Do physical symptoms predict psychological issues in patients with cancer?: the Memorial Symptom Assessment Scale-Short Form.

OBJECTIVES: This study aimed to determine if individual physical symptoms were predictive of psychological disorders. METHODS: This study was a secondary analysis of data from two studies which used the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) to assess both physical and psychological symptoms. Correlation between individual symptoms and the validated psychological subscale (MSAS-PSYCH) were performed using Spearman's coefficient. Linear regression analysis was performed to assess whether correlated symptoms predicted the presence of psychological disorders. RESULTS: 1507 patients' data were analysed. The physical symptoms of pain, lack of energy, drowsiness, dizziness, constipation, 'feeling bloated' and 'I don't look like myself' were correlated with MSAS-PSYCH. Other physical symptoms existed independently to psychological symptoms. None of these physical symptoms were independently predictive of a mood disorder. CONCLUSIONS: This study presents a large data set evaluating psychological symptom correlations. There are certain physical symptoms which correlate with mood disorders, but these are not independently predictive. It is not known whether the correlative data are cause or effect. Comprehensive assessment remains essential to assess all problems. TRIAL REGISTRATION NUMBER: The trial registered was at National Institute for Health Research Clinical Research Network Portfolio (Central Portfolio Management System (CPMS) ID 30723) Integrated Research Application System Identification (IRAS) ID 198753.

Validation of a French version of the Breakthrough Pain Assessment Tool in cancer patients: Factorial structure, reliability and responsiveness.

OBJECTIVE: Breakthrough cancer pain should be properly assessed for better-personalized treatment plan. The Breakthrough Pain Assessment Tool is a 14-item tool validated in English developed for this purpose; no French version is currently available and validated. This study aimed to translate it in French and assess the psychometric properties of a French version of the Breakthrough Pain Assessment Tool (BAT-FR). METHODS: First, translation and cross-cultural adaptation of the 14 items (9 ordinal and 5 nominal) of the original BAT tool in French language was made. Second, assessments of validity (convergent, divergent and discriminant validity), factorial structure (exploratory factor analysis) and test-retest reliability of the 9 ordinal items were done with data of 130 adult cancer patients suffering from breakthrough pain in a hospital-academic palliative care center. Test-retest reliability and responsiveness of total and dimension scores derived from these 9 items were also assessed. Acceptability of the 14 items was also assessed on the 130 patients. RESULTS: The 14 items had good content and face validity. Convergent and divergent validity, discriminant validity and test-retest reliability of the ordinal items were acceptable. Test-retest reliability and responsiveness of total and dimensions derived from ordinal items were also acceptable. The factorial structure of the ordinal items had two dimensions similar to the original version: "1-pain severity and impact" and "2-pain duration and medication". Items 2 and 8 had a low contribution to the dimension 1 they were assigned and item 14 clearly changed of dimension compared with the original tool. The acceptability of the 14 items was good. CONCLUSION: The BAT-FR has shown acceptable validity, reliability and responsiveness supporting its use for assessing breakthrough cancer pain in French-speaking populations. Its structure needs nevertheless further confirmation.

UK palliative medicine trainees and multisource communication skills feedback: an educational tool?

BACKGROUND: Multisource feedback provides ratings of a trainee doctor's performance from a range of assessors and enables 360 degree feedback on communication skills and team working behaviours. It is a tool used throughout palliative medicine training in the UK. There are limited data on the value of multisource feedback from a palliative medicine trainee perspective. AIM: To study the views of palliative medicine trainees regarding multisource feedback as an educational tool to develop communication skills. DESIGN: A multimodal study encompassing a focus group and questionnaire mailed to all deanery palliative doctors. SETTING/PARTICIPANTS: All palliative medicine trainees within a UK training deanery. RESULTS: Over half of responding trainees thought multisource feedback had little or no impact on their clinical practice. Improvements in delivery of multisource feedback to maximise learning were identified, including skilled feedback and facilitation by educational supervisors. CONCLUSIONS: Despite multisource feedback currently having limited benefits, a number of recommendations are suggested to improve this.

An audit of end-of-life symptom control in patients with corona virus disease 2019 (COVID-19) dying in a hospital in the United Kingdom.

BACKGROUND: The literature contains limited information on the problems faced by dying patients with COVID-19 and the effectiveness of interventions to manage these. AIM: The aim of this audit was to assess the utility of our end-of-life care plan, and specifically the effectiveness of our standardised end-of-life care treatment algorithms, in dying patients with COVID-19. DESIGN: The audit primarily involved data extraction from the end-of-life care plan, which includes four hourly nursing (ward nurses) assessments of specific problems: patients with problems were managed according to standardised treatment algorithms, and the intervention was deemed to be effective if the problem was not present at subsequent assessments. SETTING/PARTICIPANTS: This audit was undertaken at a general hospital in England, covered the 8 weeks from 16 March to 11 May 2020 and included all inpatients with COVID-19 who had an end-of-life care plan (and died). RESULTS: Sixty-one patients met the audit criteria: the commonest problem was shortness of breath (57.5%), which was generally controlled with conservative doses of morphine (10-20 mg/24 h via a syringe pump). Cough and audible respiratory secretions were relatively uncommon. The second most common problem was agitation/delirium (55.5%), which was generally controlled with standard pharmacological interventions. The cumulative number of patients with shortness of breath, agitation and audible respiratory secretions increased over the last 72 h of life, but most patients were symptom controlled at the point of death. CONCLUSION: Patients dying of COVID-19 experience similar end-of-life problems to other groups of patients. Moreover, they generally respond to standard interventions for these end-of-life problems.

Validation of the Dutch Version of the Breakthrough Pain Assessment Tool in Patients With Cancer.

CONTEXT: Essential for adequate management of breakthrough cancer pain is a combination of accurate (re-)assessment and a personalized treatment plan. The Breakthrough Pain Assessment Tool (BAT) has been proven to be a brief, multidimensional, reliable, and valid questionnaire for the assessment of breakthrough cancer pain. OBJECTIVES: The aim of this study was to examine the validity and reliability of the Dutch Language version of the BAT (BAT-DL) in patients with cancer. METHODS: The BAT was forward-backward translated into the Dutch language. Thereafter, the psychometric properties of the BAT-DL were tested, that is factor structure, reliability (internal consistency and test-retest reliability), validity (content validity and construct validity), and the responsiveness to change. RESULTS: The BAT-DL confirmed the two-factor structure in 170 patients with cancer: pain severity/impact factor and pain duration/medication efficacy factor. The Cronbach's alpha coefficient was 0.72, and the intraclass correlation for the test-retest reliability was 0.81. The BAT-DL showed to be able to differentiate between different group of patients and correlated significantly with the Brief Pain Inventory. In addition, the BAT-DL was capable to detect clinically important changes over time. CONCLUSION: The BAT-DL is a valid and reliable questionnaire to assess breakthrough pain in Dutch patients with cancer and is a relevant questionnaire for daily practice.

A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life.

BACKGROUND: The provision of clinically assisted hydration at the end-of-life is one of the most contentious issues in medicine. AIM: The aim of this feasibility study was to answer the question 'can a definitive (adequately powered) study be done?' DESIGN: The study was a cluster randomised trial, with sites randomised on a one-to-one basis to intervention 'A' (regular mouth care and usual other care) or intervention 'B' (clinically assisted hydration, mouth care and usual other care). Participants were assessed every 4 h, and data collected on clinical problems, therapeutic interventions and overall survival. SETTING/PARTICIPANTS: The study was conducted at 12 sites/'clusters' with specialist palliative care teams (4 cancer centres and 8 hospices), and participants were cancer patients in the last week of life who were unable to maintain sufficient oral fluid intake. RESULTS: The study achieved its pre-determined criteria for success. Two hundred patients were recruited to the study, and 199 participants completed the study, over a 1-year period. A total of 38.5% participants discontinued clinically assisted hydration due to adverse effects: none of these adverse events were rated as 'severe' or worse in intensity. The primary reasons for discontinuation were site problems ( n = 2), localised oedema ( n = 13), generalised oedema ( n = 5), respiratory secretions ( n = 6) and nausea and vomiting ( n = 1). CONCLUSION: The results of this feasibility study suggest that a definitive study can be done, but that minor changes are needed to the protocol to standardise the administration of clinically assisted hydration (which may reduce the incidence of certain adverse effects).

Disparities Between Clinician and Patient Perception of Breakthrough Pain Control.

CONTEXT: There are disparities in the level of symptom severity as perceived by patients and health professionals. There is limited information about patients' and clinicians' global assessment of breakthrough pain control, the need to change analgesics, and change in breakthrough pain over time. OBJECTIVES: To establish whether patients and clinicians independently agree on adequacy of breakthrough pain control, management strategy, and impression of change over time. METHODS: One hundred patients with breakthrough cancer pain were assessed and followed up one week later by a palliative medicine specialist. The patient and clinician independently answered the same questions about the adequacy of the patient's breakthrough pain control and breakthrough pain management. The results were compared with items on the Breakthrough Pain Assessment Tool (BAT). RESULTS: At initial consultation, 35% of patients rated their breakthrough cancer pain as inadequately controlled compared with 72% of clinicians. Breakthrough pain analgesics were changed in 68% of cases. At one-week follow-up consultation, 62% of patients considered their breakthrough cancer pain to be better, and in 57% of cases, the clinicians also categorized the pain this way. CONCLUSION: There are significant differences in global impressions of breakthrough pain between patients and pain clinicians that become less disparate as a therapeutic relationship evolves. Therapeutic decisions were based on clinical rather than patient perceptions.

Accuracy of a Diagnostic Algorithm to Diagnose Breakthrough Cancer Pain as Compared With Clinical Assessment.

CONTEXT: Breakthrough cancer pain (BTCP) is a heterogeneous condition, and there are no internationally agreed standardized criteria to diagnose it. There are published algorithms to assist with diagnosis, but these differ in content. There are no comparative data to support use. OBJECTIVES: To compare the diagnostic ability of a simple algorithm against a comprehensive clinical assessment to diagnose BTCP and to assess if verbal rating descriptors can adequately discriminate controlled background pain. METHODS: Patients with cancer pain completed a three-step algorithm with a researcher to determine if they had controlled background pain and BTCP. This was followed by a detailed pain consultation with a clinical specialist who was blinded to the algorithm results and determined an independent pain diagnosis. The sensitivity, specificity, and positive and negative predictive values were calculated for the condition of BTCP. Further analysis determined which verbal pain severity descriptors corresponded with the condition of controlled background pain. RESULTS: The algorithm had a sensitivity of 0.54 and a specificity of 0.76 in the identification of BTCP. The positive predictive value was 0.7, and the negative predictive value was 0.62. The sensitivity of a background pain severity rating of mild or less to accurately categorize controlled background pain was 0.69 compared with 0.97 for severity of moderate or less; however, this was balanced by a higher specificity rating for mild or less, 0.78 compared with 0.2. CONCLUSION: The diagnostic breakthrough pain algorithm had a good positive predictive value but limited sensitivity using a cutoff score of "mild" to define controlled background pain. When the cutoff level was changed to moderate, the sensitivity increased, but specificity reduced. A comprehensive clinical assessment remains the preferred method to diagnose BTCP.

Stercoral Perforation of the Colon: A Potentially Fatal Complication of Opioid-Induced Constipation.

Stercoral perforation of the colon is a rare complication of constipation, and there have only been a few reported cases of stercoral perforation of the colon secondary to opioid-induced constipation. This article describes such a case in a cancer survivor with chronic cancer-related pain and reviews the medical/surgical literature on stercoral perforation of the colon.

Development and validation of the breakthrough pain assessment tool (BAT) in cancer patients.

CONTEXT: The successful management of breakthrough pain depends on a combination of adequate assessment, appropriate (individualized) treatment, and adequate re-assessment. Currently, there is no fully validated clinical assessment tool for breakthrough pain in cancer patients. OBJECTIVES: The aim of this project was to develop and validate a breakthrough pain assessment tool (the BAT) for use in the clinical setting. METHODS: The content of the BAT was determined by reviewing the medical literature, conducting a Delphi process with experts in breakthrough pain and/or pain assessment and conducting semi-structured interviews with cancer patients with breakthrough pain. The tool was then subjected to a series of standard psychometric tests to assess its factor structure, validity (i.e., content validity, construct validity), reliability (i.e., internal consistency, test-retest reliability), and responsiveness to change. RESULTS: The BAT comprised two pages with 14 questions. Factor analysis confirmed the presence of two underlying factors. Psychometric testing confirmed that the tool is valid, reliable, and responsive to change. CONCLUSION: This study provides initial evidence for the validity and reliability of the breakthrough pain assessment tool which may be used to facilitate the management of patients with breakthrough cancer pain in the clinical setting.

An observational study to determine the prevalence of alcohol use disorders in advanced cancer patients.

CONTEXT: observational studies in North America suggest alcohol dependence is a common problem in advanced cancer patients and is associated with a high burden of physical and psychological symptoms. The prevalence of all types of alcohol use disorders, and the relationship between alcohol use disorders and symptoms, has not been studied. OBJECTIVES: this observational, cross-sectional study was designed to determine the prevalence of alcohol use disorders in patients with advanced cancer and establish if such patients have a higher symptom burden. METHODS: sequential patients referred to the palliative medicine team at a United Kingdom cancer centre completed the Alcohol Use Disorders Identification Test, Hospital Anxiety and Depression Scale (HADS) and Memorial Symptom Assessment Scale-Short Form (MSAS-SF). RESULTS: 120 patients participated in the study. Twenty-two (18%) patients screened positively for the presence of an alcohol use disorder. This study found no significant association between alcohol use disorders and the presence of anxiety (P = 0.38) or depression (P = 0.81) on the HADS or the global distress index subscale (P = 0.142), physical symptom distress index subscale (P = 0.734), or the psychological distress index subscale (P = 0.154) on the MSAS-SF. Current smoking status was the only independent predictor for the presence of an alcohol use disorder (P < 0.001). Seven (6%) patients screened positively for high-risk alcohol use disorders. Current smoking status (P < 0.001) and male gender (p < 0.001) were independent predictors of this problem. CONCLUSIONS: alcohol use disorders in this cohort of patients were not associated with a higher symptom burden, and the prevalence was lower than the general United Kingdom population.

Validity of the memorial symptom assessment scale-short form psychological subscales in advanced cancer patients.

CONTEXT: The Memorial Symptom Assessment Scale-Short Form (MSAS-SF) is designed to evaluate physical and psychological symptom burden in advanced cancer patients. There are no current data assessing the validity of the MSAS-SF psychological symptom scores when compared with anxiety and depression. OBJECTIVES: This observational cross-sectional study was designed to determine the relationship between the MSAS-SF subscales and the presence of anxiety and depression. METHODS: Advanced cancer patients attending a U.K. oncology center completed the MSAS-SF and the Hospital Anxiety and Depression Scale. RESULTS: One hundred twenty patients participated in the study. There was an association between the presence of anxiety and depression and the MSAS-SF global distress index. There was no association between the presence of anxiety and depression and the MSAS-SF physical symptom subscale. The MSAS-SF psychological symptom subscale was more closely correlated with anxiety than depression. CONCLUSION: These results support the validity of the MSAS-SF global distress index and psychological subscales in the assessment of patients with anxiety and depressive disorders.

Breakthrough pain: a qualitative study involving patients with advanced cancer.

CONTEXT: Breakthrough cancer pain is associated with a high burden of physical, psychological and social problems in quantitative studies. Individual experiences of living with breakthrough pain have not been studied. OBJECTIVES: This study aims to explore the individual experience of living with breakthrough cancer pain using a qualitative methodology. METHODS: In depth semi-structured interviews were conducted in ten patients with breakthrough cancer pain, and a qualitative content analysis was performed. RESULTS: The overarching themes that emerged were daily living, communication with health care professionals and management of breakthrough pain. CONCLUSIONS: Recognising the impact of breakthrough pain and the issues expressed by patients regarding communication and medication gives the clinician a framework for assessment and intervention.