Subjective and Objective Assessment of Taste and Smell Sensation in Advanced Cancer.

CONTEXT: Taste and smell abnormalities (TSA) occur throughout the cancer trajectory regardless of cancer primary site and contribute to cancer-associated malnutrition. TSA etiology is poorly understood. Tumor-related inflammation is a possible cause. OBJECTIVE: This study examined the prevalence, characteristics, and severity of TSA in advanced cancer and explored the relationship between TSA and nutritional status. No previous study combined subjective and objective measures for both taste and smell assessment in this population. METHOD: Consecutive advanced cancer hospice patients were recruited. A modified version of the "Taste and Smell Survey" assessed subjective TSA. Validated taste strips and "Sniffin' Sticks" were the objective measures. The abridged patient-generated subjective global assessment evaluated nutritional status. RESULTS: A 93% prevalence of TSA in 30 patients with advanced cancer was identified. When subjective and objective evaluations were combined, 28 had taste abnormalities, 24 smell abnormalities, and 24 both. Taste changes included "persistent bad taste" (n = 18) and changes in how basic tastes were perceived. Half reported smell was not "as strong" as prediagnosis, while more than half (n = 16) had an objective smell abnormality. Most (97%) were at risk of malnutrition. Fatigue, dry mouth, early satiety, and anorexia were common nutrition-impact symptoms. No statistically significant relationship was found between TSA and malnutrition scores. CONCLUSIONS: TSA were highly prevalent. Subjective taste and smell changes did not always accord with objective TSA, suggesting both assessments are valuable. TSA characteristics varied, and particular foods tasted and smelled different and were not enjoyed as before. TSA are common, high-impact problems in advanced cancer.

Impact of a dedicated cancer-associated thrombosis service on clinical outcomes: a mixed-methods evaluation of a clinical improvement exercise.

OBJECTIVES: Cancer-associated thrombosis (CAT) complex condition, which may present to any healthcare professional and at any point during the cancer journey. As such, patients may be managed by a number of specialties, resulting in inconsistent practice and suboptimal care. We describe the development of a dedicated CAT service and its evaluation. SETTING: Specialist cancer centre, district general hospital and primary care. PARTICIPANTS: Patients with CAT and their referring clinicians. INTERVENTION: A cross specialty team developed a dedicated CAT service , including clear referral pathways, consistent access to medicines, patient's information and a specialist clinic. PRIMARY AND SECONDARY OUTCOME MEASURES: The service was evaluated using a mixed-methods evaluation , including audits of clinical practice, clinical outcomes, staff surveys and qualitative interviewing of patients and healthcare professionals. RESULTS: Data from 457 consecutive referrals over an 18-month period were evaluated. The CAT service has led to an 88% increase in safe and consistent community prescribing of low-molecular-weight heparin, with improved access to specialist advice and information. Patients reported improved understanding of their condition, enabling better self-management as well as better access to support and information. Referring clinicians reported better care standards for their patients with improved access to expertise and appropriate management. CONCLUSIONS: A dedicated CAT service improves overall standards of care and is viewed positively by patients and clinicians alike. Further health economic evaluation would enhance the case for establishing this as the standard model of care.

The treatment of cancer associated thrombosis: does one size fit all? Who should get LMWH/warfarin/DOACs?

Whilst the term cancer associated thrombosis (CAT) offers an overarching term for all thrombotic events encountered during the cancer journey, the reality is that this is a far too simplistic reflection of a complex multifactorial process occurring within a heterogeneous population. The management of CAT needs to consider factors beyond the thrombus itself: patients must be treated as individuals within the context of their own cancer journey and their preferences for different treatment options. The breath of pathological, pharmacological and psychosocial variants means it is highly unlikely that one treatment regime will be appropriate for all patients. It is inevitable that regimes may need to be modified and anticoagulant agents changed according to clinical and patient preference needs. There is strong evidence supporting the use of low molecular weight heparin first line in the treatment of acute CAT. The evidence for warfarin and the direct acting oral anticoagulants is not as strong but, as oral agents, may be preferred by some patients. This paper shall identify the various treatment options available, factors which will influence the decision making process and when it is justifiable to treat patients differently to the established protocol.

The usefulness of phlebotomy in the palliative care setting.

OBJECTIVES: To establish the reasons for phlebotomy and evaluate the usefulness of blood testing in the palliative setting. METHODS: The design was that of a questionnaire-based prospective study conducted in the 30-bed Specialist Palliative Care Unit at Milford Care Centre between March 23 and May 23, 2010. A questionnaire was completed by the performing clinician following each venipuncture, which included details of the admitted patient, the blood tests performed, the reason(s) for testing, and the usefulness of blood testing in diagnosing and influencing management. RESULTS: Fifty blood tests were conducted on 37 inpatients. The mean age of patients was 66.7 years and 54.1% were male. The top three diagnoses were malignancy of bowel, ovary, and prostate, respectively. The top three reasons for venipuncture were to manage medications, establish the need for blood transfusion, and guide management of sepsis. Thirty percent of phlebotomy sessions changed management, 40.7% ruled in an important diagnosis, and 86% ruled out an important diagnosis. Forty-eight percent of phlebotomy sessions had at least one type of test "added on" that in hindsight was unnecessary. CONCLUSIONS: Blood testing is a useful tool in the palliative setting to guide management and to ascertain diagnoses relevant to symptom control. For reasons of laboratory time and economic cost, unnecessary additional tests should be kept to a minimum.