The role of empathic nursing telephone interventions with advanced cancer patients: A qualitative study.

PURPOSE: Effective symptom management and provider-patient communication are critical components of quality palliative cancer care. Studies suggest nurse-telephone-interventions are feasible, acceptable and may improve the provision and satisfaction with care. However, little is known about what specific elements of nurse-telephone-interventions are most beneficial. The study's purpose was to describe the nature and key elements of therapeutic calls made by nurses to advanced cancer patients to understand what may have previously contributed to improvement in patients who received the intervention. METHODS: As part of a larger study on methylphenidate and/or a nurse-telephone-intervention for fatigue in advanced cancer patients from a tertiary hospital, nurse calls were made to 95 patients. This qualitative descriptive study used thematic analysis of transcribed telephone calls between nurses and advanced cancer patients. RESULTS: The overarching theme of these calls was supporting patients with empathy. Empathy in these conversations included nurses' efforts to understand patients' experiences, nurses communicating their understanding back to patients and nurses taking action in response to their understanding of patients' experiences. While humor and validation were used to communicate empathy, problem solving and providing support constituted the content of empathic communication. CONCLUSIONS: This study illustrates a nurse-telephone-interventions that embraced multiple components of clinical empathy. Nurse-telephone-interventions are feasible and acceptable with diverse, advanced cancer patients. The growing evidence base underscoring the numerous benefits of medical empathy may serve as a basis for adopting simple, feasible and accessible approaches such as empathic nurse-telephone-interventions in both research and clinical practice.

Exploratory Study of Low Resolution Electromagnetic Tomography (LORETA) Real-Time Z-Score Feedback in the Treatment of Pain in Patients with Head and Neck Cancer.

Acute pain from mucositis in patients with head and neck cancer (HNC) undergoing radiation therapy (RT) is common, and may not respond well to narcotics. We used low resolution electromagnetic tomography z-score neurofeedback (LFBz) to investigate whether patients could modify brain wave activity associated with acute pain and whether this would reduce the experience of pain. HNC patients scheduled for RT had baseline pre-pain onset measures (EEG and numeric rating scale) collected before RT and then at pain onset before using analgesics, after each LFBz session and at the end of RT. Up to six sessions of LFBz training were offered over the remaining RT. Up to six 20-min sessions of LFBz were offered over the remaining RT. Data were collected before and after each LFBz session and at the end of RT. Seventeen patients recruited; fourteen were treated and reported decreased pain perception. LFBz allowed patients to modify their brain activity in predesignated areas of the pain matrix toward the direction of their baseline, pre-pain condition (including Brodmann areas (BAs) 3, 4, 5, 13, 24, and 33). LFBz can modify brain regions relevant for pain and these changes were associated with self-reported decreases in pain perception.

Insulin resistance and body composition in cancer patients.

Cancer cachexia, weight loss with altered body composition, is a multifactorial syndrome propagated by symptoms that impair caloric intake, tumor byproducts, chronic inflammation, altered metabolism, and hormonal abnormalities. Cachexia is associated with reduced performance status, decreased tolerance to chemotherapy, and increased mortality in cancer patients. Insulin resistance as a consequence of tumor byproducts, chronic inflammation, and endocrine dysfunction has been associated with weight loss in cancer patients. Insulin resistance in cancer patients is characterized by increased hepatic glucose production and gluconeogenesis, and unlike type 2 diabetes, normal fasting glucose with high, normal or low levels of insulin. Cancer cachexia results in altered body composition with the loss of lean muscle mass with or without the loss of adipose tissue. Alteration in visceral adiposity, accumulation of intramuscular adipose tissue, and secretion of adipocytokines from adipose cells may play a role in promoting the metabolic derangements associated with cachexia including a proinflammatory environment and insulin resistance. Increased production of ghrelin, testosterone deficiency, and low vitamin D levels may also contribute to altered metabolism of glucose. Cancer cachexia cannot be easily reversed by standard nutritional interventions and identifying and treating cachexia at the earliest stage of development is advocated. Experts advocate for multimodal therapy to address symptoms that impact caloric intake, reduce chronic inflammation, and treat metabolic and endocrine derangements, which propagate the loss of weight. Treatment of insulin resistance may be a critical component of multimodal therapy for cancer cachexia and more research is needed.

Insulin resistance and body composition in cancer patients.

Cancer cachexia, weight loss with altered body composition, is a multifactorial syndrome propagated by symptoms that impair caloric intake, tumor byproducts, chronic inflammation, altered metabolism, and hormonal abnormalities. Cachexia is associated with reduced performance status, decreased tolerance to chemotherapy, and increased mortality in cancer patients. Insulin resistance as a consequence of tumor byproducts, chronic inflammation, and endocrine dysfunction has been associated with weight loss in cancer patients. Insulin resistance in cancer patients is characterized by increased hepatic glucose production and gluconeogenesis, and unlike type 2 diabetes, normal fasting glucose with high, normal or low levels of insulin. Cancer cachexia results in altered body composition with the loss of lean muscle mass with or without the loss of adipose tissue. Alteration in visceral adiposity, accumulation of intramuscular adipose tissue, and secretion of adipocytokines from adipose cells may play a role in promoting the metabolic derangements associated with cachexia including a proinflammatory environment and insulin resistance. Increased production of ghrelin, testosterone deficiency, and low vitamin D levels may also contribute to altered metabolism of glucose. Cancer cachexia cannot be easily reversed by standard nutritional interventions and identifying and treating cachexia at the earliest stage of development is advocated. Experts advocate for multimodal therapy to address symptoms that impact caloric intake, reduce chronic inflammation, and treat metabolic and endocrine derangements, which propagate the loss of weight. Treatment of insulin resistance may be a critical component of multimodal therapy for cancer cachexia and more research is needed.

European Society for Medical Oncology (ESMO) position paper on supportive and palliative care.

Oncology has come a long way in addressing patients' quality of life, together with developing surgical, radio-oncological and medical anticancer therapies. However, the multiple and varying needs of patients are still not being met adequately as part of routine cancer care. Supportive and palliative care interventions should be integrated, dynamic, personalised and based on best evidence. They should start at the time of diagnosis and continue through to end-of-life or survivorship. ESMO is committed to excellence in all aspects of oncological care during the continuum of the cancer experience. Following the 2003 ESMO stand on supportive and palliative care (Cherny N, Catane R, Kosmidis P. ESMO takes a stand on supportive and palliative care. Ann Oncol 2003; 14(9): 1335-1337), this position paper highlights the evolving and growing gap between the needs of cancer patients and the actual provision of care. The concept of patient-centred cancer care is presented along with key requisites and areas for further work.

Postoperative MRI Evaluation of a Radiofrequency Cordotomy Lesion for Intractable Cancer Pain.

BACKGROUND AND PURPOSE: There are limited data on the use of postoperative imaging to evaluate the cordotomy lesion. We aimed to describe the cordotomy lesion by using postoperative MR imaging in patients after percutaneous cordotomy for intractable cancer pain. MATERIALS AND METHODS: Postoperative MR imaging and clinical outcomes were prospectively obtained for 10 patients after percutaneous cordotomy for intractable cancer pain. Area, signal intensity, and location of the lesion were recorded. Clinical outcomes were measured by using the Visual Analog Scale and the Brief Pain Inventory-Short Form, and correlations with MR imaging metrics were evaluated. RESULTS: Ten patients (5 men, 5 women; mean age, 58.5 ± 9.6 years) were included in this study. The cordotomy lesion was hyperintense with central hypointense foci on T2-weighted MR imaging, and it was centered in the anterolateral quadrant at the C1-C2 level. The mean percentage of total cord area lesioned was 24.9% ± 7.9%, and most lesions were centered in the dorsolateral region of the anterolateral quadrant (66% of the anterolateral quadrant). The number of pial penetrations correlated with the percentage of total cord area that was lesioned (r = 0.78; 95% CI, 0.44-0.89; P = .008) and the length of T2-weighted hyperintensity (r = 0.85; 95% CI, 0.54-0.89; P = .002). No significant correlations were found between early clinical outcomes and quantitative MR imaging metrics. CONCLUSIONS: We describe qualitative and quantitative characteristics of a cordotomy lesion on early postoperative MR imaging. The size and length of the lesion on MR imaging correlate with the number of pial penetrations. Larger studies are needed to further investigate the clinical correlates of MR imaging metrics after percutaneous cordotomy.

Differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor oncology specialists.

BACKGROUND: Patients with hematologic malignancies often receive aggressive care at the end-of-life. To better understand the end-of-life decision-making process among oncology specialists, we compared the cancer treatment recommendations, and attitudes and beliefs toward palliative care between hematologic and solid tumor specialists. PATIENTS AND METHODS: We randomly surveyed 120 hematologic and 120 solid tumor oncology specialists at our institution. Respondents completed a survey examining various aspects of end-of-life care, including palliative systemic therapy using standardized case vignettes and palliative care proficiency. RESULTS: Of 240 clinicians, 182 (76%) clinicians responded. Compared with solid tumor specialists, hematologic specialists were more likely to favor prescribing systemic therapy with moderate toxicity and no survival benefit for patients with Eastern Cooperative Oncology Group (ECOG) performance status 4 and an expected survival of 1 month (median preference 4 versus 1, in which 1 = strong against treatment and 7 = strongly recommend treatment, P < 0.0001). This decision was highly polarized. Hematologic specialists felt less comfortable discussing death and dying (72% versus 88%, P = 0.007) and hospice referrals (81% versus 93%, P = 0.02), and were more likely to feel a sense of failure with disease progression (46% versus 31%, P = 0.04). On multivariate analysis, hematologic specialty [odds ratio (OR) 2.77, P = 0.002] and comfort level with prescribing treatment to ECOG 4 patients (OR 3.79, P = 0.02) were associated with the decision to treat in the last month of life. CONCLUSIONS: We found significant differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor specialists, and identified opportunities to standardize end-of-life care.

Indicators of integration of oncology and palliative care programs: an international consensus.

BACKGROUND: Recently, the concept of integrating oncology and palliative care has gained wide professional and scientific support; however, a global consensus on what constitutes integration is unavailable. We conducted a Delphi Survey to develop a consensus list of indicators on integration of specialty palliative care and oncology programs for advanced cancer patients in hospitals with ≥100 beds. METHODS: International experts on integration rated a list of indicators on integration over three iterative rounds under five categories: clinical structure, processes, outcomes, education, and research. Consensus was defined a priori by an agreement of ≥70%. Major criteria (i.e. most relevant and important indicators) were subsequently identified. RESULTS: Among 47 experts surveyed, 46 (98%), 45 (96%), and 45 (96%) responded over the three rounds. Nineteen (40%) were female, 24 (51%) were from North America, and 14 (30%) were from Europe. Sixteen (34%), 7 (15%), and 25 (53%) practiced palliative care, oncology, and both specialties, respectively. After three rounds of deliberation, the panelists reached consensus on 13 major and 30 minor indicators. Major indicators included two related to structure (consensus 95%-98%), four on processes (88%-98%), three on outcomes (88%-91%), and four on education (93%-100%). The major indicators were considered to be clearly stated (9.8/10), objective (9.4/10), amenable to accurate coding (9.5/10), and applicable to their own countries (9.4/10). CONCLUSIONS: Our international experts reached broad consensus on a list of indicators of integration, which may be used to identify centers with a high level of integration, and facilitate benchmarking, quality improvement, and research.

Heart rate variability as a measure of autonomic dysfunction in men with advanced cancer.

Autonomic dysfunction is common in patients with cancer and may have considerable negative effects on quality of life and mortality. This study retrospectively compared heart rate variability measured by the standard deviation of normal-to-normal intervals (SDNN) to Ewing test score, a composite score from a battery of five defined autonomic tests, in detection of autonomic dysfunction in 47 men with advanced cancer. The Ewing test score has been validated for diagnosis of autonomic dysfunction but is time-consuming and requires considerable patient co-operation; we hypothesised that SDNN, a much simpler test, is a useful alternative. The patients were categorised into three groups according to Ewing score: ≤ 2 (mild or no autonomic dysfunction), 2.5-3 (moderate) and ≥ 3.5 (severe). The SDNN (mean ± SD) for the three groups were 57.1 ± 26.9 ms 62.3 ± 22.4 ms and 37.7 ± 20.3 ms respectively. A significant negative correlation was found between Ewing score and SDNN (r = -0.40, P = 0.005). A SDNN of ≤ 40 ms had 63% sensitivity and 75% specificity in the diagnosis of severe autonomic dysfunction (i.e. Ewing score ≥ 3.5). The positive predictive value of SDNN ≤ 40 ms in predicting moderate/severe autonomic dysfunction was 89%.

Testosterone replacement for fatigue in hypogonadal ambulatory males with advanced cancer: a preliminary double-blind placebo-controlled trial.

BACKGROUND: Uncontrolled studies show fatigue, anorexia, depression, and mortality are associated with low testosterone in men with cancer. Testosterone replacement improves quality of life and diminishes fatigue in patients with non-cancer conditions. The primary objective was to evaluate the effect of testosterone replacement on fatigue in hypogonadal males with advanced cancer, by the Functional Assessment of Chronic Illness Therapy-Fatigue subscale (FACIT-Fatigue) at day 29. METHODS: This is a randomized, double-blinded placebo-controlled trial. Outpatients with advanced cancer, bioavailable testosterone (BT) <70 ng/dL and fatigue score >3/10 on the Edmonton Symptom Assessment Scale were eligible. Intra-muscular testosterone or sesame seed oil placebo was administered every 14 days to achieve BT levels 70-270 ng/dL. RESULTS: Sixteen placebo and 13 testosterone-treated subjects were evaluable. No statistically significant difference was found for FACIT-fatigue scores between arms (-2 ± 12 for placebo, 4 ± 8 for testosterone, p = 0.11). Sexual Desire Inventory score (p = 0.054) and performance status (p = 0.02) improved in the testosterone group. Fatigue subscale scores were significantly better (p = 0.03) in those treated with testosterone by day 72. CONCLUSIONS: Four weeks of intramuscular testosterone replacement in hypogonadal male patients with advanced cancer did not significantly improve quality of life. Larger studies of longer duration are warranted.

Frequency of opioid use in a population of cancer patients during the trajectory of the disease.

AIMS: Bearing in mind that Denmark has one of the world's highest legal uses of strong opioids per capita, the aim of the present study was to describe the frequency of opioid use in a complete, population-based cohort of cancer patients at different time points during the trajectory of the disease, and to analyse the influence of different factors on opioid use close to death. MATERIALS AND METHODS: All incident cancer patients registered in 1997-1998 (n=4006) from a population of 470,000 were followed individually from diagnosis to death (non-survivors) or for 5 years (survivors). The use of opioids was obtained from a prescription database covering the whole population. RESULTS: Among the 43% cancer patients who survived for 5 years, 12% used opioids at diagnosis, 38% during follow-up and 10% after 5 years. For the non-survivors, 80% used opioids sometime during follow-up. At diagnosis, use related inversely to the cancer type's 5-year survival, and ranged from 20 to 46%; before death 64-76% used opioids. The odds ratios for opioid use at death were smaller for breast cancer (0.53; confidence interval 0.33-0.85), haemopoietic cancer (0.28; confidence interval 0.17-0.44) and the group of miscellaneous cancers (0.54; confidence interval 0.36-0.83) compared with colorectal cancer. Older age, longer disease duration and male gender (0.76; confidence interval 0.59-0.99) reduced the odds of opioid use at death. CONCLUSIONS: Judged by the use of opioids, moderate to severe pain is frequent throughout the trajectory of the cancer disease. The frequency of opioid use was in accordance with the frequency of moderate to severe cancer-related pain described in published studies. This completely population-based data set enables analyses of the actual practice regarding cancer patients' use of opioids, and it can serve as a more effective template for the management of cancer pain than the traditional measures, such as opioid consumption per capita, for international comparisons.

Loss of adipose tissue and plasma phospholipids: relationship to survival in advanced cancer patients.

BACKGROUND & AIMS: Extensive loss of adipose tissue is a key feature of cancer cachexia. Advanced cancer patients also exhibit low plasma phospholipids. It is not known whether these processes coincide across the cancer trajectory nor has their relationship with survival been defined. Changes in adipose tissue mass and plasma phospholipids were characterized within 500days prior to death and prognostic significance assessed. METHODS: Adipose tissue rate of change was determined in a retrospective cohort of patients who died of colorectal and lung cancers (n=108) and who underwent >2 computed tomography scans in the last 500days of life. Plasma phospholipid fatty acids were measured prospectively in a similar cohort of patients with metastatic cancer (n=72). RESULTS: Accelerated loss of adipose tissue begins at 7months from death reaching an average loss of 29% of total AT 2months from death. Plasma phospholipid fatty acids were 35% lower in patients closest to death versus those surviving >8months. Losses of phospholipid fatty acids and adipose tissue occur in tandem and are predictive of survival. CONCLUSIONS: Depletion of plasma phospholipids likely indicates a deficit of essential fatty acids in the periphery which may contribute to loss of adipose tissue.

Utilización de opioides subcutáneos de forma intermitente para el manejo del dolor por cáncer en pacientes en cuidados paliativos / No disponible

Objetivo: revisar la utilidad de la administración subcutánea de opioides para el control del dolor en pacientes en situación de enfermedad terminal. Material y método: se ha realizado una revisión de la bibliografía relevantes obre el tema mediante búsqueda en MEDLINE hasta diciembre de 2008. Se ha aportado además la experiencia de nuestro grupo en esta técnica. Hemos revisado 40 artículos de los que 23 hacían referencia explícita a la administración de opioides por esta vía. Resultados y conclusiones: la administración intermitente de opioides por vía subcutánea es una buena alternativa para lograr el control del dolor en el paciente con enfermedad terminal. El infusor de Edmonton permite realizarlo de forma segura, económica y cómoda por parte de cuidadores en domicilio (AU)

Objective: to review the literature on the use of subcutaneous intermittent opioids for pain control in patients with terminal illness. Material and methods: we conducted a review of the relevant literature on the subject by searching MEDLINE through December 2008. We also reviewed the experience of our group with this technique. We reviewed 40 articles, of which 23 reported on the administration of opioids subcutaneously. Results and conclusions: the intermittent administration of opioids subcutaneously is a good alternative to achieve pain control in patients with terminal illness. The Edmonton injector allows for safe, inexpensive, comfortable administration by patients and caregivers at home (AU)

Hidratación en Cuidados Paliativos: cuándo, cómo, por qué / No disponible

Antecedentes: la gran mayoría de los pacientes en la fase terminal de su enfermedad experimenta una importante reducción de la ingesta oral antes de morir, debido a diferentes causas relacionadas con su cáncer o su tratamiento. La disminución de la ingesta es vivida por el paciente y su familia con cierta angustia debido a las características vitales que tienen la alimentación y la hidratación. Esta, entre otras razones, hacen del manejo de la deshidratación en estos pacientes un tema polémico incluso entre los profesionales dedicados a los cuidados paliativos. Objetivo: revisar la literatura científica en relación con la valoración del estado de hidratación de los pacientes con cáncer terminal, la toma de decisiones respecto a la rehidratación y la adecuada administración de fluidos en aquellos pacientes en los que una cuidadosa evaluación individualizada después de indicación. Material y método: una revisión narrativa de la literatura y utilizando la base de datos de Pubmed. Capítulos de libros sobre temas de medicina paliativa y onconlogía relacionados y los números anteriores de Medicina Paliativa. La revisión se realizó en los idiomas inglés y español. Se seleccionaron aquellos artículos en los que la deshidratación y/o la rehidratación se trataban de una manera relevante o aportaban algún dato significativo al tema. Resultados: para alcanzar una adecuada hidratación, el paciente terminal necesita menores cantidades de agua pero al mismo tiempo tiene un mayor riesgo de déficit de esta. El mantenimiento del balance de líquidos en estos pacientes, muchos de ellos ancianos, es complejo y confuso. Se necesitan más estudios que identifiquen mejor aquellos subgrupos de pacientes que pueden beneficiarse de la hidratación. Si se decide hidratar hay varias vías y se debería realizar un seguimiento de la deshidratación y de la retención de líquidos. Conclusión: los síntomas habitualmente relacionados con la deshidratación son difíciles de interpretar debido a que la enfermedad maligna en sí misma, su tratamiento o la presencia de infección pueden producir síntomas similares. Una adecuada valoración del estado de hidratación de la implicación de la deshidratación en el estado del paciente deberían preceder a la valoración de las ventajas o desventajas de hidratar, que debe incluir, también, los deseos del paciente y de su familia. En caso de duda, una breve prueba de hidratación podría ser adecuada. Si se decide la hidratación, existen diferentes métodos que permiten adaptarla a las situaciones de los pacientes. Si no se va a beneficiar de la hidratación sería recomendable que las medicaciones, como por ejemplo, los opioides, fueran disminuidas gradualmente para evitar su acumulación y toxicidad (AU)

Background: a great majority of patients with end-stage disease experience a severily reduced oral intake before death, which is due to a variety of causes related to their cancer or its treatment. Reduced oral intake is perceived by patients and their families with distress because of implications related to eating and hydration. This perception and the fact that there is no evidence-based research to determine how it is best to proceed surround this issue of much controversy even among palliative care professionals. Objective: to review the existing literature regarding the assessment of hydration in cancer patients, the process of decision making regarding hydration, and the methods and outcomes of artificial hydration. Material and method: we conducted a narrative review using the Pubmed database as well as references within the identified papers, chapters in textbooks of palliative medicine and oncology, and previous issues of Medicina Paliativa. The review was conducted both in English and Spanish. Results: terminal cancer patients need less fluid for adequate hydration; however, they are at increased risk for fluid deficiency, often precipitated by minor variations in fluid intake, infection, and other conditions. Conclusion: the main symptoms of dehydration are difficult to interpret due to the presence of multiple symptoms related to cancer and cancer therapy. A careful assessment is needed before a decision is made regarding fluid administration. In unclear cases a brief trial of parenteral hydration may be useful. The subcutaneous and rectal routes are useful alternatives to the intravenous route, particularly in the community setting. If hydration is not considered appropriate a progressive reduction of drugs likely to accumulate in the presence of dehydration -including opioids- is indicated (AU)

Tratamiento domiciliario de la obstrucción intestinal alta: a propósito de un caso clínico / No disponible

La obstrucción intestinal maligna alta presenta síntomas intensos como dolor y vómitos que requieren intervenciones complejas y frecuentes ingresos hospitalarios. Presentamos un caso clínico con el objetivo de señalar la posibilidad de tratamiento domiciliario de esta patología cuando el paciente lo desea. La utilización de fármacos de reconocida eficacia en el tratamiento sintomático de la obstrucción intestinal como morfina, corticoides, butilbromurode hioscina, haloperidol y octeotrido y la hipodermoclisis, fueron las herramientas farmacológicas utilizadas. La administración combinada de fármacos en infusión continua nos permitió conseguir un adecuado alivio de los síntomas. Su administración fue bien tolerada y aceptada por el paciente y familia

Malignant upper bowel obstruction causes severe symptoms such as pain and vomiting, which require complex treatment and frequent hospital admissions. We report a case of malignant upper bowel obstruction to show that it can be satisfactorily treated in the patient’s home if the patient so wishes. The use of drugs with established efficacy in the sympthomatic treatment of obstruction, including morphine, dexamethasone, hioscynebutylbromide, haloperidol, and octreotide, together with hypodermoclysis, was our pharmacological tool. A continous subcutaneous infusion of combined drugs allowed us to obtain acceptable symptom relief. Home hypodermoclysis was well accepted, and managed by the patient and his or her family

Vías alternativas a la vía oral para administración sistémica de opioides en Cuidados Paliativos. Revisión de la literatura / Alternative routes for opioid administration in Palliative Care. Review of literature

Más del 80% de los pacientes en fase terminal presentan dificultad para recibir medicamentos por vía oral, existe un creciente interés en desarrollar otras formas de administración sistémica de opioides diferentes a la ruta oral, con el fin de realizar un adecuado control sintomático. El uso de vías alternativas beneficiará principalmente a pacientes con situaciones clínicas como: náuseas y vómitos, disfagia, obstrucción intestinal, delirio/sedación, disnea y dolor; pacientes que requieran manejo ambulatorio o cuidado en casa. En esta revisión de la literatura se describirán las indicaciones, limitaciones y los principales aspectos de farmacocinética y farmacodinamia delos principales opioides utilizados por las diferentes vías. Las vías subcutánea, rectal, nebulizada, sublingual, transdérmica, intranasal e iontoforesis serán descritas. La mayoría de estas vías se encuentran en fase de experimentación y se espera sean promisorias, pero en el momento no existe la suficiente evidencia para su utilización en la práctica clínica (AU)

More than 80% of the terminally ill patients have difficulty to swallow oral medications; there is an increasing interest in the development of other routes different than the oral, in order to achieve an adequate symptom control. Using alternatives routes will mainly benefit patients presenting with clinical conditions like: nausea and vomit, dysphagia, bowel obstruction, delirium/sedation, dyspnea and pain; patients that require outpatient or home care. This review of the literature is aimed at describing the indications, the limits and the main aspects of the pharmacokinetics and pharmacodynamics relative to the alternative routes of administration of opioids most commonly used in clinical practice. Subcutaneous, rectal, nebulize, sublingual, transdermal, intranasal and iontophoresis administration routes are examined. The majority of these routes is on experimental phase and hopefully will be of clinical utility in a near future, but currently there is not clear evidence for their use in the clinical practice (AU)

Abbreviated course of radiation therapy in older patients with glioblastoma multiforme: a prospective randomized clinical trial.

PURPOSE: To prospectively compare standard radiation therapy (RT) with an abbreviated course of RT in older patients with glioblastoma multiforme (GBM). PATIENTS AND METHODS: One hundred patients with GBM, age 60 years or older, were randomly assigned after surgery to receive either standard RT (60 Gy in 30 fractions over 6 weeks) or a shorter course of RT (40 Gy in 15 fractions over 3 weeks). The primary end point was overall survival. The secondary end points were proportionate survival at 6 months, health-related quality of life (HRQoL), and corticosteroid requirement. HRQoL was assessed using the Karnofsky performance status (KPS) and Functional Assessment of Cancer Therapy-Brain (FACT-Br). RESULTS: All patients had died at the time of analysis. Overall survival times measured from randomization were similar at 5.1 months for standard RT versus 5.6 months for the shorter course (log-rank test, P =.57). The survival probabilities at 6 months were also similar at 44.7% for standard RT versus 41.7% for the shorter course (lower-bound 95% CI, -13.7). KPS scores varied markedly but were not significantly different between the two groups (Wilcoxon test, P =.63). Low completion rates of the FACT-Br (45%) precluded meaningful comparisons between the two groups. Of patients completing RT as planned, 49% of patients (standard RT) versus 23% required an increase in posttreatment corticosteroid dosage (chi(2) test, P =.02). CONCLUSION: There is no difference in survival between patients receiving standard RT or short-course RT. In view of the similar KPS scores, decreased increment in corticosteroid requirement, and reduced treatment time, the abbreviated course of RT seems to be a reasonable treatment option for older patients with GBM.