Definition and classification of cancer cachexia: an international consensus.

To develop a framework for the definition and classification of cancer cachexia a panel of experts participated in a formal consensus process, including focus groups and two Delphi rounds. Cancer cachexia was defined as a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Its pathophysiology is characterised by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism. The agreed diagnostic criterion for cachexia was weight loss greater than 5%, or weight loss greater than 2% in individuals already showing depletion according to current bodyweight and height (body-mass index [BMI] <20 kg/m(2)) or skeletal muscle mass (sarcopenia). An agreement was made that the cachexia syndrome can develop progressively through various stages--precachexia to cachexia to refractory cachexia. Severity can be classified according to degree of depletion of energy stores and body protein (BMI) in combination with degree of ongoing weight loss. Assessment for classification and clinical management should include the following domains: anorexia or reduced food intake, catabolic drive, muscle mass and strength, functional and psychosocial impairment. Consensus exists on a framework for the definition and classification of cancer cachexia. After validation, this should aid clinical trial design, development of practice guidelines, and, eventually, routine clinical management.

Prevalence and correlates of pain in the Canadian National Palliative Care Survey.

BACKGROUND: Pain is a common problem for people with cancer who are nearing the ends of their lives. OBJECTIVE: In the present multicentre Canadian study of palliative cancer care, the prevalence of pain, its perceived severity and its correlates across a range of physical, social, psychological, and existential symptoms and concerns were examined. METHODS: Semistructured interviews were conducted with 381 patients. In addition to inquiring about pain, the interview also assessed 21 other symptoms and concerns, and collected information about demographic characteristics, functional status and medication use. RESULTS: Pain of any intensity was reported by 268 (70.3%) participants, although for 139 (36.5%), the severity was rated as minimal or mild. For 129 (33.9%) individuals, pain was reported as moderate to extreme, and considered by the respondents to be an important ongoing problem. Patients who reported moderate to extreme pain were younger than other participants, but had lower functional status and a shorter median survival duration. They were more likely than other participants to be treated with opioid medications (P<0.001) and, less reliably, with benzodiazepines (P=0.079). Compared with participants with no, minimal or mild pain, those with moderate to extreme pain had a higher prevalence of distressing problems on 11 of 21 other symptoms and concerns. The strongest correlations were with general malaise (rho = 0.44), suffering (rho = 0.40), nausea (rho = 0.34), weakness (rho = 0.31), drowsiness (rho = 0.29) and anxiety (rho = 0.29). CONCLUSIONS: Pain continues to be a difficult problem for many patients who are receiving palliative cancer care, particularly younger individuals who are nearing death.

Cancer pain assessment--can we predict the need for specialist input?

We can anticipate that failure to assess cancer pain adequately will inevitably lead to inappropriate application of pain management options. However, it is not always standard practice to teach the limitations of the question 'How bad is the pain?', as well as the need to consider what may complicate pain management or be a poor prognostic factor for pain control. These issues may complicate cancer pain assessment and require specialist consultation. An internationally accepted classification system for cancer pain could provide the basis for a multidimensional assessment and a common language for clinical and research work. Research dating back to the late 1980s has resulted in the development of the Edmonton Classification System for Cancer Pain. This includes many of the factors that may be prognostic for the complexity of cancer pain management and can assist an inexperienced clinician in anticipating the need for specialist advice.

Should the rate of opioid dose escalation be included as a feature in a cancer pain classification system?

The purpose of this study was to assess the need for opioid dose escalation as a feature of a pain classification system for advanced cancer patients. Opioid dose escalation was included as a prognostic feature in the original Edmonton Staging System (ESS) for pain classification, but was not included among the five features of the revised ESS (rESS): pain mechanism, incident pain, psychological distress, addictive behavior, and cognitive function. Mercadante et al.'s definition of opioid escalation index percentage (OEI%) has been used as a surrogate marker for opioid responsiveness. Our hypothesis was that younger age (<60 years), neuropathic pain, incident pain, psychological distress, and addictive behavior would be associated with an OEI% >5%. Using data from a recent multicenter validation study of the rESS, a secondary analysis of a subsample of 532 advanced cancer patients with a pain syndrome was conducted. Approximately 44% (n=232) of the patients had an OEI% >5%. There were no significant associations between OEI% and age, neuropathic pain, incident pain, psychological distress, or addictive behavior. As originally proposed as a clinical marker, the OEI% may oversimplify the complexity of pain management in advanced cancer patients. Future studies are required to better elucidate the need for opioid dose escalation as a feature of a cancer pain classification system.

Desire for euthanasia or physician-assisted suicide in palliative cancer care.

OBJECTIVE: To investigate the attitudes of terminally ill individuals toward the legalization of euthanasia or physician-assisted suicide (PAS) and to identify those who would personally desire such a death. DESIGN: In the Canadian National Palliative Care Survey, semistructured interviews were administered to 379 patients who were receiving palliative care for cancer. Patients who expressed a desire for physician-hastened death were followed prospectively. MAIN OUTCOME MEASURES: Attitudes toward the legalization of euthanasia or PAS were determined, as was the personal interest in receiving a hastened death. Demographic and clinical characteristics were also recorded, including a 22-item structured interview of symptoms and concerns. RESULTS: There were 238 participants (62.8%) who believed that euthanasia and/or PAS should be legalized, and 151 (39.8%) who would consider making a future request for a physician-hastened death. However, only 22 (5.8%) reported that, if legally permissible, they would initiate such a request right away, in their current situations. This desire for hastened death was associated with lower religiosity (p=.010), reduced functional status (p=.024), a diagnosis of major depression (p<.001), and greater distress on 12 of 22 individual symptoms and concerns (p<.025). In follow-up interviews with 17 participants, 2 (11.8%) showed instability in their expressed desire. CONCLUSION: Among patients receiving palliative care for cancer, the desire to receive euthanasia or PAS is associated with religious beliefs; functional status; and physical, social, and psychological symptoms and concerns. Although this desire is sometimes transitory, once firmly established, it can be enduring.

Edmonton, Canada: a regional model of palliative care development.

Palliative care developed unevenly in Edmonton in the 1980s and early 1990s. Health care budget cuts created an opportunity for innovative redesign of palliative care service delivery. This report describes the components that were developed to build an integrated comprehensive palliative care program, the use of common clinical assessments and outcome evaluation that has been key to establishing credibility and ongoing support. Our program has continued to develop and grow with an ongoing focus on the core areas of clinical care, education, and research.

Depression and anxiety disorders in palliative cancer care.

Depression and anxiety disorders are thought to be common in palliative cancer care, but there is inconsistent evidence regarding their relevance for other aspects of quality of life. In the Canadian National Palliative Care Survey, semi-structured interviews assessing depression and anxiety disorders were administered to 381 patients who were receiving palliative care for cancer. There were 212 women and 169 men, with a median survival of 63 days. We found that 93 participants (24.4%, 95% confidence interval=20.2-29.0) fulfilled Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for at least one anxiety or depressive disorder (20.7% prevalence of depressive disorders, 13.9% prevalence of anxiety disorders). The most frequent individual diagnosis was major depression (13.1%, 95% confidence interval=9.9-16.9). Comorbidity was common, with 10.2% of participants meeting criteria for more than one disorder. Those diagnosed with a disorder were significantly younger than other participants (P=0.002). They also had lower performance status (P=0.017), smaller social networks (P=0.008), and less participation in organized religious services (P=0.007). In addition, they reported more severe distress on 14 of 18 physical symptoms, social concerns, and existential issues. Of those with a disorder, 39.8% were being treated with antidepressant medication, and 66.7% had been prescribed a benzodiazepine. In conclusion, it appears that depression and anxiety disorders are indeed common among patients receiving palliative care. These disorders contribute to a greatly diminished quality of life among people who are dying of cancer.

Mental disorders and the desire for death in patients receiving palliative care for cancer.

OBJECTIVES: The desire for death in terminally ill patients is associated with depression and anxiety, but not all patients who report it meet criteria for mental disorders. We examined the characteristics of subgroups of palliative cancer patients who expressed a desire for death that occurred either with or without a concurrent depressive or anxiety disorder. DESIGN: Cross-sectional survey. SETTING: Eight Canadian palliative care programs. PARTICIPANTS: 377 patients with cancer. MAIN OUTCOME MEASURES: Desire for Death Rating Scale; Structured Interview of Symptoms and Concerns. RESULTS: Most participants (69.5%) had no desire for death. Of the remainder, 69 (18.3%) acknowledged occasional transient thoughts, and 46 (12.2%) reported an apparently genuine desire to die. In the latter group, 24 individuals (52.2%) were diagnosed with a mental disorder and 22 (44.8%) were not. Individuals with no serious desire for death and no mental disorder reported the least distress in physical, social, existential, and psychological symptoms and concerns; those with a mental disorder and a significant desire for death reported the most. The subgroup of patients with a serious desire for death but no concurrent mental disorders still reported increased distress due to physical symptoms and social concerns, as well as a higher prevalence of global suffering. CONCLUSIONS: The expression of a desire for death by a terminally ill patient should raise a suspicion about mental health problems, but is not in itself clearly indicative of one. Nevertheless, it may serve as a catalyst to review the individual's physical symptom management and interpersonal concerns, and overall sense of suffering.

From "Breakthrough" to "Episodic" Cancer Pain? A European Association for Palliative Care Research Network Expert Delphi Survey Toward a Common Terminology and Classification of Transient Cancer Pain Exacerbations.

CONTEXT: Cancer pain can appear with spikes of higher intensity. Breakthrough cancer pain (BTCP) is the most common term for the transient exacerbations of pain, but the ability of the nomenclature to capture relevant pain variations and give treatment guidance is questionable. OBJECTIVES: To reach consensus on definitions, terminology, and subclassification of transient cancer pain exacerbations. METHODS: The most frequent authors on BTCP literature were identified using the same search strategy as in a systematic review and invited to participate in a two-round Delphi survey. Topics with a low degree of consensus on BTCP classification were refined into 20 statements. The participants rated their degree of agreement with the statements on a numeric rating scale (0-10). Consensus was defined as a median numeric rating scale score of ≥7 and an interquartile range of ≤3. RESULTS: Fifty-two authors had published three or more articles on BTCP over the past 10 years. Twenty-seven responded in the first round and 24 in the second round. Consensus was reached for 13 of 20 statements. Transient cancer pain exacerbations can occur without background pain, when background pain is uncontrolled, and regardless of opioid treatment. There exist cancer pain exacerbations other than BTCP, and the phenomenon could be named "episodic pain." Patient-reported treatment satisfaction is important with respect to assessment. Subclassification according to pain pathophysiology can provide treatment guidance. CONCLUSION: Significant transient cancer pain exacerbations include more than just BTCP. Patient input and pain classification are important factors for tailoring treatment.

A multicenter study of the revised Edmonton Staging System for classifying cancer pain in advanced cancer patients.

The comparative analysis of analgesic interventions for cancer pain is greatly compromised by the lack of well-validated and clinically acceptable tools, which allow a composite classification of pain and patient population characteristics. Although the Edmonton Staging System (ESS) for cancer pain was developed for this purpose, clinical and research utility has been limited due to problems associated with the assessment of some items, especially in relation to definitions and terminology. To overcome these limitations, we designed a revised ESS (rESS) and conducted a multicenter study to determine its inter-rater reliability and predictive value. In revising the rESS, we hypothesized that patients with less problematic pain features would require a shorter time to achieve stable pain control, require less complicated analgesic regimens, be more responsive to opioid therapy, and use lower opioid doses. The rESS items include mechanism of pain, presence or absence of incidental pain, presence or absence of psychological distress and addictive behavior, and level of cognitive function. Patients with cancer pain who were consecutively admitted to two different hospice centers, an acute care consultation service in a teaching hospital or a tertiary palliative care unit in a second teaching hospital were evaluated for study entry. Two independent palliative care specialists completed the rESS where possible within 24 hours of each other. Patients' pain ratings and opioid consumption were recorded daily until the study endpoint (i.e. achievement of stable pain control, discharge or death). Seven hundred and forty-six patients were eligible for study entry and of these, 619 (83%) had a pain syndrome. Inter-rater reliability estimates ranged from 0.67 (pain mechanism) to 0.95 (presence of addiction). In the univariate Cox regression analysis, younger patients (<60), as well as patients with neuropathic pain, incidental pain, psychological distress, or co-morbid psychological distress and addiction, required a significantly longer time to achieve stable pain control (P<0.05). In the multivariate Cox regression analysis, only age (<60), neuropathic pain and incidental pain were significantly associated with time to reach stable pain control (P

Parenteral nutrition in advanced cancer: indications and clinical practice guidelines.

Cachexia is a disturbing and disfiguring aspect of many advanced cancers. Parenteral nutrition (PN) is a controversial and expensive treatment for cancer cachexia. Guidelines for the use of PN for these patients have been suggested. These two case reports will highlight some of the issues around the etiology of cancer cachexia, the clinical dilemmas and the use of clinical practice guidelines.

Custom-made capsules and suppositories of methadone for patients on high-dose opioids for cancer pain.

In a prospective, open study, 37 advanced cancer patients in poor pain control receiving high doses of subcutaneous hydromorphone (mean daily dose: 276 +/- 163 mg) were switched to methadone by use of custom-made capsules (21 patients) or suppositories (16 patients). The change in opioid took place over 6.5 +/- 3.6 days (oral) and 3.2 +/- 2.7 days (rectal). The methadone/hydromorphone dose ratios were 1.2 +/- 1.3 and 3 +/- 2 for the oral and rectal routes, respectively (P = 0.03) as compared to an expected ratio of 5-7, based on single dose available data. Pain intensity (VAS 0-100 mm) and the number of extra doses of analgesic per day were 51 +/- 22 and 3.2 +/- 2.7 with hydromorphone, versus 34 +/- 21 (P < 0.001) and 2.1 +/- 1.9 (P = 0.03) with methadone, respectively. The total cost of treatment was Canadian $148 +/- 202 with methadone as compared to Canadian $2135 +/- 472 with hydromorphone (P < 0.001). Toxicity was limited to mild sedation in all patients and proctitis in 2 patients on suppositories (one of whom required discontinuation of methadone). Plasma levels obtained in 6 patients on suppositories revealed large inter-individual variation in methadone level (ng/ml) to dose (mg/day) ratio (range: 0.8-8.5). Within individuals, the ratio remained constant over a range of doses. We conclude that a slow switch-over to methadone is a safe, effective and low cost alternative in selected cancer patients receiving high doses of opioids for poor prognostic pain syndromes.

Palliation of malignant bowel obstruction using a percutaneous cecostomy.

Bowel obstruction is a common complication of metastatic gastrointestinal and ovarian cancers, and can cause distressing symptoms. Along with medical options, surgical options should be considered in all patients with bowel obstruction, including percutaneous gastrostomy. We report the case of a patient with metastatic colon cancer with an obstructing recurrence at the primary site who was not eligible for major surgery or percutaneous gastrostomy and was managed with a percutaneous cecostomy for symptom control.

Evaluation of a data collection tool (TELEform) for palliative care research.

INTRODUCTION: The Alberta Cancer Board Palliative Care Research Initiative (ACBPCRI) encourages province-wide collaboration on palliative care research projects. Because of geographic differences in information system infrastructure, it is necessary to evaluate and adopt a data collection tool that will span the variability in system hardware and software. We assessed TELEform (Cardiff Sofware Inc., Vista CA), an optical recognition-based technology that scans data collection paper forms and exports data to a computer database. We examined work place suitability, data quality, and effective resource utilization (time and cost) during the data collection tool evaluation. METHODS: Two hospices and two hospitals from the cities of Edmonton and Calgary participated in the revised Edmonton Staging System (rESS) project that used TELEform as its data collection tool. The evaluation was conducted over a period of 7 months. Data source such as e-mail and summary notes collected primarily through meetings and discussions with management, caregivers, researchers, and clerical staff was used to assess work practice and resource utilization. Descriptive statistics was employed to examine data quality and resource utilization. RESULTS: One hundred seventy eight patients were recruited during the 7-month trial. The costs and time involved in staff training, logistic support, and equipment startup were found to be reasonable. Data error and missing data were 0.4% and 0.6%, respectively. We initially encountered several problems with TELEform. The optical recognition tool could not easily pick up handwritten data. Furthermore, it was unforgiving in the sense that an error was not correctable by an eraser on the paper form. Data collectors found TELEform usage to be easy and simple because it retained the familiarity of paper-based recording. CONCLUSION: It is important to develop an information infrastructure to support research project data collection for different health settings across health regions. The TELEform based on optical recognition was able to respond to the need for current information processing. We believe that TELEform is a useful tool in terms of work practice, data quality, and resource utilization.

Hydration management at the end of life.

The management of parenteral hydration at the end of life remains controversial. The debate centers on whether and/or how often patients should be hydrated, the volume of hydration received, and the benefit verses side effects of parenteral hydration. In order to clarify the routine practice of physicians involved in the end-of-life care in Edmonton, Alberta, Canada, we investigated the routine management of hydration by attending physicians caring for patients dying in a palliative care unit (PCU) at Norwood Capital Care, and in acute care wards at the Royal Alexandra Hospital (RAH) both while receiving and while not receiving consult advice from the Palliative Care Program. We conducted a retrospective chart review of 50 consecutive patients who died in each of the 3 sites included in the study. Data from the last 7 days prior to and including the date of death (day 0) was recorded. The majority of patients at all sites received hydration. The volume of hydration ordered in the Norwood PCU site was significantly different compared to both RAH groups on all days studied (p < 0.005). The RAH palliative care group showed a trend for lower hydration volumes compared to the RAH acute care group with significant differences on days 1 and 2 (p < 0.05). Throughout the week, for all of the hydrated patients in the Norwood PCU site, hypodermoclysis (HDC) was ordered; for nearly all of the hydrated patients in the RAH acute care group, intravenous (IV) hydration was ordered; and for approximately one third of the hydrated RAH palliative care consult group HDC was ordered, and for the remainder IV hydration was ordered. The RAH acute care group represented the largest percentage of hydrated patients receiving diuretics while the Norwood hospice site represented the lowest. The data raise the possibility that more patients in the RAH acute care group were overhydrated and may have developed symptoms such as edema, ascites, and respiratory distress. This study suggests that hydration at the end of life is managed differently in different settings of care and highlights areas for education to improve management.

Thrombosis and anticoagulation in palliative care: an evolving clinical challenge.

There is a clear recognition of the relationship between thrombosis and neoplastic diseases. In recent years, there have been a few reports dealing with some of the features of clinical progression and management of venous thromboembolism (VTE) in palliative care patients. In this report, we present four cases that describe some of the diverse aspects of this clinically challenging area to illustrate the symptom and quality of life issues for patients, and the management challenge for palliative care clinicians. Perhaps the most important issue in the palliative care setting is the need to balance the inconvenience of the various diagnostic and therapeutic options, particularly in settings where progression has resulted in a deteriorated physical and cognitive condition. We need to recognize that VTE does cause significant problems for some of our patients. We will always need to balance issues of life expectancy, comfort and quality of life, and risk and benefits of anticoagulation, and align these problems with the individual patient, and the family dynamics and desires we encounter.

The cultural differences in perceived value of disclosure and cognition: Spain and Canada.

A previous multicentre international study on sedation at the end of life has detected major differences between Canadian and Spanish patients. This was particularly evident in the need to sedate Spanish patients for psychological/existential distress. This study was designed to explore the hypothesis that marked differences in the value patients and families attach to disclosure and cognition were a factor. The study population included patients referred to two palliative care consulting services based in acute care hospitals in Madrid, Spain (M), and in Edmonton, Canada (E). Questions addressed the issue of clear thinking, pain/nausea-medication-induced somnolence/confusion, anxiety/antidepressant-medication-induced somnolence/confusion, details of diagnosis. One hundred patients were evaluated on each site. Patients and families in E placed a higher value on clear thinking, change in medication causing somnolence/confusion, and wanting full disclosure. Patients and families in E agreed almost 100% of the time, while agreement in M varied from 42% to 67%. These results suggest major differences in the perceived value of clear cognition and disclosure of information between patients and families in E and M. The lack of agreement between patients and families in M is a further significant factor that may complicate communication with patients and families, as well as medical management.

Developing palliative care surveillance in Canada: results of a pilot study.

OBJECTIVE: A pilot study compiled data from six palliative care centres across Canada to assess the feasibility of developing a national surveillance system. METHODS: Data provided for the three-year period between 1993-1997 were combined into a comparative minimum data set. Analyses included 6,369 care episodes from five centres, plus 948 patients from one centre. RESULTS: Care was provided in various settings including acute care wards, dedicated palliative care units, tertiary care, chronic care, and at home. Palliative care patients comprised equal numbers of men and women, with a median age of 69 years; 92% had cancer diagnoses. Median length of stay (LOS) for each care episode was 13 days, increasing to 40-43 days for a patient's entire time in care. LOS varied greatly, by care setting, from seven days (dedicated unit), to 19 days (tertiary unit), 37 days (home), and 54 days (chronic care). Our findings are similar to those reported from national surveys in Australia and the United Kingdom. SUMMARY: This study generated useful baseline data and identified key issues requiring resolution before establishing a national surveillance system, including the need to track patients across care settings.