Pilot study of multi-gene pharmacogenetic testing for pain management in oncology palliative medicine.

Aim: We evaluated the application and clinical impact of multi-gene pharmacogenetic testing in oncology palliative medicine. Patients & methods: In a single-arm pilot trial, cancer patients with uncontrolled pain were assessed in a palliative medicine clinic at baseline and received pharmacogenetic testing. Results were used as applicable up to the final visit (day 30). Pain scores, opioid prescribing, and use of pharmacogenetic test results were collected. Results: In 75 patients, the median baseline pain score was 7/10. Of 54 evaluable at the final visit, 28 required opioid modifications and 19 had actionable genotypes, mostly CYP2D6. Pain improvement (≥2-point reduction) was higher than historical data (56 vs 30%; p < 0.001). There were no differences in pain improvement between those with and without actionable genotypes (61 vs 53%). Conclusion: Multi-gene testing identified actionable genotypes and may improve cancer pain.

Can video consultations replace face-to-face interviews? Palliative medicine and the Covid-19 pandemic: rapid review.

During the Covid-19 pandemic, a strategy to minimise face-to-face (FtF) visits and limit viral spread is essential. Video consultations offer clinical assessment despite restricted movement of people.We undertook a rapid literature review to identify the highest currently available level of evidence to inform this major change in clinical practice. We present a narrative synthesis of the one international and one national guideline and two systematic reviews-all published within the last 18 months.The global evidence appears to support video consultations as an effective, accessible, acceptable and cost-effective method of service delivery. Organisations must ensure software is simple, effective, reliable and safe, with the highest level of security for confidentiality.Although video consultations cannot fully replace FtF, they can radically reduce the need for FtF and the risk of Covid-19 spread in our communities while maintaining high standards of care. For patient safety, it will be critical to follow the WHO guidance regarding: a standard operating procedure; clinical protocols for when video consultations can (and cannot) be used; policies to ensure equity of access in disadvantaged populations; adequate staff training; and administrative support to coordinate appointments.

Supportive care in cancer-a MASCC perspective.

The term 'supportive care' arose from the medical oncology literature predominantly in the context of managing the toxicities of cancer treatment but embraces all symptom management through treatment and survivorship. Supportive care should be patient-centred with good communication which includes family and carers and applies across the cancer experience from diagnosis, treatment, survivorship to end of life care. Supportive care encompasses physical and functional, psychological, social and spiritual well-being to improve the quality of life. Supportive care must be evidence-based and thus further research is essential. Supportive care requires screening for some symptoms and tools for patients to report their outcomes. Supportive care has to accommodate new physical toxicities, emotional distress as well as financial toxicity. Supportive care is often delivered by medical oncologists but any organ-related specialist, geriatrician, palliative care clinician, pain specialist, nutritionist, psycho-oncologist, social worker, physiotherapist, nurse or allied health worker who is required to relieve a patient's symptoms or side effects may be involved in a multidisciplinary way. The field is evolving to embrace technology such as eHealth and mHealth capabilities which will enhance integrated care.

The use of olanzapine as an antiemetic in palliative medicine: a systematic review of the literature.

BACKGROUND: Olanzapine is an atypical antipsychotic that has affinity for many central nervous system receptors. Its efficacy is supported by several studies in the prevention and treatment of chemotherapy-induced nausea and vomiting. No recommendations exist on the antiemetic use of olanzapine in the palliative care setting. The aim of this work is to complete the initial work of Fonte et al. published in 2015, to determine whether the literature supports the use of olanzapine as an antiemetic in palliative situations and, in practice, to propose a therapeutic schema adapted to the palliative setting. METHODS: Systematic review of the literature according to the PRISMA criteria. We searched the PubMed, Cochrane, RefDoc, EMBase databases and the gray literature databases. The bibliographic search was conducted between November 2016 and August 2017. RESULTS: Thirteen articles were included: 2 case studies, 3 case series, 3 retrospective studies, 2 prospective studies, 2 literature reviews. All studies concluded on the efficacy of olanzapine as an antiemetic in the palliative care setting. No serious adverse effects were reported. Based on the data from the literature review, we propose a therapeutic scheme adapted to the palliative care context. CONCLUSION: Action of olanzapine on many receptors and its tolerance profile make it an interesting antiemetic treatment in palliative medicine. But to date, studies are scarce and have a low statistical power. Further investigation is therefore needed to determine the benefit of this treatment in palliative care patients, compared to usual treatments.

Impact of sequential lines of palliative chemotherapy in patients with recurrent/metastatic esophageal squamous cell carcinoma: A retrospective analysis of 107 patients at a single center.

AIM: This study was conducted to evaluate the efficacy of palliative chemotherapy by the lines of chemotherapy in recurrent/metastatic esophageal squamous cell carcinoma (ESCC) and to compare the efficacy between the patients with initially metastatic ESCC and those with recurrent/progressed ESCC after curative treatment. MATERIALS AND METHODS: All 107 patients who began palliative chemotherapy for recurrent/metastatic ESCC from March 2015 to October 2017 were included, and grouped according to previous treatment: Groups A (previous chemoradiation alone, n = 30), B (previous surgery alone, n = 11), C (previous chemoradiation and surgery, n = 30), and D (initially metastatic or de novo stage IV, n = 36). Groups A, B, and C (pretreated group) and Group D (treatment-naïve group) were reorganized according to treatment history. Overall response rate (ORR) and survival data were retrospectively evaluated for each group, lines of chemotherapy, and chemotherapeutic regimen. RESULTS: ORR was 25.2%, 7.3%, and 3.4% in first-, second-, and third-line chemotherapy, respectively. The median progression-free survival (PFS) was 4.7, 2.0, and 2.2 months in first-, second-, third-line chemotherapy, respectively. The median overall survival (OS) after first-line palliative chemotherapy was 10.1 months, and it was not significantly different between pretreated and treatment-naive groups. Previous surgery, good performance, ≥3 lines of chemotherapy, and low C-reactive protein level were linked to a significantly longer OS in multivariate analysis. CONCLUSION: Because PFS rapidly declines with advancement of line of chemotherapy, incorporation of effective treatment modalities in early line treatments is crucial in the management of recurrent/metastatic ESCC. If tolerable, continuing advanced lines of chemotherapy may prolong survival.

Should Oncologists Recommend Cannabis?

OPINION STATEMENT: Cannabis is a useful botanical with a wide range of therapeutic potential. Global prohibition over the past century has impeded the ability to study the plant as medicine. However, delta-9-tetrahydrocannabinol (THC) has been developed as a stand-alone pharmaceutical initially approved for the treatment of chemotherapy-related nausea and vomiting in 1986. The indication was expanded in 1992 to include treatment of anorexia in patients with the AIDS wasting syndrome. Hence, if the dominant cannabinoid is available as a schedule III prescription medication, it would seem logical that the parent botanical would likely have similar therapeutic benefits. The system of cannabinoid receptors and endogenous cannabinoids (endocannabinoids) has likely developed to help us modulate our response to noxious stimuli. Phytocannabinoids also complex with these receptors, and the analgesic effects of cannabis are perhaps the best supported by clinical evidence. Cannabis and its constituents have also been reported to be useful in assisting with sleep, mood, and anxiety. Despite significant in vitro and animal model evidence supporting the anti-cancer activity of individual cannabinoids-particularly THC and cannabidiol (CBD)-clinical evidence is absent. A single intervention that can assist with nausea, appetite, pain, mood, and sleep is certainly a valuable addition to the palliative care armamentarium. Although many healthcare providers advise against the inhalation of a botanical as a twenty-first century drug-delivery system, evidence for serious harmful effects of cannabis inhalation is scant and a variety of other methods of ingestion are currently available from dispensaries in locales where patients have access to medicinal cannabis. Oncologists and palliative care providers should recommend this botanical remedy to their patients to gain first-hand evidence of its therapeutic potential despite the paucity of results from randomized placebo-controlled clinical trials to appreciate that it is both safe and effective and really does not require a package insert.

Atuação do psicólogo nos cuidados paliativos em cardiologia / The work f the psychologist in palliative care in cardiology

Trata-se de um artigo de reflexão que visa contextualizar, a partir da literatura e da prática, a atuação do psicólogo nos cuidados paliativos, especificamente em cardiologia. A abordagem dos cuidados paliativos em cardiologia está ainda sendo desenvolvida; teve origem com pacientes terminais de câncer. O psicólogo paliativista que atua junto à equipe multidisciplinar abrange várias áreas, como a biológica, psicológica, religiosa, espiritual, social e familiar. A atuação visa o atendimento aos pacientes, familiares e equipe, oferecendo suporte para a melhor qualidade de vida naquele momento. O psicólogo participa das conferências familiares, abre espaços para a discussão de casos, promove encontros multidisciplinares, cuida do burnout da equipe, lida com os conflitos e implementa as habilidades de comunicação. O instrumento fundamental para o trabalho é a melhora constante da comunicação, que visa agregar e harmonizar a equipe, diminuir os conflitos e impactos nas relações com o paciente, a família e os membros, esclarecendo, orientando e diminuindo a dor como um todo. Desse modo, cria uma rede de continência e um projeto terapêutico para as necessidades de cada paciente e família

This is a reflection article that aims to contextualize, based on the literature and practice, the work of the psychologist in palliative care, specifically in cardiology. The palliative care approach in cardiology is still being developed; it originated with terminal cancer patients. The palliative psychologist who works alongside the multidisciplinary team covers various areas such as biological, psychological, religious, spiritual, social and family-related. Their work aims to provide care to patients, families and staff, offering support for the best quality of life at that time. The psychologist participates in family meetings, opens spaces for discussion of cases, promotes multidisciplinary meetings, takes care of team burnout, deals with conflicts, and implements communication skills. The essential tool for the work is the constant improvement of communication, which aims to bring together and fine-tune the team, reduce conflicts and impacts in the relations with the patient, the family and the members, clarifying, guiding and reducing the overall pain. Thus, the psychologist creates a network of moderation and a therapeutic project for the needs of each patient and family

Changes in opinions on palliative sedation of palliative care specialists over 16 years and their effects on clinical practice.

PURPOSES: Despite extensive debate on palliative sedation over the last few decades, no studies have explored longitudinal changes in physicians' opinion. Moreover, little is known about how physicians' opinions affect their practice. This study aimed to clarify (1) changes in palliative care specialists' opinions on palliative sedation and (2) the effects of these opinions on clinical practice. METHODS: In 2000 and 2016, nationwide questionnaire surveys involving Japanese palliative care specialists were performed: measurement was based on agreement with opinions on palliative sedation. In 2016, the physicians reported their practice of continuous deep sedation (CDS) and answered their thoughts on what factors lead to a good death as factors potentially affecting their practice. RESULTS: Of the 695 physicians enrolled in the 2016 survey, 469 responded (67%) and 417 were analyzed (60%). Compared with 54 physicians in 2000, the present respondents were more likely to consider palliative sedation is difficult to perform based on appropriate indications (ES = 0.84, P < 0.001), is unnecessary if conventional palliative care is performed sufficiently (ES = 0.30, P = 0.013), and may result in legal action (ES = 0.35, P = 0.003). The physicians' opinions more strongly affected their practice than their characteristics or thoughts on good death components. CONCLUSIONS: Recently, palliative care specialists in Japan tend to encounter more difficulties determining what conventional palliative care is and what palliative sedation is. They also fear legal ramifications. It is necessary to standardize methods of alleviating patients' suffering, to make CDS criteria clearer, and to create a legal basis that respects patients' rights at their end of life.

Recent advances in non-surgical management of cancer in the elderly.

This article summarizes the seminal publications from mid-2016 through 2017 in the area of medical care for older adults with cancer. Areas addressed include chemotherapy tolerance and efficacy in the aged, geriatric fitness assessments, and advancements in palliative and supportive care. The practice-changing finding from this past year's publications is that antipsychotics should not be used in the management of terminal delirium in older adults receiving palliative care. The other trials demonstrated an improved understanding of the utility of geriatric assessments in patients with cancer, developed the body of information about which chemotherapy agents are safe and effective in older adults (and which are not), and expanded our understanding of good palliative and supportive care.

Los últimos románticos... / The last of the romantics...

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Systematic review and meta-analysis on non-opioid analgesics in palliative medicine.

Non-opioid analgesics are widely used for pain relief in palliative medicine. However, there is a lack of evidence-based recommendations addressing the efficacy, tolerability, and safety of non-opioids in this field. A comprehensive systematic review and meta-analysis on current evidence can provide a basis for sound recommendations in clinical practice. A database search for controlled trials on the use of non-opioids in adult palliative patients was performed in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, and EMBASE from inception to 18 February 2018. Endpoints were pain intensity, opioid-sparing effects, safety, and quality of life. Studies with similar patients, interventions, and outcomes were included in the meta-analyses. Our systematic search was able to only identify studies dealing with cancer pain. Of 5991 retrieved studies, 43 could be included (n = 2925 patients). There was no convincing evidence for satisfactory pain relief by acetaminophen alone or in combination with strong opioids. We found substantial evidence of moderate quality for a satisfactory pain relief in cancer by non-steroidal anti-inflammatory drugs (NSAIDs), flupirtine, and dipyrone compared with placebo or other analgesics. There was no evidence for a superiority of one specific non-opioid. There was moderate quality of evidence for a similar pain reduction by NSAIDs in the usual dosage range compared with up to 15 mg of morphine or opioids of equianalgesic potency. The combination of NSAID and step III opioids showed a beneficial effect, without a decreased tolerability. There is scarce evidence concerning the combination of NSAIDs with weak opioids. There are no randomized-controlled studies on the use of non-opioids in a wide range of end-stage diseases except for cancer. Non-steroidal anti-inflammatory drugs, flupirtine, and dipyrone can be recommended for the treatment of cancer pain either alone or in combination with strong opioids. The use of acetaminophen in the palliative setting cannot be recommended. Studies are not available for long-term use. There is a lack of evidence regarding pain treatment by non-opioids in specific cancer entities.

Attitudes to specialist palliative care and advance care planning in people with COPD: a multi-national survey of palliative and respiratory medicine specialists.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) guidelines recommend early access to palliative care together with optimal, disease-directed therapy for people with advanced disease, however, this occurs infrequently. This study explored the approaches of respiratory and palliative medicine specialists to palliative care and advance care planning (ACP) in advanced COPD. METHODS: An online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom. RESULTS: Five hundred seventy-seven (33.1%) responses were received, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Most respiratory doctors (140, 80.9%) were very or quite comfortable providing a palliative approach themselves to people with COPD. 113 (63.8%) respiratory doctors recommended referring people with advanced COPD to specialist palliative care, mainly for access to: psychosocial and spiritual care (105, 59.3%), carer support (104, 58.5%), and end-of-life care (94, 53.1%). 432 (98.2%) participants recommended initiating ACP discussions. Palliative medicine doctors were more likely to recommend discussing: what palliative care is (p < 0.0001), what death and dying might be like (p < 0.0001) and prognosis (p = 0.004). Themes highlighted in open responses included: inadequate, fragmented models of care, with limited collaboration or support from palliative care services. CONCLUSIONS: While both specialties recognised the significant palliative care and ACP needs of people with advanced COPD, in reality few patients access these elements of care. Formal collaboration and bi-directional support between respiratory and palliative medicine, are required to address these unmet needs.

Differing Approaches to Managing the Chronic Breathlessness Syndrome in Advanced COPD: A Multi-National Survey of Specialists.

This study explored the approaches of respiratory and palliative medicine specialists to managing the chronic breathlessness syndrome in patients with severe chronic obstructive pulmonary disease. A voluntary, online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom (UK). Five hundred and seventy-seven (33.0%) responses were received from 1,749 specialists, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Palliative medicine doctors in ANZ and the UK had similar approaches to managing chronic breathlessness, whereas respiratory and palliative medicine doctors had significantly different approaches (p < 0.0001). Both specialties most commonly recommended a combination of non-pharmacological and pharmacological breathlessness management strategies. Respiratory doctors focussed more on pulmonary rehabilitation, whereas palliative medicine doctors recommended breathing techniques, anxiety management and the handheld fan. Palliative medicine doctors (197 (74.9%)) recommended short acting oral morphine for breathlessness, as compared with 73 (41.2%) respiratory doctors (p < 0.0001). Respiratory doctors cited opioid concerns related to respiratory depression and lack of knowledge. Nineteen (10.7%) respiratory doctors made no specific recommendations for managing chronic breathlessness. Both specialties reported actively managing chronic breathlessness, albeit with differing approaches. Integrated services, which combine the complementary knowledge and approaches of both specialities, may overcome current gaps in care and improve the management of distressing, chronic breathlessness.

Palliative Medicine Family Conferences Reduce Spokesperson Distress and Enhance Communication in Advanced Cancer.

INTRODUCTION: Family conferences (FCs) may be important in communication. There is limited evidence about their value in palliative medicine. We examined specific information needs of patient-identified spokespersons (SP) and if the needs were met by a subsequent FC. Further data were collected on FC attendee characteristics, changes in SP distress, and SP assessment of FC value. METHODS: We conducted a prospective observational study of the family SP perspective of consecutive first time palliative medicine FCs for cancer patients. The SP completed standardized questionnaires and a Distress Thermometer pre- and post-FC. RESULTS: Seventy-eight FCs were eligible. Daughters/sons were the largest single attendee group. The median FC duration was 45 minutes (range 30-100). The location was usually at the bedside. Distress thermometer (DT) scores fell in 51%, rose in 26%, were stable in 23%, and were unaffected by patient presence. On average, there was a one-unit reduction in DT scores post compared to pre (p = 0.0059, 95% CI -1.5 to -0.3). The SP wanted information on a median of 15 (range 13, 17; 83%) questionnaire items beforehand; a median of 12 (range 10-14; 67%) were discussed. Overall, 62% of the total items were "needs met" in ≥50% of the SP. CONCLUSIONS: The FC attracted multiple participants; usually sons and daughters. Duration was typically 45 minutes and usually at the bedside. Nearly all SPs found the concept valuable both before and after the FC. Distress decreased or remained stable in most SPs. Most of their self-identified information needs were met. Thematic analysis of qualitative data supported the value of FC. Formal FCs are powerful and important communication tools in advanced cancer.

La atención al final de la vida: deliberando sobre hechos y valores / End of life care: deliberating on facts and values

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Systematic review and meta-analysis of cannabinoids in palliative medicine.

We provide a systematic review and meta-analysis on the efficacy, tolerability, and safety of cannabinoids in palliative medicine. The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PubMed, Scopus, and http://clinicaltrials.gov, and a selection of cancer journals were searched up until 15th of March 2017. Of the 108 screened studies, nine studies with a total of 1561 participants were included. Overall, the nine studies were at moderate risk of bias. The quality of evidence comparing cannabinoids with placebo was rated according to Grading of Recommendations Assessment, Development, and Evaluation as low or very low because of indirectness, imprecision, and potential reporting bias. In cancer patients, there were no significant differences between cannabinoids and placebo for improving caloric intake (standardized mean differences [SMD]: 0.2 95% confidence interval [CI]: [-0.66, 1.06] P = 0.65), appetite (SMD: 0.81 95% CI: [-1.14, 2.75]; P = 0.42), nausea/vomiting (SMD: 0.21 [-0.10, 0.52] P = 0.19), >30% decrease in pain (risk differences [RD]: 0.07 95% CI: [-0.01, 0.16]; P = 0.07), or sleep problems (SMD: -0.09 95% CI: [-0.62, 0.43] P = 0.72). In human immunodeficiency virus (HIV) patients, cannabinoids were superior to placebo for weight gain (SMD: 0.57 [0.22; 0.92]; P = 0.001) and appetite (SMD: 0.57 [0.11; 1.03]; P = 0.02) but not for nausea/vomiting (SMD: 0.20 [-0.15, 0.54]; P = 0.26). Regarding side effects in cancer patients, there were no differences between cannabinoids and placebo in symptoms of dizziness (RD: 0.03 [-0.02; 0.08]; P = 0.23) or poor mental health (RD: -0.01 [-0.04; 0.03]; P = 0.69), whereas in HIV patients, there was a significant increase in mental health symptoms (RD: 0.05 [0.00; 0.11]; P = 0.05). Tolerability (measured by the number of withdrawals because of adverse events) did not differ significantly in cancer (RD: 1.15 [0.80; 1.66]; P = 0.46) and HIV patients (RD: 1.87 [0.60; 5.84]; P = 0.28). Safety did not differ in cancer (RD: 1.12 [0.86; 1.46]; P = 0.39) or HIV patients (4.51 [0.54; 37.45]; P = 0.32) although there was large uncertainty about the latter reflected in the width of the CI. In one moderate quality study of 469 cancer patients with cancer-associated anorexia, megestrol was superior to cannabinoids in improving appetite, producing >10% weight gain and tolerability. In another study comparing megestrol to dronabinol in HIV patients, megestrol treatment led to higher weight gain without any differences in tolerability and safety. We found no convincing, unbiased, high quality evidence suggesting that cannabinoids are of value for anorexia or cachexia in cancer or HIV patients.

Pediatric palliative oncology: the state of the science and art of caring for children with cancer.

PURPOSE OF REVIEW: Pediatric palliative oncology (PPO) is an emerging field that integrates the principles of palliative care early into the illness trajectory of children with cancer. PPO providers work with interdisciplinary clinicians to provide optimal medical and psychosocial care to children with cancer and their families. Ongoing advances in the field of pediatric oncology, including new treatment options for progressive cancers, necessitate the early integration of palliative care tenets including holistic care, high-quality communication, and assessment and management of refractory symptoms. RECENT FINDINGS: Research in this emerging field has expanded dramatically over the past several years. This review will focus on advancements within several key areas of the field, specifically regarding investigation of the communication needs and preferences of patients and families, exploration of educational initiatives and interventions to teach PPO principles to clinicians, study of patient-reported and parent-reported tools to better assess and manage refractory symptoms, and development of novel models to integrate palliative care within pediatric oncology. SUMMARY: Research findings in the field of PPO, concurrent with advances in the treatment of pediatric cancer, may help improve survival and quality of life for children with cancer.