Management of Fatigue in Patients with Advanced Cancer.

OPINION STATEMENT: Fatigue is a common and distressing symptom experienced by patients with cancer. It is most common in patients with locally advanced or metastatic incurable disease. It can have profound effects on quality-of-life and physical functioning. In addition to general supportive measures (directed at tackling contributory conditions and comorbidities), a variety of specific interventions have been developed which can be broadly categorised as physical therapies, psychological therapies or medication. There is some evidence that each of these approaches can have benefits in patients with earlier stage disease, those undergoing active treatment and in cancer survivors. The best evidence is for aerobic exercise, yoga, cognitive-behavioural therapy (CBT) and psycho-educational interventions. Less strong evidence supports the use of medications such as methylphenidate or ginseng. In patients with advanced disease, it is likely that the mechanisms of fatigue or the factors contributing to fatigue maintenance may be different. Relatively fewer studies have been undertaken in this group and the evidence is correspondingly weaker. The authors recommend the cautious use of aerobic exercise (e.g. walking) in those who are still mobile. The authors advise considering the use of psycho-educational approaches or CBT in those patients who are able to engage in such forms of therapy. In patients near the end-of-life, the authors advise use of dexamethasone (short-term use) and other pharmacological treatments only on the basis of a clinical trial.

The development of palliative care education and training for GPs in Yangon, Myanmar: a workshop success.

BACKGROUND: Palliative care is an important but often overlooked component of primary care. In Myanmar, early emergence of palliative care is being seen, however no formal community-based services yet exist. Present challenges include resource scarcity and inadequate education and training. AIM: Our goal was to improve understanding and approach towards palliative care by GPs in Yangon. METHOD: An initial survey was performed among 42 GPs in Yangon, Mandalay, and Meiktila in March 2019 demonstrating a gap in current training needs and willingness by GPs for this to be improved. A 2-day workshop, the first ever of its kind, was subsequently designed and held for 20 local GPs, consisting of interactive seminars delivered in Burmese. RESULTS: Improvement in knowledge and confidence were used as measures of success. A true/false-style quiz was distributed pre- and post-workshop demonstrating a mean total score improvement of 15%. Self-reported confidence rating scores regarding confidence when: 1) managing palliative patients; 2) providing holistic care; and 3) breaking bad news, increased by a mean of 25%. CONCLUSION: The greatest outcome from this workshop, by far, was the enthusiasm and awareness it generated, support was even gained from the President of the Myanmar Medical Association despite his initial reservations about developing this area. Ultimately, the workshop behaved as an advocate for the introduction of a regular palliative care lecture into the local Diploma in Family Medicine curriculum; it also spurred a group of GPs to further this work and turn the workshop into a regular teaching event.

Continuing professional development for GPs in Myanmar: a pilot programme.

BACKGROUND: The quality of general practice in Myanmar is currently highly variable. No formalised system of revalidation yet exists and so engagement with continuing professional development (CPD) activities and motivation to further one's own knowledge is sporadic. AIM: To train GPs in three key areas; 1) recording CPD activities and maintaining a portfolio logbook; 2) reflecting on learning; and 3) what a future formalised CPD credit system may involve. METHOD: Sixty-one GPs were recruited in March 2019 and given training on the above. Logbooks were issued, which were completed by the GPs while attending a simultaneous 3-month 'GP CPD Refresher' course, organised by the GP Society of Myanmar. The logbooks were then marked and individualised feedback given before issuing CPD accredited certificates. RESULTS: All GPs agreed the pilot helped them to better understand how to maintain a CPD logbook and the importance of doing so (retention rate = 67%). All GPs also reported they would now be more likely to continue to keep a portfolio. Finally, all GPs surveyed felt a credit reward system, used as tangible evidence of CPD participation, would positively influence their future engagement with CPD. CONCLUSION: Improving general practice is a key component in helping Myanmar develop its healthcare system; one step required is making engagement with CPD compulsory for the revalidation of clinicians. This pilot has highlighted existing inadequacies within current training of GPs, as well as the potential benefits of implementing a CPD credit reward system.