Palliative and Supportive Care

It is a propitious time for the publication of Dr. Wein’s thoughtful paper on sedation in the imminently dying. Although this intervention has been accepted by most palliative care specialists for many years, it seems to be unfamiliar to many oncologists. The numerous surveys[1-7] and published guidelines[8] that have informed discussions of the technique have not appeared in the oncology literature and probably have been read by few of the front-line clinicians who care for dying cancer patients. Like the broader model of palliative care of which it is part, sedation in the imminently dying must be “mainstreamed”-ie, understood in all its complexity by clinicians whose patients may benefit most from its skillful application.

Sedation is a clinically important therapeutic intervention in the imminently dying patient. As the patient with an advanced, irreversible illness nears the end of life, symptoms accumulate that are progressively more difficult to

Sen. Don Nickles (R-OK) says maybe he will, and maybe he won’t,make the changes to his Pain Relief Promotion Act (S. 1272) that the American Medical Association (AMA) is requesting. S. 1272 is the Senate version of a bill (HR 2260) that

NEW YORK-Esophagitis was less frequent and less severe in patients with locally advanced non-small-cell lung cancer (NSCLC) treated with standard chemotherapy and thoracic radiation when amifostine (Ethyol) was added to the regimen, according to a report at the Chemotherapy Foundation Symposium XVII.

CLEVELAND-Communicating bad news is an essential part of end-of-life care as well as an important skill in all areas of medicine. Although many physicians feel unprepared to deliver bad news, it is a skill that can be learned and improved, said Donna S. Zhukovsky, MD, director of the Cancer Pain Clinic in the Palliative Medicine Program, Cleveland Clinic Foundation.

FORT LAUDERDALE, Fla-Oral transmucosal fentanyl citrate (Actiq) provides superior analgesia, compared with immediate-release morphine sulfate, for the treatment of breakthrough cancer pain, according to a multicenter study presented at the 18th Annual Scientific Meeting of the American Pain Society.

CLEVELAND-While the majority of Americans wish to die in the comfort of their homes, most are actually dying in institutions, often with pain and other symptoms poorly controlled.

MONTREAL--A recent survey of the 16 Canadian medical schools showed that only one, McGill Uni-versity, recorded more than 20 formal teaching hours in palliative care, and five schools had less than 5 hours, Neil MacDonald, MD, said at the congress.

TORONTO, Ontario-Communication in palliative care is vital for two overlapping reasons, Robert Buckman, MD, said in his presentation at the pain management in palliative care workshop.

VIENNA, Austria-Management of breakthrough pain can sometimes be problematic in patients who are using transdermal fentanyl (Duragesic) as an alternative to morphine. Odette Spruyt, MD, reported at the 9th World Congress on Pain that sufentanil (Sufenta) used sublingually may help solve this problem. Dr. Spruyt is in the Palliative Care Service, Peter MacCallum Cancer Institute, East Melbourne, Victoria, Australia.

OXFORD, UK-Epidural delivery of opioids effectively relieves pain in patients with advanced cancer who are intolerant of or insensitive to high-dose oral morphine, but improvement in quality of life may be more difficult to achieve, Christopher Glynn, MB, said at a workshop on pain management in palliative care, held at the Vancouver meeting.

Looks like Congress will pass a bill that makes it clear that physicians can prescribe pain medication for terminally ill patients, including those with cancer, without running afoul of the Drug Enforcement Administration (DEA). The DEA has charge of the

Prostate cancer is the most commonly diagnosed cancer among American men. The majority of patients with advanced disease have metastatic bone lesions, which are frequently very painful. These lesions tend to respond well to treatment with both nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, although careful dose titration and individualized treatment plans may be needed to achieve maximal analgesia. Opioid side effects are often transient or well controlled with additional medication. Patients with intolerable side effects may experience fewer adverse reactions with a different opioid. Palliative radiation provides pain relief in up to 80% of prostate cancer patients with single or at most a few sites of localized bone pain. Bisphosphonates, powerful inhibitors of osteoclast-mediated bone resorption, are promising new agents for the treatment of painful bone lesions in prostate cancer patients. Radioisotopes, which deliver high-dose radiation to bone lesions without significantly affecting normal bone, are highly effective in providing some degree of pain relief in up to 80% of patients with diffuse, painful bone metastases. Also, chemotherapy shows promise in alleviating pain and possibly extending survival in patients with advanced prostate cancer.[ONCOLOGY 13(11):1537-1549, 1999]

FORT LAUDERDALE, Fla-How common is severe cancer-related fatigue? In a survey study at the Cleveland Clinic, 72 of 172 palliative medicine consult patients contacted said they were too tired to participate. “While fatigue is fairly common in patients with advanced cancer, the extent of their fatigue was surprising,” Kristine Nelson, MD, said at the Cleveland Clinic’s Palliative Medicine 1999 meeting.

VIENNA, Austria-Since most palliative care pain patients will require one or more changes in drugs due to inadequate pain relief, “physicians caring for terminally ill patients must be familiar with multiple drugs and routes of delivery,” Eduardo Bruera, MD, chairman of the Pain Department, M.D. Anderson Cancer Center, said at the 9th World Congress on Pain, sponsored by the International Association for the Study of Pain.

In the decades since hormone replacement therapy (HRT) was introduced, there has never been more controversy surrounding it than at present. Physicians and patients are faced with many questions regarding risk and few definitive answers.

Health-related quality of life (HRQL) is a multidimensional construct that represents the patient’s perspective on valued aspects of health and functioning. Over the last several years, the pharmaceutical industry, as well as health care providers and the patient advocacy community, have shown increasing interest in HRQL as an outcome measure. Pharmaceutical companies and other sponsors of cancer clinical trials are seeking novel approaches with which to establish the benefits of treatment and to differentiate their products from other marketed products. Health care providers hope to provide cancer patients with therapies that positively affect their quality of life. To date, however, most oncology drug approvals have been based on traditional end points, such as survival and tumor response rate. This article will focus on some of the lessons learned from recent reviews of HRQL data and will describe some of the many challenges that lie ahead. ONCOLOGY 13(10):1439-1442, 1999]

Depression is the most common postoperative complication seen in patients who have undergone surgery for brain tumors, but it is seldom recognized or treated, according to preliminary findings of a study presented at the annual meeting of the

Cancer patients who suffer from the debilitating side effect of oral ulcers as a result of chemotherapy can be effectively treated with Zilactin-B, a nonprescription analgesic gel containing hydroxypropyl cellulose and benzocaine, according to an article

The “Chemotherapy Experiences” national patient survey was conducted by Roper Starch Worldwide on behalf of the Oncology Nursing Society (ONS) and Amgen between December 3, 1998, and January 7, 1999. The survey was designed

NEW YORK-For 10 years, Cancer Care, Inc., a national nonprofit social service agency, has been giving away wigs at its Manhattan headquarters to women who have lost their hair due to treatment but cannot afford to purchase their own. “Our whole philosophy at Cancer Care is to normalize the cancer experience,” says Carolyn Messner, ACSW, director of education and training at Cancer Care.

Depression is a common complication of cancer, occurring in about 25% of all patients. If left untreated, depression can contribute to poor treatment compliance, increased hospital stays, and mortality. Medical issues,

Peaceful Dying is a work of considerable effort and organization. Dr. Tobin has painstakingly analyzed his experience as a physician caring for patients with terminal illness and compiled a step-by-step guide to help both patients and their families

This article on the management of breakthrough pain by Simmonds is one of a number of excellent reviews on the palliative aspects of cancer care published in ONCOLOGY over the last 2 years. Breakthrough pain is a frequent, poorly understood

Breakthrough pain is defined as the transient exacerbation of pain occurring in a patient with otherwise stable, persistent pain. Breakthrough pain is relatively common among cancer patients, particularly those with moderate

Predicting the survival of terminal cancer patients is a difficult task. To better understand this difficulty, we divide prognostication into two distinct elements: foreseeing and foretelling. Foreseeing is a physician’s silent cognitive

The 14 reports in this special supplement discuss theuse of the cytoprotectant amifostine in patients withcancer of the head and neck, esophagus, lung, andcervix, as well as those with lymphoma and acutemyelogenous leukemia. Discussions focus on thepotential of this agent to both reduce radiation sideeffects such as xerostomia and permit doseescalation of chemotherapy and/or radiotherapy.Improvements in treatment outcome and quality oflife as a result of cytoprotection are examined.

Photodynamic therapy (PDT) relieves swallowing problems associated with esophageal cancer in the majority of patients treated, according to a study conducted from November 1996 to June 1998 at the University of Pittsburgh Cancer Institute.

FT. LAUDERDALE, Fla-Has Dr. Kevorkian hijacked the media? Many people may not know that palliative care is an alternative to physician-assisted suicide, journalist and author Suzanne Gordon said at the Cleveland Clinic’s 1999 Palliative Medicine conference. Her most recent book is Life Support: Three Nurses on the Front Lines (Back Bay Books Little Brown, 1998)

Locally advanced or metastatic adenocarcinoma of the stomach still carries a poor prognosis, with 5-year survival rates of < 15%. Palliative chemotherapeutic regimens for this disease are largely 5-FU–based. We