Thursday, 29 May 2008

Palliative rehabilitation and amyotrophic lateral sclerosis

Palliative rehabilitation and amyotrophic lateral sclerosis: a perfect match.
NeuroRehabilitation, 2007, vol. 22, no. 6, p. 407-8
Publication type Editorial.
Journal subset

Bulletin of the American College of Surgeons, Feb 2008, vol. 93, no. 2

The art of medicine at the end of life: the challenges ahead.
Bulletin of the American College of Surgeons, Feb 2008, vol. 93, no. 2, p. 19-21

Hospice and palliative medicine: surgeons effectively push for new specialty.
Bulletin of the American College of Surgeons, Feb 2008, vol. 93, no. 2, p. 8-12

Easing of suffering in children with cancer at the end of life

Easing of suffering in children with cancer at the end of life: is care changing?
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 1 Apr 2008, vol. 26, no. 10, p. 1717-23
Wolfe-Joanne, Hammel-Jim-F, Edwards-Kelly-E, Duncan-Janet, Comeau- Michael et al
PURPOSE: In the past decade studies have documented substantial suffering among children dying of cancer, prompting national attention on the quality of end-of-life care and the development of a palliative care service in our institutions. We sought to determine whether national and local efforts have led to changes in patterns of care, advanced care planning, and symptom control among children with cancer at the end of life. METHODS: Retrospective cohort study from a US tertiary level pediatric institution. Parent survey and chart review data from 119 children who died between 1997 and 2004 (follow- up cohort) were compared with 102 children who died between 1990 and 1997 (baseline cohort). RESULTS: In the follow-up cohort, hospice discussions occurred more often (76% v 54%; adjusted risk difference (RD), 22%; P < .001) and earlier (adjusted geometric mean 52 days v 28 days before death; P = .002) compared with the baseline cohort. Do-not-resuscitate orders were also documented earlier (18 v 12 days; P = .031). Deaths in the intensive care unit or other hospitals decreased significantly (RD, 16%; P = .024). Parents reported less child suffering from pain (RD, 19%; P = .018) and dyspnea (RD, 21%; P = .020). A larger proportion of parents felt more prepared during the child's last month of life (RD, 29%; P < .001) and at the time of death (RD, 24%; P = .002). CONCLUSION: Children dying of cancer are currently receiving care that is more consistent with optimal palliative care and according to parents, are experiencing less suffering. With ongoing growth of the field of hospice and palliative medicine, further advancements are likely.

Interventions for alleviating cancer-related dyspnea: a systematic review

Interventions for alleviating cancer-related dyspnea: a systematic review.
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 10 May 2008, vol. 26, no. 14, p. 2396-404
Ben-Aharon-Irit, Gafter-Gvili-Anat, Paul-Mical, Leibovici-Leonard, Stemmer-Salomon-M.
PURPOSE: Dyspnea is one of the most distressing symptoms experienced by terminally ill cancer patients. This study aimed to evaluate the role of interventions for the palliation of dyspnea. METHODS: We conducted a systematic review of randomized controlled trials assessing all pharmacologic and nonpharmacologic interventions for dyspnea palliation in cancer patients, and searched the Cochrane Library, MEDLINE, conference proceedings, and references. Two reviewers independently appraised the quality of trials and extracted data. RESULTS: Our search yielded 18 trials. Fourteen evaluated pharmacologic interventions: seven assessing opioids (a total of 256 patients), five assessing oxygen (137 patients), one assessing helium-enriched air, and one assessing furosemide. Four trials evaluated nonpharmacologic interventions (403 patients). The administration of subcutaneous morphine resulted in a significant reduction in dyspnea Visual Analog Scale (VAS) compared with placebo. No difference was observed in dyspnea VAS score when nebulized morphine was compared with subcutaneous morphine, although patients preferred the nebulized route. The addition of benzodiazepines to morphine was significantly more effective than morphine alone, without additional adverse effects. Oxygen was not superior to air for alleviating dyspnea, except for patients with hypoxemia. Nursing- led interventions improved breathlessness. Acupuncture was not beneficial. CONCLUSION: Our review supports the use of opioids for dyspnea relief in cancer patients. The use of supplemental oxygen to alleviate dyspnea can be recommended only in patients with hypoxemia. Nursing-led nonpharmacologic interventions seem valuable. Only a few studies addressing this question were performed. Thus, further studies evaluating interventions for alleviating dyspnea are warranted.

Tuesday, 27 May 2008

New cancer research journal

BioMed Central has launched the following new open access journal:
Title: Journal of Experimental & Clinical Cancer Research
Editor(s)-in-chief: Mauro Castelli
This journal ( JECCR ), the official journal of the "Regina Elena" National Cancer Institute , aims to provide a high-quality forum for basic, clinical and translational work in oncology.
The journal publishes scientific studies on the immunological, epidemiological, pathological, biological and clinical aspects of oncology. Topics considered range from molecular genetics via infectious agents to surgery and therapeutic approaches and outcomes. Systematic reviews of clinical and basic research, as well as clinical practice guidelines, are especially welcome.
An established journal published since 1982, JECCR is tracked/indexed by Thomson Scientific, Medline, Embase and CAS. To browse articles published in the journal previously please visit the journal's existing website here . The current articles are in their provisional PDF format, but the full-text and final PDF versions will be available shortly.

Journal of palliative medicine, Jan-Feb 2008, vol. 11, no. 1

To sleep before we die...: when is palliative sedation an option for the dying person?
p. 131-2
Author affiliation

Health literacy in palliative medicine #153.
p. 105-6
Reisfield-Gary-M, Wilson-George-R.

Palliative medicine review: prognostication.
p. 84-103, 93 refs
Glare-Paul-A, Sinclair-Christian-T.
Prognostication, along with diagnosis and treatment, is a traditional core clinical skill of the physician. Many patients and families receiving palliative care want information about life expectancy to help plan realistically for their futures. Although underappreciated, prognosis is, or at least should be, part of every clinical decision. Despite this crucial role, expertise in the art and science of prognostication diminished during the twentieth century, due largely to the ascendancy of accurate diagnostic tests and effective therapies. Consequently, Doctor, how long do I have? is a question most physicians find unprepared to answer effectively. As we focus on palliative care in the twenty-first century, prognostication will need to be restored as a core clinical proficiency. The discipline of palliative medicine can provide leadership in this direction. This paper begins by discussing a framework for understanding prognosis and how its different domains might be applied to all patients with life limiting illness, although the main focus of the paper is predicting survival in patients with cancer. Examples of prognostic tools are provided, although the subjective assessment of prognosis remains important in the terminally ill. Other issues addressed include: the importance of prognostication in terms of clinical decision-making, discharge planning, and care planning; the impact of prognosis on hospice referrals and patient/family satisfaction; and physicians' willingness to prognosticate.

Prognosticating: the end of a series. Introduction.
p. 82-3
Liao-Solomon, Arnold-Robert-M.

Palliative sedation as part of a continuum of palliative care.
p. 76-81
Carr-Mark-F, Mohr-Gina-Jervey.
Three issues seem to animate those who advocate the move toward a broad allowance of physician-assisted death. The first is the supposed failure of palliative care in extreme cases. We challenge the notion that palliative care ever fails. When palliative sedation is understood to be a routine continuation of palliative care, as opposed to a last-ditch response to a dramatic failure, then palliative care will never fail. The second focuses on helping patients maintain a sense of control in their final days and hours. We believe that continued intimate involvement in each of the final stages that is essential in the palliative care-palliative sedation continuum will be more effective palliative care and still grant control to the patient under the principle of respect for autonomy. The third issue is the charge that palliative sedation is a euphemism for physician-assisted death. We reject that charge.

A nationwide VA palliative care quality measure: the family assessment of treatment at the end of life.
p. 68-75
Casarett-David, Pickard-Amy, Bailey-F-Amos, Ritchie-Christine-Seel et al
OBJECTIVES: To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system. DESIGN: Nationwide telephone survey. SETTING: Five VA medical centers. PARTICIPANTS: Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate. MEASUREMENTS: The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patient's death (3 items). RESULTS: Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p < 0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p < 0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p < 0.001). CONCLUSIONS: The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

(Using) complementary and alternative medicine: the perceptions of palliative patients with cancer.
p. 58-67
Eliott-Jaklin-A, Kealey-Colin-P, Olver-Ian-N.
Use of complementary and alternative medicine (CAM) is increasingly common within Western societies, including Australia. This parallels calls for or claims of integration of CAM into mainstream medical practice, with oncology and palliative care specifically nominated as appropriate arenas for integration. However, there is an absence of studies examining patient perceptions of both CAM and CAM users. In this study, 28 adult patients with cancer close to death were interviewed regarding treatment decisions at the end of life, including decisions about CAM. Thematic analysis of transcribed interviews found consistent differences in talk around CAM between 12 users and 16 nonusers of CAM, primarily related to the perceived value of these treatments. Drawing upon a mind-body discourse that holds individuals responsible for their health, users valued CAM for the perceived benefit to physical or psychological well-being and compatibility with a holistic approach to health care, deemed to complement or augment conventional medicine. However, some were self- critical of their failure to continue with CAM, despite practical and financial difficulties experienced. Nonusers devalued CAM as unable to cure their disease (but did not similarly devalue conventional medicine), and negatively construed CAM users as desperate, or as challenging medical wisdom. Despite increased legitimation and medicalization of CAM, patients assess CAM differently to allopathic medicine, with different (positive and negative) assessments attributable to users. The misperception by many (nonusers) that CAM are intended to cure and available negative moral and social judgments centred around CAM use may deter patient uptake of CAM in areas where they have proven efficacy in symptom control.

Interval between first palliative care consult and death in patients diagnosed with advanced cancer at a comprehensive cancer center.
p. 51-7
Osta-Badi-El, Palmer-J-Lynn, Paraskevopoulos-Timotheos et al
PURPOSE: Most referrals to palliative care and hospice occur late in the trajectory of the disease although an earlier intervention could decrease patients' symptom distress. The purpose of this study was to determine the interval between first palliative care consult (PC1) and death (D) in patients diagnosed with advanced cancer (aCA) at our comprehensive cancer center and if such interval has increased over time. METHODS: The study group was 2868 consecutive patients who had their PC1 during a 30-month period. We reviewed the charts for information about demographics, cancer type, date of cancer (CA) diagnosis, aCA diagnosis, PC1, and D. aCA was defined as locally recurrent or metastatic. RESULTS: One thousand four hundred four patients (49%) were female, 1791 (62%) were less than 65 years old, 2563 (89%) had solid tumors, and 2004 (70%) were white. The median PC1-D, aCA-PC1, aCA-D, and CA-D intervals were 42, 147, 250, and 570 days, respectively. The median PC1-D interval was longer in patients with solid tumors (p < 0.0001), less than 65 years old (p = 0.002), and females (p = 0.004). PC1-D was not affected by ethnicity (p = 0.42). The median PC1-D interval in 5 consecutive half-years was 46, 56, 42, 41, and 34 days, respectively (p = 0.02). The number of PC1 in this period increased from 544 to 654 (20%). The ratio of PC involvement in the aCA-D period (PC1-D/aCA-D) decreased from 0.30 to 0.26 over the 5 half-year periods (p = 0.0004). CONCLUSIONS: The first palliative care consultation to death interval has decreased over time at our center. Education is needed among our referring physicians for earlier access to palliative care. Prospective studies are needed to establish the appropriate timing of the first palliative care consultation.

Research funding for palliative medicine.
p. 36-43, 12 refs
Gelfman-Laura-P, Morrison-R-Sean.
BACKGROUND: Medical care for seriously ill patients has been acknowledged to be inadequate and multiple reports have called for increased investment in palliative medicine research. OBJECTIVE: To identify funding sources of palliative medicine research published form 2003-2005 and to examine National Institutes of Health (NIH) funding of palliative medicine research from 2001-2005. METHODS: We sought to identify United States publications related to adult palliative medicine research from 2003-2005 and their funding sources. We reviewed all articles published in the major palliative medicine journals and additionally, we reviewed all articles published in major medicine journals and relevant sub-specialty journals which were identified in Pub-Med using the key words palliative care, end-of-life care, hospice and end-of-life. From all identified articles, we abstracted all sources of funding detailed. We then compiled a list of U.S. palliative medicine researchers from 2001-2005 using the published first and last authors in the above article review, the editorial boards of palliative medicine journals, and other organizations. To examine NIH funding, we cross-matched this list of researchers against all NIH grants funded from 2001-2005. RESULTS: We identified 388 palliative medicine research articles and 2,197 investigators. Seventy-two percent of papers identified received extramural funding: 31% from the NIH, 51% from foundations, and 16% from other sources. Only 109 investigators received NIH funding and the National Cancer Institute (NCI), National Institute of Nursing Research (NINR), and National Institute on Aging (NIA) funded 85% of all NIH awards. CONCLUSIONS: Research funding, particularly federal funding, for palliative medicine research is inadequate to support improvements in care for the most seriously ill patients and their families.

Borders without Doctors.
p. 31-2

Expressive writing in patients receiving palliative care: a feasibility study.
p. 15-9
Bruera-Eduardo, Willey-Jie, Cohen-Marlene, Palmer-J-Lynn.
BACKGROUND: Patients with advanced cancer receiving palliative care often experience severe physical and psychosocial symptoms. However, there are limited resources for psychological and emotional support. Expressive writing has shown decreased anxiety level in young and healthy people suffering from a number of stressors. OBJECTIVE: The purpose of this study was to determine the feasibility of expressive writing in patients receiving palliative care and the most suitable outcomes of expressive writing in this patient population. DESIGN: In this pilot study, patients were randomly assigned to either the expressive writing group (EW) or the neutral writing group (NW). Anxiety level before and after the writing session was compared between the two groups. Writing materials were content analyzed using standard qualitative research methods. RESULTS: A total of 24 patients (12 in EW and 12 in NW) were enrolled in the study between October 2006 and January 2007. Although the majority of patients (83%-100%) were able to complete all baseline assessments, poor adherence was observed during the follow-ups. Only 8% of patients completed the 2-week study. There was no significant difference in the State-Trait Anxiety Inventory (STAI) State-Anxiety scores at baseline, before and after each writing session between the EW and NW groups. DISCUSSION: Our rapid accrual suggests that palliative care patients are interested in participating in studies such as expressive writing. The high level of adherence to the baseline assessments indicates that these assessments were not particularly difficult for our patients to complete. Future studies may need to include patients with better performance status, better patient education, means of emotional expression (i.e., audio recording, telephone interview) and improved adherence. CONCLUSION: We conclude that clinical trials of expressive writing in the palliative care setting are not feasible unless they undergo major modification in methods compared to those previous reported in other patient population. Our findings will hopefully assist researchers considering similar studies.

Social workers advocate for a seat at palliative care table.
p. 10-4
Meier-Diane-E, Beresford-Larry.

Team, diversity, and building communities.
p. 5-7

Evidence-based medicine and palliative care.
p. 2-4

British journal of community nursing, Jan 2008, vol. 13, no. 1

The evolving role of the community nurse specialist in palliative care.
p. 26-30, 38 refs,
The community clinical nurse specialist in palliative care role has evolved in an uncoordinated manner resulting in a variety of grades of nurse with differing role expectations. In general the CNS role consists of a clinical, educational, strategic and managerial remit. The reality of working with such a diverse role creates tension and conflict for the CNS between personal, organization and practical expectations. Despite this the community palliative care CNS is central to the future development of palliative care services in the community generating a culture of sharing knowledge and expertise. This will however require further investigation into the impact these demands will have on the individual.

Dealing sensitively with sexuality in a palliative care context.
p. 20-5, 47 refs
Woodhouse-Jan, Baldwin-Moyra-A.
Sexuality is integral to a person's identity and is encompassed in holistic palliative care. Current directives emphasize psychosocial support that is sensitive to a variety of issues, including sexuality, and offer community nurses the mandate to facilitate expressing sexuality. Nurses fail to address sexuality for a variety of reasons. Appreciating patients' individuality and avoiding making assumptions are some of the requirements to enabling expression of sexuality. Nurses need wisdom and determination to discuss such issues, and it is important that they recognize opportunities and cues as they arise. This article provides an examination of the issues surrounding sexuality outlining an approach that captures' constant attention to details. This guides the 'what', 'how' and 'why' sexuality in palliative care can be addressed. Ethics and safety aspects are briefly discussed and implications for practice suggested. Educating staff and focused education for the patient can positively influence sexuality and individuals' quality of life.

From cure to palliation: concept, decision and acceptance.

From cure to palliation: concept, decision and acceptance.
Full text available at BMJ Publishing Group for NHS BMJ Publishing Group
Journal of medical ethics, Dec 2007, vol. 33, no. 12, p. 685-8
Loefmark-R, Nilstun-T, Bolmsjoe-I-Agren.
The aim of this paper is to present and discuss nurses' and physicians' comments in a questionnaire relating to patients' transition from curative treatment to palliative care. The four-page questionnaire relating to experiences of and attitudes towards communication, decision-making, documentation and responsibility of nurses and physicians and towards the competence of patients was developed and sent to a random sample of 1672 nurses and physicians of 10 specialties. The response rate was 52% (n = 844), and over one- third made comments. The respondents differed in their comments about three areas: the concept of palliative care, experiences of unclear decision-making and difficulties in acceptance of the patient's situation. The responses are analysed in terms of four ethical theories: virtue ethics, deontology, consequentialism and casuistry. Many virtues considered to be appropriate for healthcare personnel to possess were invoked. Compassion, honesty, justice and prudence are especially important. However, principles of medical ethics, such as the deontological principle of respect for self-determination and the consequence of avoidance of harm, are also implied. Casuistry may be particularly helpful in analysing certain areas of difficulty-namely, what is meant by palliative care, decision-making and accepting the patient's situation. Keeping a patient in a state of uncertainty often causes more suffering than necessary. Communication among the staff and with patients must be explicit. Many of the staff have not had adequate training in communicating with patients who are at the end of their life. Time for joint reflection has to be regained, and training in decision-making is essential. In our opinion, palliative care in Sweden is in need of improvement.

Surgical oncology, Dec 2007 vol. 16, no. 4

Surgery for palliation and treatment of advanced breast cancer.
p. 249-57, 55 refs
Alvarado-Michael, Ewing-Cheryl-A, Elyassnia-Dino, Foster-Robert-D, Shelley-Hwang-E.

Palliation of hepatic tumors.
p. 277-91, 166 refs
Cunningham-Steven-C, Choti-Michael-A, Bellavance-Emily-C, Pawlik- Timothy-M.
Palliation is treatment aimed at alleviating the symptomatic effects of a disease rather than at curing the disease. The four most common types of liver tumors that often require palliative treatment include hepatocellular carcinoma (HCC), cholangiocarcinoma (CC), metastatic colorectal carcinoma (mCRC), and metastatic neuroendocrine tumors (m NET). Modalities employed in the palliative treatment of these tumors most often include resection, stenting, chemotherapy, radiation, ablation, and the general treatment of liver failure symptoms. Many of these modalities can be applied to the palliative care of all hepatic tumor types, regardless of the specific tumor histology--as incurable cancers often converge along a final common pathway. We herein provide a review of the therapeutic approaches to palliate hepatic tumors, as well as how such therapies are designed to alleviate the symptoms of patients with end-stage liver tumors.
Journal-Article, Review.

Palliation of colorectal cancer.
p. 299-310, 115 refs
Wasserberg-Nir, Kaufman-Howard-S.
Patients with advanced incurable colorectal cancer (CRC) face a grim prognosis. The goal of palliative intervention is directed at alleviating disease-related symptoms and improving quality of life. The provision of optimal palliative care for these patients is a compound and demanding process. This dilemma becomes more challenging when patients with advanced metastatic colorectal disease present with an incurable and asymptomatic primary lesion. Treatment options are numerous and include a variety of surgical and nonsurgical interventions. Most data regarding the role of surgery in palliation of CRC are from retrospective, nonrandomized case series. Surgical resection may provide good palliation of symptoms and prevent future tumor-related complications. Metal stents are also able to provide good palliative relief of obstruction and should be used when appropriate. The best palliative care will often require a multidisciplinary approach that involves input from surgical and nonsurgical teams, where treatment plans will be made in accordance with the wishes of the patient and family with a goal of decreasing morbidity and a focus on quality of life.
Journal-Article, Review.

Palliation of thoracic malignancies.
p. 259-65, 61 refs
Gasper-Warren-J, Jamshidi-Ramin, Theodore-Pierre-R.
The sequelae of advanced malignancies of the chest, whether primary or metastatic, can be severely debilitating. In this review, we discuss the advances in palliative treatment for several intrathoracic complications of malignancy. The treatment of malignant pleural and pericardial effusions now includes a range of chemical sclerosants and percutaneous or surgical interventions. A new generation of promising stent and ablation technologies allows for the treatment of intrinsic or extrinsic airway obstruction. Similar techniques are being explored for esophageal obstruction, while the possible benefit of palliative radiation and chemotherapy continues to be investigated. Although their symptoms are often severe, patients with advanced thoracic malignancies have a growing number and variety of palliative treatment options to improve their quality of life.

Palliative care in orthopaedic surgical oncology.
p. 311-30, 171 refs
Aubert-Pamela-M, O-Donnell-Richard-J.
Hundreds of thousands of Americans are affected every year by skeletal complications of oncologic disease. Recent developments in medical oncology, radiation oncology and radiology, particularly with respect to the use of bisphosphonate medication and radiofrequency techniques, have served to greatly lessen the morbidity associated with metastatic skeletal disease. Similarly, there has been significant advancement in the field of orthopaedic oncology in the areas of internal fixation, endoprosthetic implant design, and minimally invasive kyphoplasty technology. Given the palliative intent of intervention in this patient population, the goal of treatment of skeletal metastases must be optimization of limb function and ultimately, quality of life.
Journal-Article, Review.

Palliative management of gastric cancer
p. 267-75, 99 refs
Cunningham-Steven-C, Schulick-Richard-D.
Advanced gastric cancer and its palliative treatment have a long and interesting history. Today, gastric adenocarcinoma is the second leading cause of cancer death worldwide. Unfortunately, many cases are not diagnosed until late stages of disease, which underscores the importance of the palliative treatment of gastric cancer. Palliative care is best defined as the active total care of patients whose disease is not responsive to curative treatment. Although endoscopy is the most useful method for securing the diagnosis of gastric adenocarcinoma, computed tomography may be useful to assess local and distant disease. The main indication for the institution of palliative care is the presence of advanced gastric cancer for which curative treatment is deemed inappropriate. The primary goal of palliative therapy of gastric cancer patients is to improve quality, not necessarily length, of life. Four main modalities of palliative therapy for advanced gastric cancer are discussed: resection, bypass, stenting, and chemotherapy. The choice of modality depends on a variety of factors, including individual patient prognosis and goals, and should be made on case-by-case basis. Future directions include the discovery and development of serum or stool tumor markers aimed at prevention, improving prognostication and stratification, and increasing awareness and education.
Journal-Article, Review.

Palliation of advanced thyroid malignancies.
p. 237-47, 154 refs
Greenblatt-David-Yue, Chen-Herbert.
While most thyroid cancers are slow-growing and have an excellent prognosis after appropriate treatment, a subset of thyroid cancers behave aggressively, and approximately 1500 individuals in the US will die of the disease in the year 2007. Advanced thyroid malignancies can cause distressing and life-threatening symptoms by local invasion in the neck, growth of distant metastases in the lung, bone, and other organs, and tumor production of bioactive substances in the case of medullary thyroid cancer. This article will review palliative modalities, including surgery, radioactive iodine, external beam radiation, and chemotherapy, as well as novel targeted therapies, for the treatment of patients with advanced thyroid malignancies.
Journal-Article, Review.

Palliative care for patients with advanced pancreatic and biliary cancers
p. 293-7, 22 refs
Nakakura-Eric-K, Warren-Robert-S.
Because most patients with pancreatic and biliary cancer have advanced disease, the palliation of debilitating symptoms is critically important in patient management. A multidisciplinary team consisting of representatives from surgery, medical oncology, gastroenterology, radiology, and palliative care medicine is essential for the optimal palliation of symptoms. In this article, the key issues in palliative care for patients with advanced pancreatic and biliary cancer are discussed. In particular, the prevention and amelioration of suffering due to obstructive jaundice, gastric outlet obstruction, cancer-related pain, pancreatic enzyme insufficiency, and thromboembolic disease is addressed. To this end, an algorithm for the multidisciplinary management of these challenging patients is proposed with the goal of providing clinicians with a useful framework for providing palliative care for patients with advanced pancreatic and biliary cancer.
Journal-Article, Review.

Medical oncology, 2008 vol. 25, no. 1

Correlation of quality of life with tumor response in patients receiving palliative chemotherapy for advanced gastrointestinal tumors.
p. 81-7
Shin-Dong-Bok, Bang-Soo-Mee, Park-Se-Hoon et al
We prospectively evaluated the association of tumor response with change of quality of life (QOL) in patients with advanced gastrointestinal tumors receiving palliative chemotherapy. Out of 133 eligible patients, 90 (68%) completed the European Organization for Research and Treatment Quality of Life Questionnaire C-30 (EORTC QLQ C-30) at baseline and at regular intervals during palliative chemotherapy. Among the 90 available patients, 88 patients could be evaluated for response, and 32 (36%) responded. Taking into account 32 patients who had stable disease, 64 (73%) achieved a clinical benefit, defined as an objective response or stable disease. Improvement in the emotional functioning or global QOL was observed before the fourth cycle of chemotherapy in responders (P = 0.039) and patients with clinical benefit (P = 0.026). Grade 3 or 4 toxic effects occurred in 39% of patients; however, this did not adversely affect the global or other domains of QOL. Therefore, change of QOL during the chemotherapy was closely related with clinical outcomes. We should apply the QOL assessment to all patients who received palliative chemotherapy for their gastrointestinal tumors.

Survival and erythropoietin receptor protein in tumours from patients randomly treated with rhEPO for palliative care.
p. 22-9
Loennroth-Christina, Svensson-Marie, Wang-Wenhua, Koerner-Ulla et al
BACKGROUND: Recombinant erythropoietin (rhEPOalpha) corrects anaemia, improves physical functioning and quality of life in cancer patients. However, published reports have suggested risks for tumour stimulation by provision EPO to patients with remaining tumour cells perhaps related to the presence of EPO receptor protein in tumour tissue. Therefore, the aim of the present study was to exclude a possibility that cancer patients who respond favourably to EPO treatment have mainly tumours with low EPO receptor protein expression. METHODS: Tumour tissue was evaluated in 87 patients out of 108 randomly allocated for treatment with rhEPOalpha (n = 50) versus controls (n = 58). Tumour cell proliferation (Ki-67 index) and EPO receptor protein expression were evaluated by immunohistochemistry. RESULTS: EPO treatment varied between 2 and 35 months, in doses between 10,000 and 40,000 Units/week. Ki-67 index did not differ between study and control patients before EPO treatment. Tumour tissue erythropoietin receptor protein was also similar between treated and untreated patients. Around 40% of tumour cells contained EPO receptors. Survival did not differ among EPO treated and control patients analysed as intention to treat, while survival was significantly improved in EPO treated patients per protocol treatment (P < 0.05). Ki-67 index and tumour tissue erythropoietin receptor protein did not predict survival, which systemic inflammation (ESR) did (P < 0.02). CONCLUSIONS: Our results support that reported risk to accelerate disease progression by EPO treatment in palliative care is not justified in patients with solid, gastrointestinal cancer despite tumour presence of EPO receptor protein.