Palliative and Supportive Care

Sanofi-Synthelabo announced the commercial availability of Eligard (leuprolide acetate, 7.5 mg) for the palliative treatment of advanced prostate cancer at the 2002 annual meeting of the American Urological Association. Recommended in the prostate

Concern about prescribing controlled substances underlies, in part, the undertreatment of pain, even in palliative care settings. That the same is true for human immunodeficiency virus (HIV) patients is therefore not surprising, particularly given injection drug use as a risk factor.

SAN FRANCISCO-St. John’s wort, a popular herbal preparation that is commonly used to treat depression and other illnesses, alters the metabolism of the anticancer agent irinotecan (Camptosar), according to the results of a study presented at the 93rd Annual Meeting of the American Association for Cancer Research (AACR abstract 2443).

ST. PETERSBURG, Florida-Xerostomia, or mouth dryness, typically seen acutely with head and neck radiation, is also the most common late complication following radiation therapy for head and neck cancer, Avraham (Avi) Eisbruch, MD, said at the LENT (Late Effects of Normal Tissues) IV workshop on late effects criteria and applications. Dr. Eisbruch is associate professor of radiation oncology, University of Michigan Medical School, Ann Arbor.

NEW YORK CITY-Integrating palliative care early in the course of cancer treatment may permit patients to tolerate their treatments better and have a better quality of life, according to Rose Anne Indelicato, ANP, OCN. A nurse practitioner, Department of Pain Management and Palliative Care, at Beth Israel Medical Center in New York City, Ms. Indelicato described the multifaceted roles of department’s advanced practice nurses (APNs). In addition to education and research, APNs are responsible for direct patient care, much of it over the telephone. Their patients received assessment of pain and symptom management earlier in their disease which may promote longer survival, Ms. Indelicato noted.

Payne, Coyne, and Smith present a concise review of the surprisingly meager literature regarding costs of end-of-life cancer care, an issue with substantial ethical and financial implications. They present evidence that improved coordination of care holds the potential to lower costs, or at least to offer better services at the same cost. The authors are to be commended for pursuing more rigorous studies regarding this difficult-to-quantify area of medical and social services. Moreover, they appropriately highlight the difficulties in attempting to capture direct costs of medical care and the far more elusive indirect costs.

Often, Congressional financing of programs can be secured only with indirect arguments. In the 1950s, the Eisenhower administration convinced Congress to fund the interstate highway system by claiming it was essential to enable Americans to evacuate cities in case of a nuclear attack by the Soviet Union. In the 1970s, advocates trying to persuade Congress to pay for dialysis argued that the procedure would be inexpensive, and that people would return to work and pay for themselves. Similarly, in the early 1980s, proponents of hospice advocated Medicare coverage because it was cheaper and better care for the dying.

It is with great pleasure that I comment on the excellent article authored by Drs. Ahrendt and Pitt, who have provided a well-written, succinct, up-to-date review focusing on adenocarcinoma of the pancreas. The authors introduce the topic, discuss preoperative staging and assessment of resectability, cover the critical issues regarding resectional therapy and palliative surgery, and provide data on the results of such therapy, including mortality, morbidity, and quality-of-life outcomes. Emphasizing the importance of this topic, the authors note that pancreatic cancer is the fifth leading cause of cancer death in the United States.

Only a few studies have assessed the economic outcomes of palliative therapy. The major areas of interest include hospice care, the process and structure of care, symptom management, and palliative chemotherapy

Docetaxel (Taxotere)-based regimens can be included among the most effective treatment options for the management of patients with advanced, androgen-independent prostate cancer. Results with docetaxel as a single agent and in combination regimens with estramustine (Emcyt) have consistently achieved a palliative response, reduced serum PSA levels by 50% or more, and produced objective responses in patients with measurable disease. In addition, encouraging survival data have been demonstrated in several phase II trials.

SAN ANTONIO-Targeted support with G-CSF (filgrastim, Neupogen) based on cycle 1 ANC (absolute neutrophil count) nadirs improves the delivery of planned-dose-on-time chemotherapy and significantly reduces the incidence of febrile neutropenia and related hospitalizations, according to study from The University of Texas M.D. Anderson Cancer Center study using a prospective risk model. Edgardo Rivera, MD, assistant professor of breast medical oncology, presented the results at the 24th San Antonio Breast Cancer Symposium (abstract 3).

A substantial minority of the women who see themselves as being at high risk for breast cancer because of family history suffer noticeable depressive symptoms and anxiety, and the anxiety can interfere with compliance with recommendations on breast self-examination (BSE), according to studies at the UCLA Revlon Breast Center.

LOS ANGELES-Myelodysplastic syndrome and aplastic anemia are both diseases of bone marrow failure and are characterized by reticulocytopenic anemia, with variable neutropenia and thrombocytopenia. Other than that, the two diseases are substantially different from each other. Tools for diagnosing and managing these two complex diseases were updated by Ronald L. Paquette, MD, associate professor of medicine at the University of California Medical Center in Los Angeles

LONG BEACH, California-Treating anemia can reverse the declines it causes in physical function and quality of life for cancer patients and may have an impact on outcomes of cancer therapy, reported Simon Tchekmedyian, MD. Statistics suggest that anemia and its effects are under-recognized and undertreated, he noted, but barriers to treatment may fall as new therapeutic agents prove to be more effective and can be administered more easily and less frequently.

COLUMBIA, South Carolina-Anemia impairs quality of life and functional status, can interfere with cancer therapies, and now seems linked to poorer prognosis and shortened life span, at least in some cancer patients, according to Robert E. Smith, Jr., MD, president of South Carolina Oncology Associates and clinical associate professor at the University of South Carolina School of Medicine in Columbia. In his experience, and that of other oncologists, recombinant human erythropoietin (rHuEPO) and darbepoetin alfa (Aranesp) can increase hemoglobin levels, decrease fatigue, and improve quality of life for cancer patients. To get optimal treatment results with erythropoietic agents, however, requires understanding the full range of etiologies of anemia and its signs and symptoms, and a thorough work-up of patients.

EVANSTON, Illinois-Anemia is the most treatable cause of fatigue in cancer patients and aggressively managing anemia could significantly improve the quality of life of cancer patients and may also impact survival, according to David Cella, PhD. Anemia has been associated with poor prognosis and increased mortality among cancer patients, although a causal relationship has not yet been established, he noted.

LOS ANGELES-Many, if not most, oncologists agree that erythropoietic therapy can lower the need for transfusions and improve quality-of-life. This is especially true when cancer patients who suffer from fatigue have their hemoglobin levels raised from 10 g/dL or less to 12 g/dL or more. Why then are less than 30% of patients who should receive erythropoietic therapy being treated with it? (See Table 1.)

Investigators from Memphis found that cancer patients who experience breakthrough pain require additional medical services that result in higher medical costs than those incurred by cancer patients without breakthrough pain. The study, published in the February 2002 issue of the Journal of Pain, reported that patients with breakthrough pain (perhaps two-thirds of this population) require more frequent hospitalizations and doctor visits than cancer patients without breakthrough pain. Patients who suffered from breakthrough pain incurred costs of approximately $12,000 a year for medical services specific to their pain (hospitalizations, emergency room, and physician visits), whereas patients who did not have breakthrough pain (but still experienced pain) incurred costs of approximately $2,400 a year.

NEW YORK-Sipping smoothies, exercising, and keeping a journal are among the things cancer patients can do to combat fatigue and build energy, according to Eileen Donovan, PT, MEd, manager of rehabilitation services at The University of Texas M. D. Anderson Cancer Center, and Marilyn Joyce, RD, a Los Angeles-based nutritionist and author. Both women spoke at a Cancer Care teleconference about the role of exercise and nutrition in coping with fatigue.

HOUSTON-Using subjective complaints reported by patients as a basis for treatment is new, "in a sense revolutionary," said Charles S. Cleeland, PhD, and worth pursuing. Well-established pain measurement scales can be used as a model to assess multiple symptoms, including fatigue, among cancer patients and identify moderate to severe levels of symptoms that might warrant intervention, he explained. Dr. Cleeland is McCullough Professor of Cancer Research at the University of Texas M.D. Anderson Cancer Center in Houston.

LOS ANGELES-Preclinical and early clinical evidence indicates that correcting anemia might prolong survival in cancer patients, reported John Glaspy, MD, MPH, at the Fifth Quality of Life in Oncology Symposium in Pasadena, California. He called for more prospective randomized trials specifically designed to investigate the effect of anemia on survival.

NEW YORK-Management of anemia-related fatigue begins with good communication, said Patricia Ann Kramer, RN, MSN, AOCN, a San Francisco-based oncology nurse educator and consultant. Speaking at a Cancer Care teleconference, she urged patients to report their fatigue to doctors, describe it on a scale of 0 to 10, and not to feel they are taking up their doctor’s valuable time talking about it. "The squeaky wheel," Ms. Kramer observed, "gets the grease."

The mouth is a frequent site of complications arising from drug or radiation cancer therapy, with mucositis, xerostomia, osteoradionecrosis, and local infections being the most common. From the standpoint of dose

THOUSAND OAKS, California-Increases in hemoglobin levels appear to improve the physical, functional, emotional, and psychological well-being of cancer patients with anemia. Based on the combined results of two randomized, controlled clinical trials, data supporting this statement were presented by Joel D. Kallich, PhD, associate director, health economics and epidemiology, at Amgen, Thousand Oaks, California.

Drs. Choi and Billings provide an excellent summary of the historical developments, clinical issues, and ethical dilemmas associated with palliative care. As they recount, the British hospice movement of the 1960s began as a fringe movement away from the main academic centers and organized medicine. This separation provided a safe environment in which palliative-care practitioners could deliver clinical care while establishing a new body of knowledge. On the other hand, because of this lack of connection, palliative care is still not recognized as a specialized area of medical practice in many countries, including the United States. This perception persists despite the fact that palliative care developed earlier than other fully recognized subspecialties such as emergency medicine and critical care.

In the 1950s, a group of clinicians, who later would be the forerunners of the discipline to be known as oncology, completed the first clinical trial in acute lymphoblastic leukemia. This beginning led to the formation of a learned society in oncology. In the mid-1980s, the American Board of Internal Medicine recognized the field of oncology by providing a qualifying examination to establish its importance in the development and treatment of cancer. The impressive growth in this field over the past decade evolved through a variety of basic research advances and the introduction of clinical trials.

In their article, Drs. Choi and Billings address a number of strategic areas in palliative care. These topics include the definition and scope of the evolving field, the complexities involved in the use of modalities that carry burden or risk (such as artificial nutrition and bowel decompression), and the underappreciated importance of communication skills and a capacity for ethical reasoning.

In the United States, hospice and palliative care are two distinct expressions of the hospice interdisciplinary team approach to end-of-life care, which originated in Great Britain in the 1960s. The hospice movement developed largely as a home-care program and alternative to conventional care.

SAN FRANCISCO-Patients with inoperable non-small-cell lung cancer (NSCLC) who receive 20 Gy of radiation therapy in five fractions achieved slightly superior palliation of thoracic symptoms than those receiving a single 10-Gy dose, according to a study presented at the 43rd Annual Meeting of the American Society for Therapeutic Radiology and Oncology (abstract 30). An unexpected finding was that patients receiving the five-fraction therapy survived significantly longer, the study authors said.

Fatigue is one of the most common symptoms experienced by patients with cancer and other progressive diseases. Although reported to be a major obstacle to maintaining normal daily activities and quality of life, remarkably few studies of this syndrome have been conducted.