RESUMEN
Cannabis use among individuals with cancer is best understood using survey self-report. As cannabis remains federally illegal, surveys could be subject to nonresponse and measurement issues impacting data quality. We surveyed individuals using medical cannabis for a cancer-related condition in the Minnesota Medical Cannabis Program (MCP). Although survey responders are older, there are no differences by race and ethnicity, gender, or receipt of reduced cannabis registry enrollment fee. Responders made a more recent purchase and more recently completed an independent symptom assessment for the registry than nonresponders, suggesting some opportunity for nonresponse error. Among responders, self-report and MCP administrative data with respect to age, race, gender, registry certification, and cannabis purchase history were similar. Responders were less likely to report receipt of Medicaid than would be expected based on registry low-income enrollment eligibility. Although attention should be paid to potential for nonresponse error, surveys are a reliable tool to ascertain cannabis behavior patterns in this population.
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Exactitud de los Datos , Marihuana Medicinal , Neoplasias , Sistema de Registros , Humanos , Marihuana Medicinal/uso terapéutico , Neoplasias/epidemiología , Neoplasias/terapia , Masculino , Femenino , Persona de Mediana Edad , Adulto , Encuestas y Cuestionarios , Estados Unidos/epidemiología , Minnesota/epidemiología , Autoinforme , AncianoRESUMEN
BACKGROUND: The legal climate for cannabis use has dramatically changed with an increasing number of states passing legislation legalizing access for medical and recreational use. Among cancer patients, cannabis is often used to ameliorate adverse effects of cancer treatment. Data are limited on the extent and type of use among cancer patients during treatment and the perceived benefits and harms. This multicenter survey was conducted to assess the use of cannabis among cancer patients residing in states with varied legal access to cannabis. METHODS: A total of 12 NCI-Designated Cancer Centers, across states with varied cannabis-access legal status, conducted surveys with a core questionnaire to assess cannabis use among recently diagnosed cancer patients. Data were collected between September 2021 and August 2023 and pooled across 12 cancer centers. Frequencies and 95% confidence intervals for core survey measures were calculated, and weighted estimates are presented for the 10 sites that drew probability samples. RESULTS: Overall reported cannabis use since cancer diagnosis among survey respondents was 32.9% (weighted), which varied slightly by state legalization status. The most common perceived benefits of use were for pain, sleep, stress and anxiety, and treatment side effects. Reported perceived risks were less common and included inability to drive, difficulty concentrating, lung damage, addiction, and impact on employment. A majority reported feeling comfortable speaking to health-care providers though, overall, only 21.5% reported having done so. Among those who used cannabis since diagnosis, the most common modes were eating in food, smoking, and pills or tinctures, and the most common reasons were for sleep disturbance, followed by pain and stress and anxiety with 60%-68% reporting improved symptoms with use. CONCLUSION: This geographically diverse survey demonstrates that patients use cannabis regardless of its legal status. Addressing knowledge gaps concerning benefits and harms of cannabis use during cancer treatment is critical to enhance patient-provider communication.
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Marihuana Medicinal , Neoplasias , Humanos , Neoplasias/epidemiología , Neoplasias/psicología , Neoplasias/terapia , Femenino , Masculino , Estados Unidos/epidemiología , Persona de Mediana Edad , Prevalencia , Adulto , Marihuana Medicinal/uso terapéutico , Marihuana Medicinal/efectos adversos , National Cancer Institute (U.S.) , Encuestas y Cuestionarios , Instituciones Oncológicas/estadística & datos numéricos , Anciano , PercepciónRESUMEN
Importance: Electronic systems that facilitate patient-reported outcome (PRO) surveys for patients with cancer may detect symptoms early and prompt clinicians to intervene. Objective: To evaluate whether electronic symptom monitoring during cancer treatment confers benefits on quality-of-life outcomes. Design, Setting, and Participants: Report of secondary outcomes from the PRO-TECT (Alliance AFT-39) cluster randomized trial in 52 US community oncology practices randomized to electronic symptom monitoring with PRO surveys or usual care. Between October 2017 and March 2020, 1191 adults being treated for metastatic cancer were enrolled, with last follow-up on May 17, 2021. Interventions: In the PRO group, participants (n = 593) were asked to complete weekly surveys via an internet-based or automated telephone system for up to 1 year. Severe or worsening symptoms triggered care team alerts. The control group (n = 598) received usual care. Main Outcomes and Measures: The 3 prespecified secondary outcomes were physical function, symptom control, and health-related quality of life (HRQOL) at 3 months, measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30; range, 0-100 points; minimum clinically important difference [MCID], 2-7 for physical function; no MCID defined for symptom control or HRQOL). Results on the primary outcome, overall survival, are not yet available. Results: Among 52 practices, 1191 patients were included (mean age, 62.2 years; 694 [58.3%] women); 1066 (89.5%) completed 3-month follow-up. Compared with usual care, mean changes on the QLQ-C30 from baseline to 3 months were significantly improved in the PRO group for physical function (PRO, from 74.27 to 75.81 points; control, from 73.54 to 72.61 points; mean difference, 2.47 [95% CI, 0.41-4.53]; P = .02), symptom control (PRO, from 77.67 to 80.03 points; control, from 76.75 to 76.55 points; mean difference, 2.56 [95% CI, 0.95-4.17]; P = .002), and HRQOL (PRO, from 78.11 to 80.03 points; control, from 77.00 to 76.50 points; mean difference, 2.43 [95% CI, 0.90-3.96]; P = .002). Patients in the PRO group had significantly greater odds of experiencing clinically meaningful benefits vs usual care for physical function (7.7% more with improvements of ≥5 points and 6.1% fewer with worsening of ≥5 points; odds ratio [OR], 1.35 [95% CI, 1.08-1.70]; P = .009), symptom control (8.6% and 7.5%, respectively; OR, 1.50 [95% CI, 1.15-1.95]; P = .003), and HRQOL (8.5% and 4.9%, respectively; OR, 1.41 [95% CI, 1.10-1.81]; P = .006). Conclusions and Relevance: In this report of secondary outcomes from a randomized clinical trial of adults receiving cancer treatment, use of weekly electronic PRO surveys to monitor symptoms, compared with usual care, resulted in statistically significant improvements in physical function, symptom control, and HRQOL at 3 months, with mean improvements of approximately 2.5 points on a 0- to 100-point scale. These findings should be interpreted provisionally pending results of the primary outcome of overall survival. Trial Registration: ClinicalTrials.gov Identifier: NCT03249090.
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Monitoreo Ambulatorio , Metástasis de la Neoplasia , Medición de Resultados Informados por el Paciente , Adulto , Electrónica , Femenino , Indicadores de Salud , Humanos , Internet , Masculino , Persona de Mediana Edad , Monitoreo Ambulatorio/instrumentación , Monitoreo Ambulatorio/métodos , Metástasis de la Neoplasia/diagnóstico , Metástasis de la Neoplasia/terapia , Neoplasias/diagnóstico , Neoplasias/terapia , Neoplasias Primarias Secundarias/diagnóstico , Neoplasias Primarias Secundarias/terapia , Calidad de Vida , Encuestas y Cuestionarios , TelemedicinaRESUMEN
PURPOSE: Orteronel (TAK-700) is a nonsteroidal 17,20-lyase inhibitor suppressing androgen synthesis. We evaluated the clinical benefit of orteronel when added to androgen deprivation therapy (ADT) in patients with newly diagnosed metastatic hormone-sensitive prostate cancer. METHODS: In this open-label randomized phase III study, patients with metastatic hormone-sensitive prostate cancer were randomly assigned 1:1 to ADT with orteronel (300 mg oral twice daily; experimental arm) or ADT with bicalutamide (50 mg oral once daily; control arm). The primary objective was the comparison of overall survival (OS), targeting a 33% improvement in median survival. A stratified log-rank test with a one-sided P ≤ .022 would indicate statistical significance. Secondary end points were progression-free survival (PFS), prostate-specific antigen (PSA) level at 7 months (≤ 0.2 v 0.2 to ≤ 4 v > 4 ng/mL), and adverse event profile. RESULTS: Among 1,279 patients included in the analysis, 638 were randomly assigned to the ADT plus orteronel arm and 641 to the control arm. The median age was 68 years; 49% had extensive disease. After a median follow-up of 4.9 years, there was a significant improvement in PFS (median 47.6 v 23.0 months, hazard ratio 0.58; 95% CI, 0.51 to 0.67; P < .0001) and PSA response at 7 months (P < .0001), but not in OS (median 81.1 v 70.2 months, hazard ratio 0.86; 95% CI, 0.72 to 1.02; P = .040, one-sided). More grade 3/4 adverse events occurred in the experimental versus the control arms (43% v 14%). Postprotocol life-prolonging therapy was received by 77.4% of patients in the control arm and 61.3% of patients in the orteronel arm. CONCLUSION: The study did not meet the primary end point of improved OS with orteronel. The lack of correlation of PFS and PSA response with OS raises concerns over assumption of their consistent surrogacy for OS in the context of extensive postprotocol therapy in this setting.
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Antígeno Prostático Específico , Neoplasias de la Próstata , Anciano , Antagonistas de Andrógenos/efectos adversos , Andrógenos , Humanos , Imidazoles , Masculino , Naftalenos , Neoplasias de la Próstata/tratamiento farmacológico , Neoplasias de la Próstata/patología , Esteroide 17-alfa-HidroxilasaRESUMEN
Background: Pre-clinical studies have demonstrated the potential anticancer activity of cannabinoids, yet little clinical data exist to support this. Nearly 40% of patients with cancer using cannabis believe it will treat their cancer with numerous anecdotal reports shared online through social media platforms. Case reports have been published in peer-reviewed journals, but often lack key clinical information to validate anticancer claims. Methods: We reviewed literature in PubMed and EBSCO databases that evaluated the relationship between cannabis or the endocannabinoid system and potential anticancer activity. We also reviewed online sources, books, and ClinicalTrials.gov for reports or studies on using cannabis as cancer treatment. All case reports published in peer-reviewed journals were compiled and appraised as weak, moderate, or strong based on the quality of evidence provided supporting an anticancer effect. Strong reports met three criteria; (a) active cancer at time of cannabis administration, (b) validated laboratory or radiographic responses were reported, and (c) cannabis used without concurrent anticancer treatments. Results: Of the 207 pre-clinical articles reviewed, 107 (52%) were pre-clinical studies with original data. A total of 77 unique case reports described patients with various cancers (breast, central nervous system, gynecological, leukemia, lung, prostate, and pancreatic) using cannabis. Our appraisal showed 14% of the case reports were considered strong, 5% moderate, and the remaining 81% were weak. Ten percent of cases were in pediatric patients. Cannabidiol use was most often reported as the anticancer cannabinoid with daily doses ranging from 10 to 800 mg. Tetrahydrocannabinol use was reported in six studies, with doses ranging from 4.8 to 7.5 mg. Two small trials published data on survival in patients with recurrent glioblastoma multiforme. Conclusion: This review of clinical data suggests most published, peer-reviewed case reports provide insufficient data to support the claim for cannabis as an anticancer agent, and should not be used in place of evidence-based, traditional treatments outside of a clinical trial. No strong clinical trial data exist to confirm the pre-clinical studies that suggest cannabinoids may have an anticancer benefit. Future studies exploring anticancer potential of cannabis in patients with metastatic cancers who have not responded to traditional therapy are needed.
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Antineoplásicos , Cannabidiol , Cannabinoides , Cannabis , Alucinógenos , Marihuana Medicinal , Neoplasias , Analgésicos/uso terapéutico , Antineoplásicos/uso terapéutico , Cannabidiol/farmacología , Agonistas de Receptores de Cannabinoides/uso terapéutico , Cannabinoides/farmacología , Niño , Alucinógenos/uso terapéutico , Humanos , Marihuana Medicinal/uso terapéutico , Neoplasias/tratamiento farmacológicoRESUMEN
PURPOSE: The prevalence of medical cannabis (MC) use in patients with cancer is growing, but questions about safety, efficacy, and dosing remain. Conducting randomized, controlled trials (RCTs) using state-sponsored MC programs is novel and could provide data needed to guide patients and providers. METHODS: A pilot RCT of patients with stage IV cancer requiring opioids was conducted. Thirty patients were randomized 1:1 to early cannabis (EC, n = 15) versus delayed start cannabis (DC, n = 15). The EC group obtained 3 months (3 M) of MC through a state program at no charge, while the DC group received standard oncology care without MC for the first 3 M. Patients met with licensed pharmacists at one of two MC dispensaries to determine a suggested MC dosing, formulation, and route. Patients completed surveys on pain levels, opioid/MC use, side effects, and overall satisfaction with the study. RESULTS: Interest in the study was high as 36% of patients who met eligibility criteria ultimately enrolled. The estimated mean daily THC and CBD allotments at 3 M were 34 mg and 17 mg, respectively. A higher proportion of EC patients achieved a reduction in opioid use and improved pain control. No serious safety issues were reported, and patients reported high satisfaction. CONCLUSION: Conducting RCTs using a state cannabis program is feasible. The addition of MC to standard oncology care was well-tolerated and may lead to improved pain control and lower opioid requirements. Conducting larger RCTs with MC in state-sponsored programs may guide oncology providers on how to safely and effectively incorporate MC for interested patients.
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Cannabis , Marihuana Medicinal , Neoplasias , Analgésicos Opioides/efectos adversos , Estudios de Factibilidad , Humanos , Marihuana Medicinal/efectos adversos , Neoplasias/tratamiento farmacológico , Dolor/tratamiento farmacológico , Dolor/etiología , Satisfacción del PacienteRESUMEN
OBJECTIVES: Pancreatic adenocarcinoma is frequently associated with pain requiring opioid therapy. Opioids, however, have been implicated in causing tumor progression, ultimately shortening survival. We examined the impact of pain, opioid use, and the mu-opioid receptor (MOP-R) expression in tumor tissue on progression-free survival and overall survival of patients with metastatic pancreatic cancer. METHODS: We identified 103 patients with metastatic pancreatic adenocarcinoma receiving chemotherapy and abstracted data from Tumor Registry, in addition to pain, opioid exposure, carbohydrate antigen 19-9 values, survival, and imaging response. MOP-R expression was evaluated using an immunohistochemistry assay. The association of variables with progression-free survival and overall survival was analyzed in univariate and multivariate models. RESULTS: Patients with low opioid use (<5 mg oral morphine equivalent/d) survived longer than patients with high opioid (HO) use (≥5 mg oral morphine equivalent/d) (median overall survival of 315 vs. 150 d; hazard ratio [HR]=1.79; 95% confidence interval [CI]: 1.13, 2.84). This effect persisted on multivariate models (adjusted HR=2.76; 95% CI: 1.39, 5.48). Low opioid patients tended to respond better to treatment than HO patients, based on carbohydrate antigen 19-9. Patients with low MOP-R expression had longer median survival (230 vs. 193 d), though the HR was not significant (1.15; 95% CI: 0.71, 1.88). Baseline pain was not associated with outcomes. CONCLUSION: In patients with metastatic pancreatic adenocarcinoma, HO use is associated with decreased survival, but the severity of baseline pain and MOP-R expression score in tumor tissue does not correlate with clinical outcomes.
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Adenocarcinoma/metabolismo , Adenocarcinoma/patología , Analgésicos Opioides/farmacología , Analgésicos Opioides/uso terapéutico , Dolor en Cáncer/tratamiento farmacológico , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/patología , Receptores Opioides mu/biosíntesis , Receptores Opioides mu/efectos de los fármacos , Adenocarcinoma/mortalidad , Adenocarcinoma/secundario , Adulto , Anciano , Anciano de 80 o más Años , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Pancreáticas/mortalidad , Supervivencia sin Progresión , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
Background: We conducted a multicenter, randomized trial of early integrated palliative and oncology care in patients with advanced cancer to confirm the benefits of early palliative care (PC) seen in prior single-center studies. Methods: We randomly assigned patients with newly diagnosed incurable cancer to early integrated palliative and oncology care (n = 195) or usual oncology care (n = 196) at sites through the Alliance for Clinical Trials in Oncology. Patients assigned to the intervention were expected to meet with a PC clinician at least monthly until death, whereas usual care patients consulted PC on request. The primary endpoint was the change in quality of life from baseline to week 12 per the Functional Assessment of Cancer Therapy-General (FACT-G). Secondary outcomes included anxiety, depression, and communication about prognosis and end-of-life care. Results: Due to significant morbidity and a high proportion of measures that were not completed within the protocol window or for unknown reasons, the rate of missing data was high. We anticipated that 70% of patients (n = 280) would complete the FACT-G at baseline and week 12, but only 49.3% (n = 193/391) completed the measure. Delivery of the intervention was also suboptimal, as 14.9% (n = 29/195) of intervention patients had no PC visits by week 12. Intervention patients reported a mean 3.35 (standard deviation [SD] = 14.7) increase in FACT-G scores from baseline to week 12 compared with usual care patients who reported a 0.12 (SD = 12.7) increase from baseline (p = 0.10). Conclusion: This study highlights the difficulties of conducting multicenter trials of supportive care interventions in patients with advanced cancer. Clinical Trials Registration: NCT02349412.
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Neoplasias Gastrointestinales , Cuidado Terminal , Neoplasias Gastrointestinales/terapia , Humanos , Pulmón , Cuidados Paliativos , Calidad de VidaRESUMEN
PURPOSE: Patient-reported outcome measures (PROMs) that assess how patients feel and function have potential for evaluating quality of care. Stakeholder recommendations for PRO-based performance measures (PMs) were elicited, and feasibility testing was conducted at six cancer centers. METHODS: Interviews were conducted with 124 stakeholders to determine priority symptoms and risk adjustment variables for PRO-PMs and perceived acceptability. Stakeholders included patients and advocates, caregivers, clinicians, administrators, and thought leaders. Feasibility testing was conducted in six cancer centers. Patients completed PROMs at home 5-15 days into a chemotherapy cycle. Feasibility was operationalized as ≥ 75% completed PROMs and ≥ 75% patient acceptability. RESULTS: Stakeholder priority PRO-PMs for systemic therapy were GI symptoms (diarrhea, constipation, nausea, vomiting), depression/anxiety, pain, insomnia, fatigue, dyspnea, physical function, and neuropathy. Recommended risk adjusters included demographics, insurance type, cancer type, comorbidities, emetic risk, and difficulty paying bills. In feasibility testing, 653 patients enrolled (approximately 110 per site), and 607 (93%) completed PROMs, which indicated high feasibility for home collection. The majority of patients (470 of 607; 77%) completed PROMs without a reminder call, and 137 (23%) of 607 completed them after a reminder call. Most patients (72%) completed PROMs through web, 17% paper, or 2% interactive voice response (automated call that verbally asked patient questions). For acceptability, > 95% of patients found PROM items to be easy to understand and complete. CONCLUSION: Clinicians, patients, and other stakeholders agree that PMs that are based on how patients feel and function would be an important addition to quality measurement. This study also shows that PRO-PMs can be feasibly captured at home during systemic therapy and are acceptable to patients. PRO-PMs may add value to the portfolio of PMs as oncology transitions from fee-for-service payment models to performance-based care that emphasizes outcome measures.
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Neoplasias/terapia , Medición de Resultados Informados por el Paciente , Adulto , Estudios de Factibilidad , Femenino , Humanos , Masculino , Neoplasias/psicología , Participación de los InteresadosRESUMEN
BACKGROUND: Use of electronic patient-reported outcomes (ePROs) in routine cancer care can help identify troublesome symptoms and facilitate discussions between patients and clinicians and has been shown to improve patient satisfaction, quality of life, and survival. METHODS: Eighty patients with stage IV non-hematologic malignancies on chemotherapy participated. Patient-Reported Symptom Monitoring (PRSM) surveys were sent every 14 days via the Epic MyChart system over a 12-week period. Surveys were offered via phone or paper if patients failed to complete the automated MyChart survey by day 16. Severe symptoms or concerning symptom trends were automatically highlighted in reports for clinic staff. Patients reporting severe symptoms were routed to oncology nursing triage for standard symptom care management. RESULTS: Two hundred seventy-one surveys were sent during the 12-week study period. One hundred eighty-three surveys (66%) were completed, with 68% completed electronically via MyChart, 25% by paper, and 7% by phone call from a research coordinator. At least one severe symptom was reported on 36% of all surveys. However, most severe symptoms did not result in urgent triage follow-up because they were already being addressed and/or patients felt they were manageable. Patients and clinicians generally said the ePRO was efficient and helpful for addressing distressing symptoms and would use it in routine oncology care. CONCLUSION: ePROs can be integrated into the electronic health record using the Epic MyChart system. Patients and clinicians gave positive feedback on the system. Monitoring symptoms in real time may soon become part of standard oncology practice and requires seamless methods for collection.
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Registros Electrónicos de Salud , Neoplasias/diagnóstico , Medición de Resultados Informados por el Paciente , Adulto , Anciano , Anciano de 80 o más Años , Instituciones de Atención Ambulatoria , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/tratamiento farmacológico , Neoplasias/patología , Cuidados Paliativos/métodos , Satisfacción del Paciente , Proyectos Piloto , Calidad de Vida , Encuestas y CuestionariosRESUMEN
PURPOSE: Minnesota's medical cannabis program is unique, in that it routinely collects patient-reported scores on symptoms. This article focuses on changes in symptom severity reported by patients with cancer during their first 4 months of program participation. MATERIALS AND METHODS: Patients with cancer in Minnesota's medical cannabis program reported symptoms (anxiety, lack of appetite, depression, disturbed sleep, fatigue, nausea, pain, and vomiting) at their worst over the last 24 hours before each medical cannabis purchase. Baseline scores on each of the eight symptoms were statistically compared with the average symptom scores reported in the first 4 months of program participation. Symptom scores were also calculated as percent change from baseline, with patients achieving and maintaining at least a 30% reduction in symptoms reported in this article. Patients also reported intensity of adverse effects. RESULTS: A significant reduction in scores was found across all symptoms when comparing baseline scores with the average score submitted within the first 4 months of program participation (all Ps < .001). The proportion of patients achieving 30% or greater symptom reduction within the first 4 months of program participation varied from 27% (fatigue) to 50% (vomiting), with a smaller proportion both achieving and maintaining those improvements. Adverse effects were reported in a small proportion of patients (10.5%). CONCLUSION: Patients with cancer enrolled in Minnesota's medical cannabis program showed significant reduction across all eight symptoms assessed within 4 months of program participation. Medical cannabis was well tolerated, and some patients attained clinically meaningful and lasting levels of improvement.
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Marihuana Medicinal/uso terapéutico , Neoplasias/tratamiento farmacológico , Medición de Resultados Informados por el Paciente , Anciano , Femenino , Humanos , Masculino , Marihuana Medicinal/farmacología , Persona de Mediana Edad , Minnesota , Estados UnidosRESUMEN
PURPOSE OF REVIEW: As the legalization of medical cannabis continues across the USA, oncology care providers will be increasingly asked to provide recommendations regarding its use in the cancer setting. In this article, we review recent literature that analyzes cannabis use specifically in patients with cancer and provide an accessible guide for clinicians, researchers, and patients. RECENT FINDINGS: We aimed to answer questions about the availability of cannabis in the USA, the trials supporting its use in the cancer setting, and the important factors to consider related to safety. Thirty states plus the District of Columbia have established comprehensive medical cannabis programs, each with different regulations and products available. In June 2018, Epidiolex, a cannabis extraction product containing 99% CBD, was approved to treat refractory seizures; however, whole-plant products and non-prescription extraction products dominate the market. Recent randomized, placebo-controlled studies of nabiximols (Sativex) in patients with refractory cancer-pain have largely shown no significant benefits. Conversely, large observational studies suggest patients with cancer using cannabis report significant improvement of many common symptoms. Cannabis use appears well tolerated, with few serious adverse effects reported. Though prospective clinical trials are needed to provide the robust data required to establish the proper role of cannabinoid and cannabis-based therapy in cancer patients, physicians can draw upon the knowledge currently available to have informed discussions with their patients.
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Dolor en Cáncer/tratamiento farmacológico , Marihuana Medicinal/uso terapéutico , Humanos , Seguridad del Paciente , Pronóstico , Estados UnidosRESUMEN
BACKGROUND: Glucocorticoids are commonly used in chemotherapy regimens and may lead to hyperglycemia and increased infection rates. METHODS: We performed a retrospective analysis on 1781 patients who received intravenous chemotherapy with glucocorticoids between 2010 and 2015. Data was obtained using electronic medical record, billing modules, and tumor registry. We compared new infections and survival between patients with and without diabetes, after adjusting for demographic and cancer-related variables. RESULTS: In the first 12â¯months following chemotherapy, patients with diabetes (nâ¯=â¯330) had higher rates of hospital admissions (70.9% vs 57.4%), more infection-related admissions (37.0% vs 29.2%), and increased rates of new infections (61.2% vs 49.2%) when compared to patients without diabetes (nâ¯=â¯1451). One-year survival was worse among patients with diabetes (67.3% vs 78.3%), and in patients with at least one elevated glucose following chemotherapy (60.8% vs 78.5). After adjusting for cancer stage, age, and gender, diabetes history increased the odds of dying within one year after diagnosis by 86% (OR 1.86, 95% CI (1.37-2.52)) and of new infections by 68% (OR 1.68, 95% CI (1.26-2.24)). CONCLUSIONS: Among patients with cancer receiving intravenous chemotherapy with glucocorticoids we demonstrate those with diabetes have more hospital admissions, increased rates of infections, and worse survival.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Diabetes Mellitus/epidemiología , Glucocorticoides/administración & dosificación , Recursos en Salud/estadística & datos numéricos , Hiperglucemia/epidemiología , Infecciones/epidemiología , Neoplasias , Adulto , Anciano , Glucemia/efectos de los fármacos , Glucemia/metabolismo , Diabetes Mellitus/sangre , Diabetes Mellitus/terapia , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Hiperglucemia/sangre , Hiperglucemia/terapia , Infecciones/sangre , Infecciones/complicaciones , Infecciones/terapia , Masculino , Persona de Mediana Edad , Neoplasias/sangre , Neoplasias/complicaciones , Neoplasias/tratamiento farmacológico , Neoplasias/mortalidad , Aceptación de la Atención de Salud/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
Background: Medical cannabis has been available in the State of Minnesota since July 2015 through the Minnesota Medical Cannabis Program (MMCP). Objectives: Our study aimed to delineate oncology providers' views on medical cannabis, identify barriers to patient enrollment, and assess clinicians' interest in a clinical trial of medical cannabis in patients with stage IV cancer. Methods: From June to August 2017, we distributed a 14-question survey to Minnesota oncology physicians, advanced practice nurses, and physician assistants who care for adults and children with cancer. Descriptive analyses for each question were provided for all survey respondents. Results: Of the 529 eligible survey participants, 153 (29%) responded to our survey; 68 respondents were registered with the MMCP. Most identified themselves as a medical oncologist or medical oncology nurse practitioner/physician assistant (n=125, 82%), and most practiced in a community setting (n=102, 67%). Overall, 65% of respondents supported the use of medical cannabis. Perceived cost and inadequate research were the highest barriers to MMCP patient enrollment. The lowest barriers included lack of health group support for allowing certification of patients and risk of social stigma. Of all respondents, 36% lacked confidence in discussing the risks and benefits of medical cannabis, and 85% wanted more education. Conclusions: Although support for cannabis use in the cancer setting is growing, significant barriers remain. This study illustrates a clear need to give clinicians both data and education to guide their discussions about the benefits, risks, and cost considerations of using medical cannabis for cancer-related symptoms.
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PURPOSE: Patients with advanced cancers frequently experience pain. Opioids are commonly prescribed to treat cancer-related pain, but their use might be associated with undesirable consequences including adverse effects and tumor progression, resulting in increased heath care utilization and shorter survival. We examined these possibilities in a large cohort of patients diagnosed with ten common advanced malignancies. METHODS: We identified 1386 newly diagnosed patients with stage IV non-hematologic malignancies from 2005 to 2013 and ascertained opioid utilization within 90 days of starting anti-cancer treatment using electronic medical record and tumor registry data. Opioid utilization was stratified into low opioid (LO; < 5 mg oral morphine equivalents (OME)/day) and high opioid (HO; ≥ 5 mg OME/day). Health care utilization included tallies of emergency room, urgent care, and inpatient visits. The association of opioid use, tumor type prognosis, age, and gender with overall survival was analyzed in univariate and multivariate models. RESULTS: HO use patients (n = 624) had greater health care utilization compared to LO use patients (n = 762; p < 0.05). HO use patients also had shorter survival (median survival, 5.5 vs 12.4 months; p < 0.0001). On multivariate analysis, HO use remained associated with shorter overall survival (HR 1.4; 95% CI, 1.3-1.6; p < 0.0001) after adjusting for age, gender, and prognostic group. CONCLUSIONS: In advanced cancer patients, HO use is associated with greater health care utilization and shorter survival. Prospective studies using opioid-sparing approaches are indicated, to confirm these retrospective findings and to evaluate if these undesirable effects associated with opioid use can be mitigated.
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Analgésicos Opioides/uso terapéutico , Neoplasias/tratamiento farmacológico , Aceptación de la Atención de Salud/estadística & datos numéricos , Adulto , Anciano , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/farmacología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias/patología , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
PURPOSE: Pain commonly occurs in cancer patients, and has been associated with shorter survival. However, the importance of pain is less clear when analyzed with other known prognostic variables. This systematic review was performed to better understand how pain impacts overall survival (OS) in common cancers when key clinical variables are included in multivariate analysis. METHODS: A Medline search was completed to find studies examining the relationship between pain, clinical variables, and OS in patients with breast, colorectal, lung, or prostate cancer. Multivariate analysis included known prognostic variables including age, performance status, disease burden, and laboratory parameters. RESULTS: Fifty studies met inclusion criteria. In patients with breast, colorectal, and lung cancer, pain was not a significant prognostic factor for OS on multivariate analysis in most studies. In contrast, several studies suggest that pain is an independent prognostic factor for OS in advanced prostate cancer, even when relevant clinical prognostic variables are included. However, analgesic use was often used as a surrogate for prostate cancer pain, making it difficult to determine whether pain or opioid exposure was more important in influencing survival. CONCLUSIONS: Pain may be associated with shorter survival in patients with cancer, but the mechanism for this relationship is unknown. The available evidence is insufficient to definitively determine if pain independently influences survival in patients with breast, colorectal, or lung cancer. The majority of studies in prostate cancer show pain to be an independent prognostic factor for OS, and often also incorporate opioid analgesic use in multivariate analysis. Prospective studies are needed to better understand how opioid utilization and pain may affect cancer progression and survival in diverse malignancies.
Asunto(s)
Neoplasias/complicaciones , Dolor/etiología , Anciano , Analgésicos Opioides , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Neoplasias/mortalidad , Dolor/tratamiento farmacológico , Pronóstico , Calidad de Vida , Análisis de SupervivenciaRESUMEN
PURPOSE: Cancer-related pain is common, negatively affects quality of life and survival, and often requires treatment with opioid analgesics. Patient-reported data that describe the incidence and severity of pain, medication use, and patient satisfaction with care are lacking. METHODS: We analyzed 18 months of outpatient oncology clinic encounters from the electronic medical record to obtain data on pain levels and opioid and nonopioid treatments. In June 2014, we instituted a pain intervention by creating a pain management information handout for patients, educating clinicians on opioid cost-effectiveness, and implementing a nursing protocol to document personalized pain goals (PPGs). RESULTS: Moderate to severe pain was reported in nearly 15% of patient encounters. We observed an increase in the percentage of encounters with a documented PPG of 16% to 71% ( P < .001). On average, PPG was achieved in 84% of patients. Rates of high-cost long-acting opioid prescriptions (oxycodone controlled release and fentanyl patches), as a total of all long-acting opioids, declined from 45% preintervention to 33% postintervention ( P = .005). CONCLUSION: Our intervention improved rates of PPG documentation and decreased the number of prescriptions for high-cost long-acting opioids. Oncology clinics can implement simple quality improvement methods, such as asking patients about their PPG and educating clinicians about opioid costs, to improve outcomes and lower treatment costs.
Asunto(s)
Neoplasias/economía , Neoplasias/terapia , Manejo del Dolor/economía , Dolor/etiología , Calidad de Vida/psicología , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Manejo del Dolor/métodos , Satisfacción del PacienteRESUMEN
BACKGROUND: Preclinical studies show that opioids stimulate angiogenesis and tumor progression through the mu opioid receptor (MOR). Although MOR is overexpressed in several human malignancies, the effect of chronic opioid requirement on cancer progression or survival has not been examined in humans. METHODS: We performed a retrospective analysis on 113 patients identified in the Minneapolis VA Tumor Registry (test cohort) and 480 patients from the national VA Central Cancer Registry (validation cohort) who had been diagnosed with stage IV prostate cancer between 1995 and 2010 to examine whether MOR expression or opioid requirement is associated with disease progression and survival. All opioids were converted to oral morphine equivalents for comparison. Laser scanning confocal microscopy was used to analyze MOR immunoreactivity in prostate cancer biopsies. The effects of variables on outcomes were analyzed in univariable and multivariable models. RESULTS: In patients with metastatic prostate cancer, MOR expression and opioid requirement were independently associated with inferior progression-free survival (hazard ratio [HR] 1.65, 95% confidence interval [CI] 1.33-2.07, P<.001 and HR 1.08, 95% CI 1.03-1.13, P<.001, respectively) and overall survival (HR 1.55, 95% CI 1.20-1.99, P<.001 and HR 1.05, 95% CI 1.00-1.10, P = .031, respectively). The validation cohort confirmed that increasing opioid requirement was associated with worse overall survival (HR 1.005, 95% CI 1.002-1.008, P = .001). CONCLUSION: Higher MOR expression and greater opioid requirement are associated with shorter progression-free survival and overall survival in patients with metastatic prostate cancer. Nevertheless, clinical practice should not be changed until prospective randomized trials show that opioid use is associated with inferior clinical outcomes, and that abrogation of the peripheral activities of opioids ameliorates this effect.
Asunto(s)
Analgésicos Opioides/administración & dosificación , Neoplasias de la Próstata/mortalidad , Receptores Opioides mu/análisis , Supervivencia sin Enfermedad , Humanos , Inmunohistoquímica , Masculino , Microscopía Confocal , Metástasis de la Neoplasia , Neoplasias de la Próstata/química , Neoplasias de la Próstata/patología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Streptococcus pneumoniae is an uncommon cause of pyomyositis. It is unclear whether the clinical presentation and outcome of pneumococcal pyomyositis differ depending on the host's underlying immune status. We describe 2 patients with pneumococcal pyomyositis, review all published cases, and compare characteristics between apparently healthy hosts and at-risk hosts. A total of 35 cases of pneumococcal pyomyositis were identified, 11 in apparently healthy hosts and 24 in at-risk hosts. Two-thirds of the patients had an antecedent respiratory illness or meningitis. At-risk hosts tended to have a longer interval between the development of symptomatic muscle infection and the diagnosis of pyomyositis and a significantly higher risk of disseminated disease at presentation, as manifested by involvement of multiple noncontiguous muscles or presence of meningitis. Overall, other than 1 death, all patients recovered with antibiotics and surgical drainage, but as might be expected there was a significantly higher rate of complications among at-risk hosts.