Clinical pharmacist in oncology palliative medicine: drug compliance and patient adherence.

OBJECTIVES: Most patients in palliative oncology care are polymorbid and thus treated with multiple drugs. The therapeutic effect and safety of these drugs can be compromised by drug/drug interactions, but also by wider problems such as polypharmacy and compliance. The clinical pharmacist is, therefore, responsible for risk analysis and prevention. Our prospective open label non-randomised clinical study evaluated the importance of a clinical pharmacist in the palliative care team. METHODS: A total of 250 outpatients were included in the clinical study: 126 women (50.4%) and 124 men (49.6%), with a mean age of 71 years (range 21-94 years; SD 11.9). The patients had the performance status scale 0-3 [Formula: see text]. Clinical examinations were performed on a monthly basis (n=509 check-up visits). The clinical pharmacist prepared an educational chart for all medications used after each visit and evaluated any drug-related problems. Follow-up was 6 months. RESULTS: This study found a significant association between drug related-problems and polypharmacy (p<0.001). A low risk of drug-rfelated problems was observed during the initial visit, that is, 68 female (27.2%) and 25 male (10.4%) patients. A greater clinical-pharmaceutical risk was observed among the patients taking antihypertensive drugs (p=0.003) and/or beta blockers (p=0.048). CONCLUSION: This study confirms the essential role of a clinical pharmacist in oncology palliative care. The feedback obtained from the patients showed a notable improvement in their quality of life. Further, this clinical study confirmed the need for a personalised approach in palliative oncology care.

Long-Term Immunological Alertness and Response to COVID-19 Vaccination-Conditions for Prevention in Early Palliative Oncological Care Patients.

Aside from the general population, the COVID-19 pandemic has also affected a group of patients in palliative oncology care. In this study, long-term immune responses against SARS-CoV-2 after vaccination were monitored in a cohort of patients in palliative oncology care. This non-randomized, prospective, and open-label pilot study recruited patients from the Palliative Oncology Program and included 147 patients, of which 80 were females (54.4%) and 67 males (45.6%). The overall evaluation included current health status, SARS-CoV-2 anti-S IgG titer, and neutralizing antibodies using the SARS-CoV-2 virus neutralization test (VNT). Anti-S IgG antibody analysis revealed high (H) antibody levels in 35.7% (n = 10) and very high (VH) levels in 39.3% (n = 11) of patients after the second vaccination dose. Similarly, after the third dose, H was found in 29.6% (n = 32) and VH in 55.5% (n = 60) of patients. High and very high anti-S IgG antibody levels were consistent with high VNT titers (>2560) and H antibody levels in 17.1% (n = 12) or VH in 82.9% (n = 58) of patients. Patients with two or more doses showed H and VH antibody levels at a median of 451 and 342 days after vaccination, respectively. In this clinical trial, patients showed high and very high levels of anti-S IgG antibodies over a longer period of time. These patients did not show reduced immunological responses to the COVID-19 vaccine challenge. We can assume that prevention through vaccination can reduce the risk of complications or death from COVID-19 in patients in early palliative oncology care.

Sipping as a Nutritional Supplement in Ambulatory Palliative Oncology Care: A Pilot Study with Noninvasive Methods.

Objective: The implementation of nutritional support is a basic need of patients in palliative oncological care. This pilot study optimized the use of sipping to improve the nutritional status of cancer patients in palliative care. Materials and Method: The pilot study included 63 patients, 61.3 years of age on average (range: 32-82 years of age). The patients were assigned to either group A (no nutritional support n = 39 patients) or group B (sipping as nutritional support n = 24 patients). The patients were evaluated through by noninvasive methods: body weight, waist and arm circumference, and triceps skinfold, bioimpedance analysis, and dynamometry. Quality of life was assessed through modified questionnaires. Results: In contrast with group A, group B did not have a significant weight loss, that is, A: 81.9 ± 15.8-80.5 ± 15.8 kg (P = .028) and B: 73.9 ± 14.9-73 ± 16 kg. Body mass index A: 29 ± 5-28.5 ± 5 kg/m2 (P = .007) and B: 25.3 ± 4.7-25 ± 4.9 kg/m2 (P = .614). Waist circumference A: 93.5 ± 15.1-92.5 ± 14.8 cm (P = .008) and B: 80.1 ± 13.2-80.6 ± 12.3 cm (P = .234). Triceps skinfold A: 12.3 ± 7.2-11 ± 6.7 mm (P = .001) and B: 8.2 ± 6.1-7.9 ± 5.7 mm (P = .207). Fat free mass A: 54.8 ± 11.5-52.8 ± 11.6 kg (P = .018) and B: 54.7 ± 10.9-52.8 ± 11.5 kg (P = .207). Significantly lower dynamometer values were recorded in both groups; A: 25.6 ± 10.4-23.1 ± 10.3 kg (P = .010) and B: 27.4 ± 9.9-24.3 ± 9.1 kg (P = .009). In contrast to group B, the patients in group A showed slight variations in their health status, thus decreasing their scores into the significance limit (P = .072). Conclusion: Our results suggest that providing nutritional support in the form of sipping (∼12 g proteins, 300 kcal) on a daily basis prevents the loss of active tissue mass in palliative oncology patients. Based on these results, we recommend the inclusion of this simple nutritional support to prevent malnutrition in cancer patients in palliative care. The clinical study was registered by the internal ethics committee under the heading of its approval - Institutional Ethics Committee of the Hradec Králové Faculty Hospital, number 201311S2OP.

Cutaneous recurrence of malignant mesothelioma of the tunica vaginalis testis: a rare case report.

BACKGROUND: Mesothelioma of the tunica vaginalis testis is a rare and aggressive cancer; fewer than 90 cases have been reported. It occurs in all age groups, but its highest incidence appears between 55 and 75 years of age. Less than 5% of all malignant mesotheliomas arise from the tunica vaginalis testis. CASE REPORT: The authors present a rare case of localized malignant mesothelioma of the tunica vaginalis testis. Diagnosis and treatment are described. CONCLUSION: Mesothelioma of the tunica vaginalis testis can be asymptomatic for a long time. In more than half of the cases, the clinical manifestations imitate a hydrocele or a tumor mass in the scrotum. Despite treatment, this tumor has a very poor prognosis with a median survival of 23 months.

Palliative care among elderly cancer patients: Own experience.

BACKGROUND: Annually, more than 27,000 persons die of cancer in the Czech Republic. It is known that in addition to the demographic aging of the Czech population, the cancer burden is increased. AIM: These data clearly demonstrate the need for affordable and good follow-up care for patients, especially for older patients and/or patients with no other cancer treatment due to irreversible progression of tumor. MATERIALS AND METHODS: We are talking about so-called palliative cancer care, which can be provided at different levels. One of the most common forms of palliative cancer care is hospice care. RESULTS: Our clinic in the years 2008-2010 received a total of 446 patients. 288 of them were women and 158 men. The average age of women was 61 years (age range 20-81 years). The average age of men was 56 years (age range 18-96 years). The performance status was in the fitness category PS-0 (8%), PS-1 (54%), PS-2 (33%) and PS-3 (5%). CONCLUSION: Currently the outpatient palliative cancer care are coming more into the forefront. This type of care allows patients to stay as long as possible at home among their close relatives. Prerequisite for a well working outpatient palliative care is cooperation with general practitioners and home health care agencies.

Prognostic value of blood cell count-derived ratios in BRAF-mutated metastatic melanoma.

BACKGROUND: The treatment and prognosis of metastatic melanoma have changed during the last decade to include immunotherapy or targeted therapy as standard therapeutic options for BRAF-mutated melanoma. However, predictive and/or prognostic markers are lacking, especially in clinical situations where several options are available. The aim of this study was to determine the association of pre-therapeutic blood cell count-derived ratios (BCDR) with survival in patients with BRAF-mutated metastatic melanoma. METHODS: We evaluated the prognostic role of BCDR in therapy-naïve patients with BRAF-mutated metastatic melanoma treated with immune checkpoint inhibitors or targeted therapy. The impact of BCDR on survival was analysed using univariate and multivariate Cox proportional hazard models. RESULTS: We enrolled 46 patients treated with BRAF inhibitors and 20 patients who received anti-PD-1 checkpoint inhibitors. The median progression-free survival (PFS) and overall survival (OS) were 8.3 and 18.2 months, respectively, with no statistical difference between groups. The objective response rate was 39% (30% in the anti-PD-1 and 44% in the targeted therapy groups). Baseline BCDR values were associated with improved PFS and OS in the immunotherapy group. Only the platelet-to-lymphocyte ratio (PLR) was associated with OS and PFS in the targeted therapy group. Independent prognostic indicators for PFS were lactate dehydrogenase, PLR and the lymphocyte-to-monocyte ratio (LMR) and those for OS were LMR, toxicity and the number of initial metastases. CONCLUSION: BCDR had a substantial prognostic value in patients with BRAF-mutated metastatic melanoma treated with immune checkpoint inhibitors. However, a prognostic role for BCDR seemed less apparent in patients treated with targeted therapies.

Aplastic anemia as a cause of death in a patient with glioblastoma multiforme treated with temozolomide.

BACKGROUND: Standard treatment of glioblastoma multiforme consists of postoperative radiochemotherapy with temozolomide, followed by a 6-month chemotherapy. Serious hematologic complications are rarely reported. CASE REPORT AND RESULTS: The authors present the case of a 61-year-old female patient with glioblastoma multiforme treated with external-beam radiation therapy and concomitant temozolomide. After completion of treatment, the patient developed symptoms of serious aplastic anemia that eventually led to death due to prolonged neutro- and thrombocytopenia followed by infectious complications. CONCLUSION: Lethal complications following temozolomide are, per se, extremely rare, however, a total of four other cases of aplastic anemia have been reported in the literature so far.

Nivolumab induced encephalopathy in a man with metastatic renal cell cancer: a case report.

BACKGROUND: Great progress has recently been made in the treatment of metastatic renal cell carcinoma, including the introduction of nivolumab, an immune checkpoint inhibitor. Despite promising results, this treatment brings a completely new spectrum of adverse events, distinct from those experienced with small-molecule kinase inhibitors. Neurologic immune-related adverse events may be serious and potentially life-threatening complications requiring immediate immunosuppressive therapy. Only a few cases of immune-related encephalitis induced by checkpoint inhibitors have been described and the data regarding the management of this serious adverse event are limited. CASE PRESENTATION: We report the case of a 63-year-old white man with metastatic renal cancer who developed severe chorea-like dyskinesia during nivolumab therapy. The findings on brain magnetic resonance imaging and flow cytometry of cerebrospinal fluid, and the positivity of anti-paraneoplastic antigen Ma2 immunoglobuline G class autoantibodies were consistent with a diagnosis of immune-related encephalitis. High-dose intravenous corticosteroid therapy was started immediately, with no signs of improvement, even when infliximab was added. Our patient refused further hospitalization and was discharged. Three weeks later, he presented with signs of severe urosepsis. Despite intensive treatment, he died 4 days after admission. CONCLUSIONS: The management of less frequent immune-related adverse events has not been fully established and more information is required to provide uniform recommendations. Immune-related encephalitis is a severe and potentially fatal complication requiring immediate hospital admission and extensive immunosuppressive therapy. The examination of cerebrospinal fluid for paraneoplastic antibodies, such as anti-N-methyl-D-aspartate receptor and anti-Ma2 antibodies, in order to distinguish autoimmune etiology from other possible causes is essential and highly recommended.

Tamoxifen and arrhythmia.

Tamoxifen is an orally active selective estrogen receptor modulator that is used in the treatment of breast cancer and is currently the world's largest selling drug for that purpose. However, it has some side effects including hot flashes, menstrual irregularity, vaginal discharges, uterine bleeding, uterine endometrial cancer, hypercoagulability, steatosis hepatis, risk of trombembolism. Long-term data from clinical trials have failed to demonstrate a cardioprotective effect and beneficial effects on serum lipid profiles. Arrhythmia secondary to tamoxifen is very rare.

Quality of life and depression among metastatic breast cancer patients.

Depression is seen in many cancer patients. It is common in the general population and in adults and children with cancer and frequently coexists with anxiety and pain. The pilot study evaluated the level of the global quality of life (QoL) and the incidence and the relevance of the depression among metastatic breast cancer patients in a programme of palliative cancer care. The study is prospective and cross-sectional. Dates were obtained during year 2008 among 41 patients. The mean age of all 41 subjects was 58 years old (aged 41-80 years old). The Czech version of Zung self-rating depression scale was performed for the evaluation of the depression. The Czech version of generic European Quality of Life Questionnaire EQ-5D was performed for the evaluation of the level of global QoL. The statistical evaluation presents that mean ZSDS (Zung self-rating depression score) certifies the presence of the signs of the moderate depression among metastatic breast cancer patients (ZSDS range was 60-69). The incidence of the depression was 61% (25 of all 41 subjects). The relevance of the depression is characterized: the severe depression was proved in five of all 25 subjects, the moderate depression in 10 of all 25 subjects, and the mild depression in 10 of all 25 subjects. The global QoL among metastatic breast cancer patients is on very low level. The mean EQ-5D score (dimension of QoL) was 55%. The mean EQ-5D VAS (subjective health status) was 59.2%. The results showed that subsist association between metastatic breast cancer, depression, and the low level of the global QoL.