Role of advance directives in palliative care units: a prospective study.

Advance directives (ADs) might be useful in achieving improved communication and satisfaction with decision making at the end-of-life. Our aims were to better characterise patients with advanced oncological disease who decided to complete ADs and to measure the effect of ADs completion on the satisfaction level with end-of-life care from both patients and their relatives. A prospective study was conducted in three palliative care units. Patients with advanced cancer were included if they met the following criteria: an estimated life expectancy of <6 months, fluency in French, Mini Mental State Examination >20 and not yet completed ADs. All the patients received information about ADs and decided whether to complete ADs or not. The level of satisfaction with involvement in the decision process concerning end-of-life care was assessed by means of a written questionnaire. In all, 53 of 228 patients were included, and 12 decided to complete ADs. Patients who completed ADs had statistically less depression one week after inclusion (P = 0.030), had a lower anxiety score on the second week and had a lower depression score on the third week. There was a trend towards a higher satisfaction level with the involvement of the patients in end-of-life care for those completing ADs (P = 0.878). In conclusion, each patient with an advanced progressive disease should be informed about ADs and be encouraged to complete the ADs with the aim to ease many fears as well as to improve communication.

[Competencies in palliative care: what should the physicians be able to do?]. / Compétences en soins patiatifs: que faut-il savoir faire en tant que médecin?

Palliative patients (patients with progressive incurable illnesses) have a number of needs, early and late in their illness trajectories. This article highlights some of the most important competencies required by physicians to address these needs. They cover a broad spectrum of domains and include pain and symptom management, communication, disclosure, prognostication, and psychological, social and spiritual needs. All physicians, generalists and specialists alike, should possess the basic competencies but should also recognize that some patients, especially those not responding to initial strategies, require timely referrals to specialized palliative care teams.

Organization of the clinical activity of geriatric oncology: report of a SIOG (International Society of Geriatric Oncology) task force.

Management for elderly cancer patients world wide is far from being optimal and few older patients are entering clinical trials. A SIOG Task Force was therefore activated to analyze how the clinical activity of Geriatric Oncology is organized. A structured questionnaire was circulated among the SIOG Members. Fifty eight answers were received. All respondents identified Geriatric Oncology, as an area of specialization, however the organization of the clinical activity was variable. Comprehensive Geriatric Assessment (CGA) was performed in 60% of cases. A Geriatric Oncology Program (GOP) was identified in 21 centers, 85% located in Oncology and 15% in Geriatric Departments. In the majority of GOP scheduled case discussion conferences dedicated to elderly cancer patients took regular place, the composition of the multidisciplinary team involved in the GOP activity included Medical Oncologists, Geriatricians, Nurses, Pharmacists, Social Workers. Fellowships in Geriatric Oncology were present in almost half of GOPs. Over 60% of respondents were willing to recruit patients over 70 years in clinical trials, while the proportion of cases included was only 20%. Enrolment in clinical trials was perceived as more difficult by 52% and much more difficult in 12% of the respondents. In conclusion, a better organization of the clinical activity in Geriatric Oncology allows a better clinical practice and an optimal clinical research. The GOP which can be set up in the oncological as well as in the geriatric environment thought a multidisciplinary coordinator effort. Future plans should also concentrate on divisions, units or departments of Geriatric Oncology.

Fewer infections, but maintained antitumor activity with lower-dose versus standard-dose cladribine in pretreated low-grade non-Hodgkin's lymphoma.

PURPOSE: To study the efficacy and the safety of cladribine (2-chlorodeoxyadenosine [2-CDA]) administered at two different dosages. PATIENTS AND METHODS: In this two-cohort study, patients with low-grade refractory/relapsing non-Hodgkin's lymphoma (NHL) received 2-CDA at a dose of 0.7 mg/kg per cycle as a continuous intravenous (i.v.) infusion (group 1, n = 44) or at a reduced dose of 0.5 mg/kg per cycle as a subcutaneous (s.c.) bolus injection (group 2, n = 60). Three 2-CDA cycles at > or = 4-week intervals were planned, then treatment could be pursued until six cycles. RESULTS: A total of 300 cycles were administered (group 1, 114 cycles; group 2, 186). Patient characteristics in both groups were comparable. The median dose-intensities were 0.17 mg/kg/wk and 0.13 mg/kg/wk for groups 1 and 2, respectively (P < or = .0001). The overall response rate for all 104 patients was 54% (95% confidence interval [CI], 45% to 66%; 15% complete response [CR] and 39% partial response [PR]). Response was similar in both patient groups (57% in group 1 and 53% in group 2; P = .72), and no association between 2-CDA dose-intensity and response rate was found (P = .35). Median remission duration was 7 and 12 months in groups 1 and 2, respectively (P = .21). Toxicity, in particular opportunistic infections (> or = grade 2, 30% in group 1 v 7% in group 2; P = .003) and myelosuppression (> or = grade 3 neutropenia, 33% v 8% of 2-CDA cycles, P < .0001), were more frequent in group 1. Multiple logistic regression analysis showed that the infection risk (grade > or = 2) was decreased by 81% with 2-CDA dose reduction in group 2 after adjusting for number of pretreatment regimens and time since diagnosis (P = .01). CONCLUSION: When administered as a s.c. bolus injection, 2-CDA at 0.5 mg/kg per cycle is safe and this dose level should not be exceeded in this patient population.

Multiple myeloma: clinical evaluation of plasma cell lymphoproliferative disorders and initial management.

After many years of nosologic errance, plasma cell lymphoproliferative disorders are now firmly classified as belonging to the lymphoma family. Their characteristic biological and clinical course starts from the localized form of plasmacytoma, progressing to the more diffuse benign gammopathy, then the premalignant conditions like indolent (IM) or smouldering (SM) myeloma, and ending at the multiple myeloma (MM) stage. During and before this multistep development, genetic and environmental factors appear to be involved and spontaneous regressions may even occur. However, when MM is diagnosed, the outcome is invariably fatal despite conventional radiotherapy and chemotherapy. Prognostic factors like G-reactive protein, the plasma cell labeling index, and beta 2-microglobulin are extremely useful not only for determining the aggressivity of the abnormal clone but also for predicting the transformation from a benign state to a definitive malignant condition. Standard single-agent chemotherapy with melphalan and multidrug combinations can significantly prolong survival, but no cure has yet been achieved. High-dose chemotherapy with stem cell support can decrease tumor burden to an undetectable level and, compared with conventional approaches, has recently proved to increase response rates, the symptom-free interval, and survival. Moreover, interferon alfa is also able to prolong the responding interval, but this has yet to be translated into a survival advantage. These new more aggressive therapies are reminiscent of the early days of leukemia treatment and should now be offered to patients in controlled trials on the basis of comorbidities rather than age or some discriminating economic factors.

ABEP as primary chemotherapy for Hodgkin's disease.

20 untreated Hodgkin's disease patients and 1 patient relapsing after radiotherapy (17 stage IIB-IV and 4 stage I-IIA) were given doxorubicin, bleomycin, etoposide and prednisone on a 21-day cycle. The response rate was 95% and 16 patients (76%) achieved complete remission. 4 patients have relapsed 2, 5, 22 and 50 months after treatment. Survival was 100% at a median follow-up of 35 months. However, due to dyspnoea on exertion in 2 patients, bleomycin will be abandoned, and the occurrence of two second malignancies questions the role of etoposide as a leukaemogenic agent.

Myelodysplastic syndrome with biclonal monosomy 7 and trisomy 8 after treatment with cladribine (2-chloro-2-deoxyadenosine) and involved field radiation therapy.

Therapy-related myelodysplastic syndrome (t-MDS) and acute nonlymphocytic leukemia (t-ANLL) are dramatic complications of cancer chemotherapy. Drugs like plant alkaloids or antimetabolites have not been reported to cause either t-MDS or t-ANLL. Monosomy 7(-7) and trisomy 8(+8) are among the most common abnormalities in myelodysplastic syndromes. Both abnormalities in two different clones of the same patient are very rarely reported. Such a myelodysplastic syndrome occurring shortly after treatment with an antimetabolite, the adenosine analogue cladribine (1-chlorodeoxadenosine), and involved field radiotherapy is reported here.

Ondansetron--a new safe and effective antiemetic in patients receiving high-dose melphalan.

A total of 33 patients with myeloma receiving treatment with high-dose melphalan (140-200 mg/m2 i.v.) were given the 5HT3 antagonist Ondansetron (Glaxo) as an antiemetic. In 42% of patients, emetic episodes were either abolished (15%) or reduced to two or less (27%). Efficacy was not related to scheduling (two regimens) or total dose. No sedative or other significant side effects were seen. Ondansetron is a highly effective non-sedative antiemetic that justifies further assessment in combination with other antiemetics in patients receiving cytotoxic drugs associated with the production of severe nausea and vomiting.

Primary pulmonary Hodgkin's disease and the dilemma of E stage.

Primary pulmonary Hodgkin's disease is rare. We report the case of a previously healthy 23-year-old woman who presented with isolated involvement of the right upper pulmonary lobe. Nodular sclerosing Hodgkin's disease was diagnosed after curative surgery. The clinical stage is felt to be IEBL+. The reasons for this staging, as opposed to a stage IV, are discussed. Adjuvant radiotherapy was given, delivering 39.6 grays in 22 courses of 1.8 grays. Three years after diagnosis, the patient is well and free of disease. A review of the literature indicates that the majority of primary pulmonary Hodgkin's disease present as a single mass amenable to curative surgery and radiation therapy. Chemotherapy can be reserved for the rare diffuse presentation.

[Treatment of aggressive non Hodgkin's lymphoma: the experience of a general hospital]. / Traitement des lymphomes non hodgkiniens agressifs: expérience d'un hôpital général.

PURPOSE: The LNH84 regimen for aggressive non Hodgkin's lymphoma consists in an intensive induction phase followed by a consolidation phase. The objectives of this study are to evaluate the feasability and activity of a modified induction phase of this regimen in an oncologic department of a general university hospital. PATIENTS: Twenty-eight consecutive patients receive three or four induction courses of CDBVP corresponding to intravenous cyclophosphamide (C), doxorubicin (D), bleomycin (B), vincristine (V) and oral prednisone (P), for a total of 89 courses. Median age is 42 years and 18 patients are male. IWF is F to J. Fourteen have B symptoms, five a bulky disease, 18 abnormal LDH and nine bone marrow involvement. RESULTS: After the induction phase, 12 patients achieve CR and 11 PR for an overall response rate of 92%. Toxicity consists in severe myelosuppression with a neutropenia WHO grade 4 in all patients. The interval between courses is lengthened for each period, with a median interval of 18.5 days between cycle 1 and 2, 19.5 days between cycle 2 and 3 and 22 days between cycle 3 and 4. Eight patients present an infection WHO grade 3 and one patient died of a treatment related pulmonary complication. At 3 years the overall survival and event free survival is 78% and 57% respectively. CONCLUSIONS: In our experience, the CDBVP protocole is a toxic regimen difficult to administer in a general hospital. Its administration out of a protocole can not be recommanded for good prognosis patients. Its interest for poor prognosis patients should be evaluated with clinical studies.