70% of the COSMIN criteria. CONCLUSION: The Piper Fatigue Scale-Revised had good content coverage, but did not comprehensively address COSMIN criteria. The EORTC-FA12 and FACIT/FACT-F had excellent psychometric properties, with each capturing different aspects of fatigue. Ultimately, the choice of CRF measure should be guided by the research question and the CRF domains most relevant to the particular research context.

Use of Dexamethasone for Severe Fatigue in the Advanced Cancer Population: A Brief Report.

Background: Fatigue is a common and distressing symptom for palliative care patients. Although the current literature emphasizes nonpharmacological management, dexamethasone is reportedly used in clinical practice. This study helps to characterize its use, efficacy, and adverse effects in a real-world setting. Objective: To improve the evidence base by exploring the use, efficacy, and side effect profile of dexamethasone for fatigue management. Methods: This international multisite prospective observational case series assessed the benefit and adverse effects of dexamethasone at baseline (T0) and at five to seven days postbaseline (T1). Fatigue scores were assessed using the symptom assessment scale (SAS) and visual analogue fatigue scale (VAFS). Adverse events were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE). The related samples Wilcoxon signed-rank test was used to compare before and after scores. Results: All 18 patients (male-female, 11:7) had advanced metastatic cancer with most in the deteriorating palliative care phase (56%). The most common dose of dexamethasone was 4 mg daily orally. At T1 (n = 12), improvement was seen in all measures of fatigue; the median SAS scores decreased from 7 to 5.5 (p = 0.007), the median VAFS scores increased from 3 to 5 (p = 0.126), and the median NCI-CTCAE fatigue scores were reduced from 3 to 2.5 (p = 0.18). Dexamethasone was well tolerated; one participant experienced grade 3 delirium. Conclusion: The small number of participants recruited for this study suggests that dexamethasone is not widely used specifically for fatigue. Our results suggest an improvement in fatigue scores from T0 to T1.

The effects of physical exercise in the palliative care phase for people with advanced cancer: a systematic review with meta-analysis.

PURPOSE: The purpose of this systematic review with meta-analysis was to evaluate the safety, feasibility and effectiveness of exercise in the palliative care phase for people with advanced cancer. METHODS: Electronic databases were searched for exercise randomised controlled trials involving individuals with incurable cancer that were published prior to April 14, 2021. Meta-analyses were performed to evaluate the effects of exercise on health outcomes. Subgroup effects for exercise mode, supervision, intervention duration and cancer diagnosis were assessed. RESULTS: Twenty-two trials involving interventions ranging between 2 weeks and 6 months were included. Interventions comprised of aerobic (n = 3), resistance (n = 4), mixed-mode (n = 14) and other exercise (n = 1) modalities. Cancer types consisted of lung (n = 6), breast (n = 3), prostate (n = 2), multiple myeloma (n = 1) and mixed cancer types (n = 10). Meta-analysis of 20 RCTs involving 1840 participants showed no difference in the risk of a grade 2-4 adverse event between exercise and usual care (n = 110 adverse events (exercise: n = 66 events; usual care: n = 44 events), RD = - 0.01 (91% CI = - 0.01, 0.02); p = 0.24). Overall median recruitment, retention and adherence rates were 56%, 80% and 69%, respectively. Meta-analysis of health outcomes showed effects in favour of exercise for quality of life, fatigue, aerobic fitness and lower-body strength (SMD range = 0.27-0.48, all p < 0.05). CONCLUSIONS: Participants who engaged in exercise experienced an increase in quality of life, fitness and strength and a decrease in fatigue. IMPLICATIONS FOR CANCER SURVIVORS: Physical activity programs were found to be safe and feasible for people with advanced cancer in the palliative care phase.

The Level of Distress From Fatigue Reported in the Final Two Months of Life by a Palliative Care Population: An Australian National Prospective, Consecutive Case Series.

CONTEXT: Fatigue is the most commonly reported symptom in life-limiting illnesses, although not much is known about the distress it causes patients as they approach death. OBJECTIVES: To map the trajectory of distress from fatigue reported by an Australian palliative care population in the last 60 days leading up to death. METHODS: A prospective, longitudinal, consecutive cohort study using national data from the Australian Palliative Care Outcomes Collaboration between July 1, 2013, and December 31, 2018. Patients were included if they had at least one measurement of fatigue on a 0-10 numerical rating scale in the 60 days before death. Descriptive statistics were used to analyse patients by diagnostic cohort and functional status. RESULTS: A total of 116,604 patients from 203 specialist palliative care services were analyzed, providing 501,104 data points. Distress from fatigue affected up to 80% of patients referred to palliative care, with the majority experiencing moderate or severe distress. Malignant and nonmalignant diagnoses were equally affected, with the neurological cohort showing the greatest variability. The degree of distress correlated with a patient's functional level; it worsened as a patient's function declined until a patient became bedbound when the reporting of distress reduced. CONCLUSIONS: Distress from fatigue is high in this cohort of patients. Interventions to reduce this distress need to be a research priority.

How Confident Are We at Assessing and Managing Fatigue in Palliative Care Patients? A Multicenter Survey Exploring the Current Attitudes of Palliative Care Professionals.

Background: Fatigue is a common and significant problem for palliative care (PC) patients, affecting up to 80% of patients. Health care professionals (HCPs) commonly underestimate its significance and lack the confidence in how to manage it, resulting in poor quality of life. It is currently not known how PC professionals manage fatigue in clinical practice or what the barriers to implementation are. Objective: To determine the current attitudes of HCPs toward fatigue management in patients with a life-limiting illness. Design/Setting: An electronic survey, created on REDCap, was distributed to all staff working directly with PC patients in both the community and inpatient setting within the Sydney Local Health District. The study duration was for four weeks (May 1-30, 2018). Results: Participants recognized that fatigue is common, but only 58.5% recognized that severe fatigue is more distressing than pain. A total of 77.2% of participants do not find fatigue an easy symptom to manage and less than half (46.9%) feel confident assessing and managing it. There was no consistent systematic approach to management although exercise, education, and pacing/energy conservation were recognized as important interventions. Themes identified as potential barriers to management included lack of resources, poor patient and staff understanding, and patient/disease factors. Conclusions: HCPs lack confidence in assessing fatigue and completing an individualized management plan; the approaches adopted are highly variable. This justifies the need for further education, as well as further research assessing the efficacy of a multimodal intervention and a guideline to assist in management.

"Bouveret's syndrome" presenting with acute pancreatitis a very rare and challenging variant of gallstone ileus.

INTRODUCTION: Bouveret's syndrome is a rare variant of gallstone ileus and describes gastric outlet obstruction secondary to an impacted stone in the duodenum. Its presentation is vague and clinical diagnosis is often difficult resulting in a delay in diagnosis. PRESENTATION OF CASE: We report a patient who presented initially with non-specific symptoms and subsequently with features in keeping with acute pancreatitis, but eventually was found to have Bouveret's syndrome. DISCUSSION: Different treatment strategies are discussed. Although endoscopic treatment combined with many newer modalities like lithotripsy have been tried, surgery remains the definitive management in the vast majority of cases. CONCLUSION: Bouveret's syndrome is a rare condition, can also present as pancreatitis and often difficult to diagnose initially, but with appropriate treatment has a good outcome.