Total Parenteral Nutrition in Middle Eastern Cancer Patients at End of Life: Is it Justified?

PURPOSE: The use of total parenteral nutrition (TPN) in terminally ill cancer patients is considered an aggressive approach with very limited benefits. We examined the practice of TPN in our end of life cancer patients and we investigated the patient and tumor characteristics that justify this practice. To our knowledge, this is the first study describing TPN administration of Middle Eastern patients with advanced cancer. METHODS: We conducted this retrospective observational study at Hotel-Dieu de France University Hospital, Lebanon. Eligible cases included all cancer patients that died at our institution between the 1st of January and the 31st of December 2014. The patients and tumors characteristics were analyzed for their potential role as determinant of TPN administration. The patients' hospitalization and causes of death were evaluated for the analysis of TPN benefits. RESULTS: Among the 129 patients enrolled, 39% had received TPN among which TPN administration correlated negatively to hyperlipidemia (OR= 0.33; 95% CI [0.12-0.87]) and to the presence of at least three cardiovascular risk factors (OR= 0.28; 95% CI [0.10 - 0.80]). However, it correlated positively to gastrointestinal tumors (OR= 3.9; 95% CI [1.3- 11.7]) and to imaging studies during the last month of life (OR= 3.4; 95% CI [1.3 - 9.0]). The TPN administration did not correlate to hospitalization during the last two weeks of life. CONCLUSION: The adoption of an optimal palliative care approach in Middle Eastern cancer patients at the end of life remains challenging. Oncologists seem to consider cardiovascular risk factors as a probable surrogate to predict complications of TPN.

The Therapeutic use of human albumin in cancer patients' management.

Human albumin (HA) has been widely used in clinical practice due to its unique physiological characteristics and pharmacokinetics. However, with the absence of clear institutional recommendations, its uncontrolled prescription remains largely controversial. An extensive review on the albumin chemistry, pharmacology, physiology and pathology was performed, and data on commercially available HA, its cost, medical usage and the related available guidelines, particularly in oncology patients were gathered. Studies assessing the appropriate use and safety of HA in cancer patients are lacking. A retrospective survey of the appropriateness of HA infusions according to the SIMTI guidelines (2009) was performed in our department. Among 53 patients who received HA infusions, only 5.7% of the indications were appropriate for HA administration. Occasionally appropriate and inappropriate indications were considered in 10% and 84.3% of the prescriptions respectively with a relatively high cost. The adoption of strict guidelines may substantially reduce the inappropriate use and the subsequent healthcare costs.