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Depression at least five times more common than PTSD after critical illness
Patients discharged from intensive care units were far more likely to report physical symptoms of depression than posttraumatic distress disorder symptoms, based on research published online April 6 in Lancet Respiratory Medicine.
"Depression and posttraumatic distress disorder are important mental health problems after critical illness, but our findings show that depression is at least five times more common than posttraumatic distress disorder and is largely somatic in nature," said James C. Jackson, Psy.D., at Vanderbilt University in Nashville, Tenn., and his associates. "This finding suggests that physical disability contributes predominantly to this depression, which has implications for the roles of physical rehabilitation vs. antidepressant medications in the prevention and management of depression after ICU admission." Lancet
Respir. Med. 2014 March 6 [doi: 10.1016/S2213-2600(14)70051-7]
The prospective, multicenter longitudinal cohort study enrolled 821 patients (median age, 61 years) treated in medical and surgical ICUs for respiratory failure, cardiogenic shock, or septic shock.
Data were available for 406 patients 3 months after discharge, of which 37% reported at least mild depression symptoms, while only 7% reported posttraumatic stress disorder (PTSD) symptoms. At 12 months after discharge, 33% of patients reported depression, compared with 7% for PTSD. Depression was primarily somatic in nature and was common even among patients with no past history of the disorder (prevalence, 30% and 29% at 3 and 12 months, respectively). Disabilities in activities of daily living affected from 23%-32% of patients.
"Our data further show that monitoring these outcomes is relevant for survivors of all ages, and that non–pharmacological interventions during the ICU stay (previously assumed to improve physical outcomes in ICU survivors) should be tested in terms of their ability to change mental health and functional outcomes," the investigators concluded.
Dr. Jackson receives grant support from the National Institutes of Health. Ten of his associates reported receiving funding, honoraria, and other support from Hospira; Abbott; Orion Pharma; the Veterans Affairs Clinical Science Research and Development Service; the Tennessee Valley Geriatric Research, Education, and Clinical Center; the National Institutes of Health; and the Vanderbilt Clinical and Translational Research Scholars Program.
Just 15 years ago, the long-term sequelae of severe sepsis and acute respiratory distress syndrome were unknown, said Dr. Hallie C. Prescott and Dr. Theodore J. Iwashyna. But as survival rates in intensive care units improved, "it became clear that something was not right. Survivors were not the same after critical illness. Rather, they had new weaknesses, cognitive impairment, depression, and early death."
But the causes and treatment of post–intensive care syndrome have eluded researchers, said Dr. Prescott and Dr. Iwashyna. The current study’s findings help fill that gap. "By differentiation of depression into cognitive and physical components, Jackson and colleagues have provided an important step towards tailoring of future interventions to specific symptoms subsets, and not the generic diagnosis of depression."
Somatic symptoms among survivors might be from functional limitations and medical comorbidities instead of a neurochemical imbalance, they added. "As such, traditional pharmacologic therapies for depression might be less likely to provide significant benefit alone (or at all). Instead, doctors might need to address the many diagnoses that contribute to poor sleep, impaired concentration, weakness, and fatigue. Although largely absent from the history of post–intensive care syndrome to date, consideration is needed of how common chronic medical conditions such as diabetes, heart failure, and chronic pulmonary disease contribute to the morbidity of survivors of critical illness."
Dr. Prescott is a clinical fellow and Dr. Iwashyna is an assistant professor of internal medicine with the University of Michigan, Ann Arbor. They reported receiving grant support from the National Institutes of Health and the Department of Veterans Affairs. These remarks were taken from their editorial accompanying Dr. Jackson’s report (Lancet 2014 [doi:10.1016/S2213-2600(14)70071-2]).
Just 15 years ago, the long-term sequelae of severe sepsis and acute respiratory distress syndrome were unknown, said Dr. Hallie C. Prescott and Dr. Theodore J. Iwashyna. But as survival rates in intensive care units improved, "it became clear that something was not right. Survivors were not the same after critical illness. Rather, they had new weaknesses, cognitive impairment, depression, and early death."
But the causes and treatment of post–intensive care syndrome have eluded researchers, said Dr. Prescott and Dr. Iwashyna. The current study’s findings help fill that gap. "By differentiation of depression into cognitive and physical components, Jackson and colleagues have provided an important step towards tailoring of future interventions to specific symptoms subsets, and not the generic diagnosis of depression."
Somatic symptoms among survivors might be from functional limitations and medical comorbidities instead of a neurochemical imbalance, they added. "As such, traditional pharmacologic therapies for depression might be less likely to provide significant benefit alone (or at all). Instead, doctors might need to address the many diagnoses that contribute to poor sleep, impaired concentration, weakness, and fatigue. Although largely absent from the history of post–intensive care syndrome to date, consideration is needed of how common chronic medical conditions such as diabetes, heart failure, and chronic pulmonary disease contribute to the morbidity of survivors of critical illness."
Dr. Prescott is a clinical fellow and Dr. Iwashyna is an assistant professor of internal medicine with the University of Michigan, Ann Arbor. They reported receiving grant support from the National Institutes of Health and the Department of Veterans Affairs. These remarks were taken from their editorial accompanying Dr. Jackson’s report (Lancet 2014 [doi:10.1016/S2213-2600(14)70071-2]).
Just 15 years ago, the long-term sequelae of severe sepsis and acute respiratory distress syndrome were unknown, said Dr. Hallie C. Prescott and Dr. Theodore J. Iwashyna. But as survival rates in intensive care units improved, "it became clear that something was not right. Survivors were not the same after critical illness. Rather, they had new weaknesses, cognitive impairment, depression, and early death."
But the causes and treatment of post–intensive care syndrome have eluded researchers, said Dr. Prescott and Dr. Iwashyna. The current study’s findings help fill that gap. "By differentiation of depression into cognitive and physical components, Jackson and colleagues have provided an important step towards tailoring of future interventions to specific symptoms subsets, and not the generic diagnosis of depression."
Somatic symptoms among survivors might be from functional limitations and medical comorbidities instead of a neurochemical imbalance, they added. "As such, traditional pharmacologic therapies for depression might be less likely to provide significant benefit alone (or at all). Instead, doctors might need to address the many diagnoses that contribute to poor sleep, impaired concentration, weakness, and fatigue. Although largely absent from the history of post–intensive care syndrome to date, consideration is needed of how common chronic medical conditions such as diabetes, heart failure, and chronic pulmonary disease contribute to the morbidity of survivors of critical illness."
Dr. Prescott is a clinical fellow and Dr. Iwashyna is an assistant professor of internal medicine with the University of Michigan, Ann Arbor. They reported receiving grant support from the National Institutes of Health and the Department of Veterans Affairs. These remarks were taken from their editorial accompanying Dr. Jackson’s report (Lancet 2014 [doi:10.1016/S2213-2600(14)70071-2]).
Patients discharged from intensive care units were far more likely to report physical symptoms of depression than posttraumatic distress disorder symptoms, based on research published online April 6 in Lancet Respiratory Medicine.
"Depression and posttraumatic distress disorder are important mental health problems after critical illness, but our findings show that depression is at least five times more common than posttraumatic distress disorder and is largely somatic in nature," said James C. Jackson, Psy.D., at Vanderbilt University in Nashville, Tenn., and his associates. "This finding suggests that physical disability contributes predominantly to this depression, which has implications for the roles of physical rehabilitation vs. antidepressant medications in the prevention and management of depression after ICU admission." Lancet
Respir. Med. 2014 March 6 [doi: 10.1016/S2213-2600(14)70051-7]
The prospective, multicenter longitudinal cohort study enrolled 821 patients (median age, 61 years) treated in medical and surgical ICUs for respiratory failure, cardiogenic shock, or septic shock.
Data were available for 406 patients 3 months after discharge, of which 37% reported at least mild depression symptoms, while only 7% reported posttraumatic stress disorder (PTSD) symptoms. At 12 months after discharge, 33% of patients reported depression, compared with 7% for PTSD. Depression was primarily somatic in nature and was common even among patients with no past history of the disorder (prevalence, 30% and 29% at 3 and 12 months, respectively). Disabilities in activities of daily living affected from 23%-32% of patients.
"Our data further show that monitoring these outcomes is relevant for survivors of all ages, and that non–pharmacological interventions during the ICU stay (previously assumed to improve physical outcomes in ICU survivors) should be tested in terms of their ability to change mental health and functional outcomes," the investigators concluded.
Dr. Jackson receives grant support from the National Institutes of Health. Ten of his associates reported receiving funding, honoraria, and other support from Hospira; Abbott; Orion Pharma; the Veterans Affairs Clinical Science Research and Development Service; the Tennessee Valley Geriatric Research, Education, and Clinical Center; the National Institutes of Health; and the Vanderbilt Clinical and Translational Research Scholars Program.
Patients discharged from intensive care units were far more likely to report physical symptoms of depression than posttraumatic distress disorder symptoms, based on research published online April 6 in Lancet Respiratory Medicine.
"Depression and posttraumatic distress disorder are important mental health problems after critical illness, but our findings show that depression is at least five times more common than posttraumatic distress disorder and is largely somatic in nature," said James C. Jackson, Psy.D., at Vanderbilt University in Nashville, Tenn., and his associates. "This finding suggests that physical disability contributes predominantly to this depression, which has implications for the roles of physical rehabilitation vs. antidepressant medications in the prevention and management of depression after ICU admission." Lancet
Respir. Med. 2014 March 6 [doi: 10.1016/S2213-2600(14)70051-7]
The prospective, multicenter longitudinal cohort study enrolled 821 patients (median age, 61 years) treated in medical and surgical ICUs for respiratory failure, cardiogenic shock, or septic shock.
Data were available for 406 patients 3 months after discharge, of which 37% reported at least mild depression symptoms, while only 7% reported posttraumatic stress disorder (PTSD) symptoms. At 12 months after discharge, 33% of patients reported depression, compared with 7% for PTSD. Depression was primarily somatic in nature and was common even among patients with no past history of the disorder (prevalence, 30% and 29% at 3 and 12 months, respectively). Disabilities in activities of daily living affected from 23%-32% of patients.
"Our data further show that monitoring these outcomes is relevant for survivors of all ages, and that non–pharmacological interventions during the ICU stay (previously assumed to improve physical outcomes in ICU survivors) should be tested in terms of their ability to change mental health and functional outcomes," the investigators concluded.
Dr. Jackson receives grant support from the National Institutes of Health. Ten of his associates reported receiving funding, honoraria, and other support from Hospira; Abbott; Orion Pharma; the Veterans Affairs Clinical Science Research and Development Service; the Tennessee Valley Geriatric Research, Education, and Clinical Center; the National Institutes of Health; and the Vanderbilt Clinical and Translational Research Scholars Program.
FROM THE LANCET
Major finding: At 3 months and 12 months after discharge, 37% and 33% of patients reported at least mild depression while only 7% reported symptoms of posttraumatic stress disorder.
Data source: Prospective, multicenter longitudinal cohort study of 821 patients with respiratory failure or shock treated in ICUs, with 448 assessed at 3 months and 382 assessed at 12 months.
Disclosures: Dr. Jackson receives grant support from the National Institutes of Health. Ten of his associates reported receiving funding, honoraria, and other support from Hospira; Abbott; Orion Pharma; the Veterans Affairs Clinical Science Research and Development Service; the Tennessee Valley Geriatric Research, Education, and Clinical Center; the National Institutes of Health; and the Vanderbilt Clinical and Translational Research Scholars Program.
Substantial delay seen in melanoma surgery for Medicare patients
DENVER – As many as 25% of Medicare patients with melanoma will experience treatment delays of up to 1.5 months, and 18% may have treatment delays as long as 3 months after a lesion is biopsied, especially if a nondermatologist is performing the excision, based on data from a review of more than 32,000 patients.
Patients who saw dermatologists for their surgery were much less likely to experience a delay in treatment, Dr. Jason Lott said at the annual meeting of the American Academy of Dermatology.
"If a primary care provider was doing the surgery – and many still do their own surgery – patients were 1.6 times more likely to have a delay of more than 1.5 months, and twice as likely to have a delay of more than 3 months," said Dr. Lott of Yale University, New Haven, Conn. "I am making the argument that specialty matters."
Other factors significantly associated with treatment delay included older patient age, comorbidities, tumor stage, and lesion location.
To examine factors contributing to a surgical delay in the United States, Dr. Lott and his colleagues conducted a population-based study of treatment waiting times in more than 32,501 Medicare patients who had been diagnosed with melanoma from 2000 to 2009. The primary outcome was the time between biopsy and surgical treatment.
The most common lesion sites were the head and neck (40%), followed by the extremities and trunk. Compared with head/neck lesions, surgery on the trunk and extremities was significantly less likely to be delayed up to 1.5 months (odds ratio, 0.74).
Melanomas were about equally divided between in situ and localized disease (48% and 44%), with the remainder having distant occurrence. Compared with in situ disease, regional and distant disease were significantly more likely to be treated later, with odds ratios ranging from 1.31 for a delay of up to 1.5 months (regional disease) to 2.15 for a delay of more than 3 months (distant disease).
Older patients had greater delays than did younger patients, with the biggest disparities between those aged 80-84 years and those aged 70-74 years, In the younger group, 54% were treated within 1 month, compared with 50% of the older patients. A delay of up to 3 months occurred in 38% of the younger group and 41% of the older group.
Patients with no medical comorbidities received significantly prompter treatment, with 54% being treated within 1 month compared with 47% of those with three comorbidities.
Expeditious treatment is certainly important to patients, Dr. Lott said, and likely important for achieving optimal outcomes. "Patients don’t like walking around knowing they have a malignancy that’s not treated, with even a marginally increased chance that something bad will happen," he noted.
That risk is not unfounded, Dr. Lott said. The United Kingdom’s "2-week" rule, implemented in 2000, mandates an urgent consultation for suspected malignancies. Patients with suspected melanomas are seen in a special pigmented lesions clinic, and often treated on the same day. In 2007, this practice was shown to positively impact melanoma survival.
Dr. Lott described a retrospective study conducted in the United Kingdom that examined outcomes in 4,399 patients, all of whom were evaluated at a pigmented lesions clinic within 2 weeks of a primary care identification of a suspicious lesion. During the study period, 96 melanomas were identified, and 96% of those were treated within 2 weeks of the primary referral. Most (74%) were excised on the day of the clinic visit.
The authors compared these results with those of 78 melanoma patients who were diagnosed in the 2 years before urgent referral became standard. These patients waited up to 34 days for a referral and up to 74 days for treatment. Patients seen in the clinic had significantly thinner tumors (Breslow thickness 1.68 vs. 2.39 mm). In addition to melanomas, 748 nonmelanoma skin cancers were treated at the clinics.
Among the melanoma patients diagnosed in the clinics, the 5-year survival rate was 82%, compared with 62% in patients diagnosed before the urgent referral.
"Earlier treatment does matter," Dr. Lott said.
Dr. Lott said he had no relevant financial conflicts to disclose.
On Twitter @alz_gal
DENVER – As many as 25% of Medicare patients with melanoma will experience treatment delays of up to 1.5 months, and 18% may have treatment delays as long as 3 months after a lesion is biopsied, especially if a nondermatologist is performing the excision, based on data from a review of more than 32,000 patients.
Patients who saw dermatologists for their surgery were much less likely to experience a delay in treatment, Dr. Jason Lott said at the annual meeting of the American Academy of Dermatology.
"If a primary care provider was doing the surgery – and many still do their own surgery – patients were 1.6 times more likely to have a delay of more than 1.5 months, and twice as likely to have a delay of more than 3 months," said Dr. Lott of Yale University, New Haven, Conn. "I am making the argument that specialty matters."
Other factors significantly associated with treatment delay included older patient age, comorbidities, tumor stage, and lesion location.
To examine factors contributing to a surgical delay in the United States, Dr. Lott and his colleagues conducted a population-based study of treatment waiting times in more than 32,501 Medicare patients who had been diagnosed with melanoma from 2000 to 2009. The primary outcome was the time between biopsy and surgical treatment.
The most common lesion sites were the head and neck (40%), followed by the extremities and trunk. Compared with head/neck lesions, surgery on the trunk and extremities was significantly less likely to be delayed up to 1.5 months (odds ratio, 0.74).
Melanomas were about equally divided between in situ and localized disease (48% and 44%), with the remainder having distant occurrence. Compared with in situ disease, regional and distant disease were significantly more likely to be treated later, with odds ratios ranging from 1.31 for a delay of up to 1.5 months (regional disease) to 2.15 for a delay of more than 3 months (distant disease).
Older patients had greater delays than did younger patients, with the biggest disparities between those aged 80-84 years and those aged 70-74 years, In the younger group, 54% were treated within 1 month, compared with 50% of the older patients. A delay of up to 3 months occurred in 38% of the younger group and 41% of the older group.
Patients with no medical comorbidities received significantly prompter treatment, with 54% being treated within 1 month compared with 47% of those with three comorbidities.
Expeditious treatment is certainly important to patients, Dr. Lott said, and likely important for achieving optimal outcomes. "Patients don’t like walking around knowing they have a malignancy that’s not treated, with even a marginally increased chance that something bad will happen," he noted.
That risk is not unfounded, Dr. Lott said. The United Kingdom’s "2-week" rule, implemented in 2000, mandates an urgent consultation for suspected malignancies. Patients with suspected melanomas are seen in a special pigmented lesions clinic, and often treated on the same day. In 2007, this practice was shown to positively impact melanoma survival.
Dr. Lott described a retrospective study conducted in the United Kingdom that examined outcomes in 4,399 patients, all of whom were evaluated at a pigmented lesions clinic within 2 weeks of a primary care identification of a suspicious lesion. During the study period, 96 melanomas were identified, and 96% of those were treated within 2 weeks of the primary referral. Most (74%) were excised on the day of the clinic visit.
The authors compared these results with those of 78 melanoma patients who were diagnosed in the 2 years before urgent referral became standard. These patients waited up to 34 days for a referral and up to 74 days for treatment. Patients seen in the clinic had significantly thinner tumors (Breslow thickness 1.68 vs. 2.39 mm). In addition to melanomas, 748 nonmelanoma skin cancers were treated at the clinics.
Among the melanoma patients diagnosed in the clinics, the 5-year survival rate was 82%, compared with 62% in patients diagnosed before the urgent referral.
"Earlier treatment does matter," Dr. Lott said.
Dr. Lott said he had no relevant financial conflicts to disclose.
On Twitter @alz_gal
DENVER – As many as 25% of Medicare patients with melanoma will experience treatment delays of up to 1.5 months, and 18% may have treatment delays as long as 3 months after a lesion is biopsied, especially if a nondermatologist is performing the excision, based on data from a review of more than 32,000 patients.
Patients who saw dermatologists for their surgery were much less likely to experience a delay in treatment, Dr. Jason Lott said at the annual meeting of the American Academy of Dermatology.
"If a primary care provider was doing the surgery – and many still do their own surgery – patients were 1.6 times more likely to have a delay of more than 1.5 months, and twice as likely to have a delay of more than 3 months," said Dr. Lott of Yale University, New Haven, Conn. "I am making the argument that specialty matters."
Other factors significantly associated with treatment delay included older patient age, comorbidities, tumor stage, and lesion location.
To examine factors contributing to a surgical delay in the United States, Dr. Lott and his colleagues conducted a population-based study of treatment waiting times in more than 32,501 Medicare patients who had been diagnosed with melanoma from 2000 to 2009. The primary outcome was the time between biopsy and surgical treatment.
The most common lesion sites were the head and neck (40%), followed by the extremities and trunk. Compared with head/neck lesions, surgery on the trunk and extremities was significantly less likely to be delayed up to 1.5 months (odds ratio, 0.74).
Melanomas were about equally divided between in situ and localized disease (48% and 44%), with the remainder having distant occurrence. Compared with in situ disease, regional and distant disease were significantly more likely to be treated later, with odds ratios ranging from 1.31 for a delay of up to 1.5 months (regional disease) to 2.15 for a delay of more than 3 months (distant disease).
Older patients had greater delays than did younger patients, with the biggest disparities between those aged 80-84 years and those aged 70-74 years, In the younger group, 54% were treated within 1 month, compared with 50% of the older patients. A delay of up to 3 months occurred in 38% of the younger group and 41% of the older group.
Patients with no medical comorbidities received significantly prompter treatment, with 54% being treated within 1 month compared with 47% of those with three comorbidities.
Expeditious treatment is certainly important to patients, Dr. Lott said, and likely important for achieving optimal outcomes. "Patients don’t like walking around knowing they have a malignancy that’s not treated, with even a marginally increased chance that something bad will happen," he noted.
That risk is not unfounded, Dr. Lott said. The United Kingdom’s "2-week" rule, implemented in 2000, mandates an urgent consultation for suspected malignancies. Patients with suspected melanomas are seen in a special pigmented lesions clinic, and often treated on the same day. In 2007, this practice was shown to positively impact melanoma survival.
Dr. Lott described a retrospective study conducted in the United Kingdom that examined outcomes in 4,399 patients, all of whom were evaluated at a pigmented lesions clinic within 2 weeks of a primary care identification of a suspicious lesion. During the study period, 96 melanomas were identified, and 96% of those were treated within 2 weeks of the primary referral. Most (74%) were excised on the day of the clinic visit.
The authors compared these results with those of 78 melanoma patients who were diagnosed in the 2 years before urgent referral became standard. These patients waited up to 34 days for a referral and up to 74 days for treatment. Patients seen in the clinic had significantly thinner tumors (Breslow thickness 1.68 vs. 2.39 mm). In addition to melanomas, 748 nonmelanoma skin cancers were treated at the clinics.
Among the melanoma patients diagnosed in the clinics, the 5-year survival rate was 82%, compared with 62% in patients diagnosed before the urgent referral.
"Earlier treatment does matter," Dr. Lott said.
Dr. Lott said he had no relevant financial conflicts to disclose.
On Twitter @alz_gal
AT THE AAD ANNUAL MEETING
Major finding: Melanoma excision delays were significantly less common when the diagnostic physician was a dermatologist, rather than a nondermatologist (OR, 0.67 for more than 1.5 months; 0.58 for more than 3 months).
Data source: A Medicare database study involving more than 32,000 patients with melanoma.
Disclosures: Dr. Lott said he had no relevant financial disclosures.
Delayed response in ipilimumab therapy
Metastatic melanoma is a deadly disease with a 5-year survival rate lower than 20%.1 In 2011, ipilimumab, a fully humanized antibody that binds to cytotoxic T-lymphocyte–associated antigen 4 (CTLA4) was approved by the US Food and Drug Administration based on improved survival in a pivotal trial.2 CTLA4 is a molecule on cytotoxic T-lymphocytes that plays a critical role in attenuating immune responses. Ipilimumab blocks the binding of B7, the ligand of CTLA4, thereby blocking the activation of CTLA4 and sustaining antitumor immune responses. The time course to response can be variable with immunotherapeutics. We report on a patient who experienced a considerable delay before responding to ipilimumab.
Click on the PDF icon at the top of this introduction to read the full article.
Metastatic melanoma is a deadly disease with a 5-year survival rate lower than 20%.1 In 2011, ipilimumab, a fully humanized antibody that binds to cytotoxic T-lymphocyte–associated antigen 4 (CTLA4) was approved by the US Food and Drug Administration based on improved survival in a pivotal trial.2 CTLA4 is a molecule on cytotoxic T-lymphocytes that plays a critical role in attenuating immune responses. Ipilimumab blocks the binding of B7, the ligand of CTLA4, thereby blocking the activation of CTLA4 and sustaining antitumor immune responses. The time course to response can be variable with immunotherapeutics. We report on a patient who experienced a considerable delay before responding to ipilimumab.
Click on the PDF icon at the top of this introduction to read the full article.
Metastatic melanoma is a deadly disease with a 5-year survival rate lower than 20%.1 In 2011, ipilimumab, a fully humanized antibody that binds to cytotoxic T-lymphocyte–associated antigen 4 (CTLA4) was approved by the US Food and Drug Administration based on improved survival in a pivotal trial.2 CTLA4 is a molecule on cytotoxic T-lymphocytes that plays a critical role in attenuating immune responses. Ipilimumab blocks the binding of B7, the ligand of CTLA4, thereby blocking the activation of CTLA4 and sustaining antitumor immune responses. The time course to response can be variable with immunotherapeutics. We report on a patient who experienced a considerable delay before responding to ipilimumab.
Click on the PDF icon at the top of this introduction to read the full article.
Current therapeutic options in hairy cell leukemia
Hairy cell leukemia (HCL) is a B-cell chronic lymphoproliferative disorder that was initially described as leukemic reticuloendotheliosis. The disease is characterized by monocytopenia, organomegaly, constitutional symptoms, and bone marrow fibrosis. Significant advances have improved the diagnosis and management of HCL over the last 55 years. Although HCL has an indolent course, most patients will require treatment of the disease. Indications to initiate therapy include disease-related symptoms, signs of bone marrow failure, or frequent infections. Asymptomatic patients without cytopenias can be observed without the need for therapeutic interventions. Therapeutic options usually consist of chemotherapy, immunotherapy, biological agents, and surgery.
Click on the PDF icon at the top of this introduction to read the full article.
Hairy cell leukemia (HCL) is a B-cell chronic lymphoproliferative disorder that was initially described as leukemic reticuloendotheliosis. The disease is characterized by monocytopenia, organomegaly, constitutional symptoms, and bone marrow fibrosis. Significant advances have improved the diagnosis and management of HCL over the last 55 years. Although HCL has an indolent course, most patients will require treatment of the disease. Indications to initiate therapy include disease-related symptoms, signs of bone marrow failure, or frequent infections. Asymptomatic patients without cytopenias can be observed without the need for therapeutic interventions. Therapeutic options usually consist of chemotherapy, immunotherapy, biological agents, and surgery.
Click on the PDF icon at the top of this introduction to read the full article.
Hairy cell leukemia (HCL) is a B-cell chronic lymphoproliferative disorder that was initially described as leukemic reticuloendotheliosis. The disease is characterized by monocytopenia, organomegaly, constitutional symptoms, and bone marrow fibrosis. Significant advances have improved the diagnosis and management of HCL over the last 55 years. Although HCL has an indolent course, most patients will require treatment of the disease. Indications to initiate therapy include disease-related symptoms, signs of bone marrow failure, or frequent infections. Asymptomatic patients without cytopenias can be observed without the need for therapeutic interventions. Therapeutic options usually consist of chemotherapy, immunotherapy, biological agents, and surgery.
Click on the PDF icon at the top of this introduction to read the full article.
An analysis of the variability of breakthrough pain intensity in patients with cancer
Background The management of breakthrough pain in patients with cancer (BTPc) generally includes an initial titration of breakthrough pain medication to an effective dose, followed by the use of that dose in all subsequent episodes. This strategy presumes that an individual patient has a degree of consistency of pain during repeat episodes; however, that presumption has not been formally assessed.
Objective To examine the variation in pain intensity of BTPc episodes within individual patients and across patients.
Methods Data were pooled from 2 randomized, double-blind, crossover studies that used fentanyl pectin nasal spray (FPNS) vs comparator to relieve BTPc. Eligible patients were adults with an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 and adequately controlled background pain. The FPNS dose was titrated prior to a double-blind treatment consisting of 10 episodes. Pain intensity was reported on an 11-point numeric scale in which 0 = no pain and 10 = worst possible pain. Inter- and intrapatient variabilities of baseline pain intensity scores per episode were analyzed by analysis of covariance via a mixed-effect model. The influences of demographics and ECOG grade at study entry were assessed.
Results Mean baseline pain intensity score was 7.3 (standard deviation, 1.76; range, 2-10) across 1,399 BTPc episodes in 152 patients. The interpatient variability of baseline pain intensity scores was 75.96%; intrapatient variability was 20.64%. Fixed terms for demographics and ECOG grade did not significantly influence baseline pain intensity score (≤ 5% level).
Limitations This was a post hoc analysis.
Conclusions Baseline pain intensity scores during episodes of BTPc vary widely between patients, but vary little within individual patients; this supports the use of a consistent maintenance dosage of analgesia for BTPc, once it has been titrated to an effective dose.
Funding/Support The study was funded by Archimedes Development Ltd.
*To read the full article, click on the PDF icon at the top of this introduction.
Background The management of breakthrough pain in patients with cancer (BTPc) generally includes an initial titration of breakthrough pain medication to an effective dose, followed by the use of that dose in all subsequent episodes. This strategy presumes that an individual patient has a degree of consistency of pain during repeat episodes; however, that presumption has not been formally assessed.
Objective To examine the variation in pain intensity of BTPc episodes within individual patients and across patients.
Methods Data were pooled from 2 randomized, double-blind, crossover studies that used fentanyl pectin nasal spray (FPNS) vs comparator to relieve BTPc. Eligible patients were adults with an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 and adequately controlled background pain. The FPNS dose was titrated prior to a double-blind treatment consisting of 10 episodes. Pain intensity was reported on an 11-point numeric scale in which 0 = no pain and 10 = worst possible pain. Inter- and intrapatient variabilities of baseline pain intensity scores per episode were analyzed by analysis of covariance via a mixed-effect model. The influences of demographics and ECOG grade at study entry were assessed.
Results Mean baseline pain intensity score was 7.3 (standard deviation, 1.76; range, 2-10) across 1,399 BTPc episodes in 152 patients. The interpatient variability of baseline pain intensity scores was 75.96%; intrapatient variability was 20.64%. Fixed terms for demographics and ECOG grade did not significantly influence baseline pain intensity score (≤ 5% level).
Limitations This was a post hoc analysis.
Conclusions Baseline pain intensity scores during episodes of BTPc vary widely between patients, but vary little within individual patients; this supports the use of a consistent maintenance dosage of analgesia for BTPc, once it has been titrated to an effective dose.
Funding/Support The study was funded by Archimedes Development Ltd.
*To read the full article, click on the PDF icon at the top of this introduction.
Background The management of breakthrough pain in patients with cancer (BTPc) generally includes an initial titration of breakthrough pain medication to an effective dose, followed by the use of that dose in all subsequent episodes. This strategy presumes that an individual patient has a degree of consistency of pain during repeat episodes; however, that presumption has not been formally assessed.
Objective To examine the variation in pain intensity of BTPc episodes within individual patients and across patients.
Methods Data were pooled from 2 randomized, double-blind, crossover studies that used fentanyl pectin nasal spray (FPNS) vs comparator to relieve BTPc. Eligible patients were adults with an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 and adequately controlled background pain. The FPNS dose was titrated prior to a double-blind treatment consisting of 10 episodes. Pain intensity was reported on an 11-point numeric scale in which 0 = no pain and 10 = worst possible pain. Inter- and intrapatient variabilities of baseline pain intensity scores per episode were analyzed by analysis of covariance via a mixed-effect model. The influences of demographics and ECOG grade at study entry were assessed.
Results Mean baseline pain intensity score was 7.3 (standard deviation, 1.76; range, 2-10) across 1,399 BTPc episodes in 152 patients. The interpatient variability of baseline pain intensity scores was 75.96%; intrapatient variability was 20.64%. Fixed terms for demographics and ECOG grade did not significantly influence baseline pain intensity score (≤ 5% level).
Limitations This was a post hoc analysis.
Conclusions Baseline pain intensity scores during episodes of BTPc vary widely between patients, but vary little within individual patients; this supports the use of a consistent maintenance dosage of analgesia for BTPc, once it has been titrated to an effective dose.
Funding/Support The study was funded by Archimedes Development Ltd.
*To read the full article, click on the PDF icon at the top of this introduction.
Implementation of an oncology exercise and wellness rehabilitation program to enhance survivorship: the Beaumont Health System experience
We developed a multidisciplinary approach to oncology rehabilitation by setting up a physical therapy screening program in a dedicated multidisciplinary clinic to improve survivorship care in the community oncology setting. In June 2011, an oncology rehabilitation program was launched as part of the overall survivorship program to provide patients with an introduction to cancer services, consultation with multiple clinicians, education about their diagnoses, and recommendation for rehabilitation services during or after treatment. The consultation was in conjunction with specialists at the multidisciplinary clinics that were already established within the organization.
Click on the PDF icon at the top of this introduction to read the full article.
We developed a multidisciplinary approach to oncology rehabilitation by setting up a physical therapy screening program in a dedicated multidisciplinary clinic to improve survivorship care in the community oncology setting. In June 2011, an oncology rehabilitation program was launched as part of the overall survivorship program to provide patients with an introduction to cancer services, consultation with multiple clinicians, education about their diagnoses, and recommendation for rehabilitation services during or after treatment. The consultation was in conjunction with specialists at the multidisciplinary clinics that were already established within the organization.
Click on the PDF icon at the top of this introduction to read the full article.
We developed a multidisciplinary approach to oncology rehabilitation by setting up a physical therapy screening program in a dedicated multidisciplinary clinic to improve survivorship care in the community oncology setting. In June 2011, an oncology rehabilitation program was launched as part of the overall survivorship program to provide patients with an introduction to cancer services, consultation with multiple clinicians, education about their diagnoses, and recommendation for rehabilitation services during or after treatment. The consultation was in conjunction with specialists at the multidisciplinary clinics that were already established within the organization.
Click on the PDF icon at the top of this introduction to read the full article.
From our pages to your practice
We have some interesting and insightful articles lined up for you this month, beginning with a Commentary by Samuel and Stone on treating HER2-positive breast cancer and asking whether the era of trastuzumab therapy is over. The Commentary and accompanying Community Translations report explore the use of pertuzumab and trastuzumab together, especially in the neoadjuvant setting. The Cleopatra trial has already shown that combining pertuzumab with trastuzumab plus docetaxel as a first-line treatment for HER2-positive metastatic breast cancer significantly prolonged progression-free survival with no increase in cardiac toxic effects, compared with placebo plus trastuzumab plus docetaxel, so perhaps using pertuzumab and trastuzumab upfront might be equally successful.
Click on the PDF icon at the top of this introduction to read the full article.
We have some interesting and insightful articles lined up for you this month, beginning with a Commentary by Samuel and Stone on treating HER2-positive breast cancer and asking whether the era of trastuzumab therapy is over. The Commentary and accompanying Community Translations report explore the use of pertuzumab and trastuzumab together, especially in the neoadjuvant setting. The Cleopatra trial has already shown that combining pertuzumab with trastuzumab plus docetaxel as a first-line treatment for HER2-positive metastatic breast cancer significantly prolonged progression-free survival with no increase in cardiac toxic effects, compared with placebo plus trastuzumab plus docetaxel, so perhaps using pertuzumab and trastuzumab upfront might be equally successful.
Click on the PDF icon at the top of this introduction to read the full article.
We have some interesting and insightful articles lined up for you this month, beginning with a Commentary by Samuel and Stone on treating HER2-positive breast cancer and asking whether the era of trastuzumab therapy is over. The Commentary and accompanying Community Translations report explore the use of pertuzumab and trastuzumab together, especially in the neoadjuvant setting. The Cleopatra trial has already shown that combining pertuzumab with trastuzumab plus docetaxel as a first-line treatment for HER2-positive metastatic breast cancer significantly prolonged progression-free survival with no increase in cardiac toxic effects, compared with placebo plus trastuzumab plus docetaxel, so perhaps using pertuzumab and trastuzumab upfront might be equally successful.
Click on the PDF icon at the top of this introduction to read the full article.
Obesity-hunger paradox prevalent in low-income cancer survivors
ARLINGTON, VA. – Low-income minority women recovering from cancer are also likely to face the paradoxical burden of obesity and hunger, a study has shown.
"It’s counterintuitive, this relationship that exists in this country where you can report having issues around hunger, food insecurity – where you don’t know where your next meal is going to come from, and whether it will be nutritious – and at the same time be obese or overweight," the poster’s presenter, Errol Philip, Ph.D., said in an interview at the annual meeting of the American Society of Preventive Oncology, where he presented the findings.
Add to that the strain of undergoing chemotherapy or other cancer interventions, and one’s quality of life is dramatically affected. Study participants whose body mass index (BMI) was near 30 kg/m2, and who self-reported skipping meals or going an entire day without food because it was not available, also tended to have the lowest scores on the Functional Assessment of Cancer Therapy scale, which measures quality of life in cancer patients, reported Dr. Philip of Memorial Sloan Kettering Cancer Center, New York.
"This obesity-hunger paradox is thought to exist because of the change in our food environment over the past 50 years," he said, noting that images of hunger in days past were of underweight individuals. "Now, those who exist on aid, who have very little access to money, are purchasing cheap calories that are highly processed, malnutritious."
For this prospective, longitudinal assessment, Dr. Philip and his colleagues, including Dr. Francesca Gany, director of the Immigrant Health and Cancer Disparities Service at Memorial Sloan Kettering Cancer Center, analyzed the self-reported food insecurity and quality-of-life scores of 426 minority cancer patients (median age, 56 years), who had either been treated for cancer of any type or were at that time undergoing cancer treatment at one of 5 urban cancer centers. Food insecurity was measured according to the U.S. Department of Agriculture’s Core Food Security Module.
The majority of participants were women (70%), half of all participants were black, and just over a third were Hispanic. The most common diagnoses were breast cancer (44%) and gastrointestinal cancer (16%). More than three-quarters of the respondents reported income below the national poverty level.
The investigators found that two-thirds of all respondents were either overweight or obese (34% and 29% respectively), with nearly three-quarters (71%) reporting food insecurity, ranging from not knowing where the next nutritious meal would be found to not eating for an entire day.
Although the BMI of men in the study did not vary significantly according to whether they experienced food insecurity, the BMI of the women in the group did. Women who reported food insecurity along with moderate hunger had the highest BMI, while those who reported food insecurity and severe hunger had the lowest (27 vs. 26.6). Women who reported their food supply was secure had, on average, a BMI of 27.2.
The women with both food insecurity and obesity had the greatest measure of impaired quality of life. As for why women should be more affected than men, Dr. Philip said several hypotheses exist, including biomechanical ones such as women’s natural propensity to gain more weight than men, and women as caretakers forsaking their own meals in order to nourish others, but that no one knows for certain.
Overall, the implications are "troubling," said Dr. Philip. "In the general population, about 15% will endorse some kind of food insecurity. For individuals living below the poverty line, that number rises to about 40%. Among those individuals who also have cancer, the number rises to 70%."
Because many cancers have been associated with excess weight and low-quality nutrition, Dr. Philip said it was important for primary care providers to be aware that while these patients are vulnerable to begin with, dealing with cancer while also juggling the effects of both obesity and a lack of nutritious food means they are even more strained.
"Primary care providers can’t make the assumption that a patient who is overweight or obese is representative of that person having sufficient food," Dr. Philip said.
Dr. Philip did not report any relevant disclosures. Support for this research was provided by grants from the National Cancer Institute, the New York Community Trust, Susan G. Komen for the Cure (Greater New York City affiliate), and the Laurie M. Tisch Illumination Fund.
This article was updated March 19, 2014.
ARLINGTON, VA. – Low-income minority women recovering from cancer are also likely to face the paradoxical burden of obesity and hunger, a study has shown.
"It’s counterintuitive, this relationship that exists in this country where you can report having issues around hunger, food insecurity – where you don’t know where your next meal is going to come from, and whether it will be nutritious – and at the same time be obese or overweight," the poster’s presenter, Errol Philip, Ph.D., said in an interview at the annual meeting of the American Society of Preventive Oncology, where he presented the findings.
Add to that the strain of undergoing chemotherapy or other cancer interventions, and one’s quality of life is dramatically affected. Study participants whose body mass index (BMI) was near 30 kg/m2, and who self-reported skipping meals or going an entire day without food because it was not available, also tended to have the lowest scores on the Functional Assessment of Cancer Therapy scale, which measures quality of life in cancer patients, reported Dr. Philip of Memorial Sloan Kettering Cancer Center, New York.
"This obesity-hunger paradox is thought to exist because of the change in our food environment over the past 50 years," he said, noting that images of hunger in days past were of underweight individuals. "Now, those who exist on aid, who have very little access to money, are purchasing cheap calories that are highly processed, malnutritious."
For this prospective, longitudinal assessment, Dr. Philip and his colleagues, including Dr. Francesca Gany, director of the Immigrant Health and Cancer Disparities Service at Memorial Sloan Kettering Cancer Center, analyzed the self-reported food insecurity and quality-of-life scores of 426 minority cancer patients (median age, 56 years), who had either been treated for cancer of any type or were at that time undergoing cancer treatment at one of 5 urban cancer centers. Food insecurity was measured according to the U.S. Department of Agriculture’s Core Food Security Module.
The majority of participants were women (70%), half of all participants were black, and just over a third were Hispanic. The most common diagnoses were breast cancer (44%) and gastrointestinal cancer (16%). More than three-quarters of the respondents reported income below the national poverty level.
The investigators found that two-thirds of all respondents were either overweight or obese (34% and 29% respectively), with nearly three-quarters (71%) reporting food insecurity, ranging from not knowing where the next nutritious meal would be found to not eating for an entire day.
Although the BMI of men in the study did not vary significantly according to whether they experienced food insecurity, the BMI of the women in the group did. Women who reported food insecurity along with moderate hunger had the highest BMI, while those who reported food insecurity and severe hunger had the lowest (27 vs. 26.6). Women who reported their food supply was secure had, on average, a BMI of 27.2.
The women with both food insecurity and obesity had the greatest measure of impaired quality of life. As for why women should be more affected than men, Dr. Philip said several hypotheses exist, including biomechanical ones such as women’s natural propensity to gain more weight than men, and women as caretakers forsaking their own meals in order to nourish others, but that no one knows for certain.
Overall, the implications are "troubling," said Dr. Philip. "In the general population, about 15% will endorse some kind of food insecurity. For individuals living below the poverty line, that number rises to about 40%. Among those individuals who also have cancer, the number rises to 70%."
Because many cancers have been associated with excess weight and low-quality nutrition, Dr. Philip said it was important for primary care providers to be aware that while these patients are vulnerable to begin with, dealing with cancer while also juggling the effects of both obesity and a lack of nutritious food means they are even more strained.
"Primary care providers can’t make the assumption that a patient who is overweight or obese is representative of that person having sufficient food," Dr. Philip said.
Dr. Philip did not report any relevant disclosures. Support for this research was provided by grants from the National Cancer Institute, the New York Community Trust, Susan G. Komen for the Cure (Greater New York City affiliate), and the Laurie M. Tisch Illumination Fund.
This article was updated March 19, 2014.
ARLINGTON, VA. – Low-income minority women recovering from cancer are also likely to face the paradoxical burden of obesity and hunger, a study has shown.
"It’s counterintuitive, this relationship that exists in this country where you can report having issues around hunger, food insecurity – where you don’t know where your next meal is going to come from, and whether it will be nutritious – and at the same time be obese or overweight," the poster’s presenter, Errol Philip, Ph.D., said in an interview at the annual meeting of the American Society of Preventive Oncology, where he presented the findings.
Add to that the strain of undergoing chemotherapy or other cancer interventions, and one’s quality of life is dramatically affected. Study participants whose body mass index (BMI) was near 30 kg/m2, and who self-reported skipping meals or going an entire day without food because it was not available, also tended to have the lowest scores on the Functional Assessment of Cancer Therapy scale, which measures quality of life in cancer patients, reported Dr. Philip of Memorial Sloan Kettering Cancer Center, New York.
"This obesity-hunger paradox is thought to exist because of the change in our food environment over the past 50 years," he said, noting that images of hunger in days past were of underweight individuals. "Now, those who exist on aid, who have very little access to money, are purchasing cheap calories that are highly processed, malnutritious."
For this prospective, longitudinal assessment, Dr. Philip and his colleagues, including Dr. Francesca Gany, director of the Immigrant Health and Cancer Disparities Service at Memorial Sloan Kettering Cancer Center, analyzed the self-reported food insecurity and quality-of-life scores of 426 minority cancer patients (median age, 56 years), who had either been treated for cancer of any type or were at that time undergoing cancer treatment at one of 5 urban cancer centers. Food insecurity was measured according to the U.S. Department of Agriculture’s Core Food Security Module.
The majority of participants were women (70%), half of all participants were black, and just over a third were Hispanic. The most common diagnoses were breast cancer (44%) and gastrointestinal cancer (16%). More than three-quarters of the respondents reported income below the national poverty level.
The investigators found that two-thirds of all respondents were either overweight or obese (34% and 29% respectively), with nearly three-quarters (71%) reporting food insecurity, ranging from not knowing where the next nutritious meal would be found to not eating for an entire day.
Although the BMI of men in the study did not vary significantly according to whether they experienced food insecurity, the BMI of the women in the group did. Women who reported food insecurity along with moderate hunger had the highest BMI, while those who reported food insecurity and severe hunger had the lowest (27 vs. 26.6). Women who reported their food supply was secure had, on average, a BMI of 27.2.
The women with both food insecurity and obesity had the greatest measure of impaired quality of life. As for why women should be more affected than men, Dr. Philip said several hypotheses exist, including biomechanical ones such as women’s natural propensity to gain more weight than men, and women as caretakers forsaking their own meals in order to nourish others, but that no one knows for certain.
Overall, the implications are "troubling," said Dr. Philip. "In the general population, about 15% will endorse some kind of food insecurity. For individuals living below the poverty line, that number rises to about 40%. Among those individuals who also have cancer, the number rises to 70%."
Because many cancers have been associated with excess weight and low-quality nutrition, Dr. Philip said it was important for primary care providers to be aware that while these patients are vulnerable to begin with, dealing with cancer while also juggling the effects of both obesity and a lack of nutritious food means they are even more strained.
"Primary care providers can’t make the assumption that a patient who is overweight or obese is representative of that person having sufficient food," Dr. Philip said.
Dr. Philip did not report any relevant disclosures. Support for this research was provided by grants from the National Cancer Institute, the New York Community Trust, Susan G. Komen for the Cure (Greater New York City affiliate), and the Laurie M. Tisch Illumination Fund.
This article was updated March 19, 2014.
AT THE ASPO ANNUAL MEETING
Major finding: Three-quarters of low-income, minority women cancer survivors who were either overweight or obese reported food insecurity.
Data source: Prospective, longitudinal study of 426 cancer patients (median age, 56 years) treated for any type of cancer in 1 of 12 urban cancer centers.
Disclosures: Dr. Philip did not report any relevant disclosures. Support for this research was provided by grants from the National Cancer Institute, the New York Community Trust, Susan G. Komen for the Cure (Greater New York City affiliate), and the Laurie M. Tisch Illumination Fund.
Patients on palliative chemo more likely to undergo intensive care
Cancer patients who received palliative chemotherapy at the end of life were significantly more likely to undergo intensive medical care and to die in an ICU, according to researchers.
These patients were also significantly more likely to be referred late to hospice care compared with terminal patients who did not receive palliative chemotherapy, said Dr. Holly Prigerson of Weill Cornell Medical College, New York, and her associates.
The prospective, multicenter cohort study enrolled 386 adults with metastatic cancers refractory to at least one chemotherapy regimen. Patients were terminally ill at enrollment. In all, 216 (56%) were receiving palliative chemotherapy when they enrolled a median of 4 months before death.
Fourteen percent of patients receiving palliative chemotherapy underwent mechanical ventilation, cardiopulmonary resuscitation, or both in the week before death, compared with 2% of patients not receiving palliative chemotherapy. The adjusted difference in risk was 10.5%. Since events were rare, adjusted risk differences were calculated and reported instead of odds ratios, as odds ratios might have exaggerated actual risk, the investigators noted.
Patients receiving palliative chemotherapy were less likely to acknowledge that their illness was terminal (35% vs. 49%, P = .04) and to report having discussed their end-of-life wishes with a physician (37% vs. 48%, P = .03. They were also less likely to have completed a do-not-resuscitate order compared with patients not receiving palliative chemotherapy (36% vs. 49%, P less than .05), the investigators reported (BMJ 2014 [doi: 10.1136/bmj.g1219]).
There was no significant difference in overall survival between patients who received palliative chemotherapy and those who did not (hazard ratio 1.11), the investigators said.
The findings show that "end of life discussions may be particularly important for patients receiving palliative chemotherapy, who should be informed by data on the likely outcomes associated with its use," the researchers said.
The study was nonrandomized, and therefore patients who received palliative chemotherapy could have differed in terms of unmeasured factors such as disease duration, the investigators noted. They recommended larger studies to confirm their findings.
The authors received research support from the National Institute of Mental Health, the National Cancer Institute, the American Cancer Society, and the Conquer Cancer Foundation. No authors reported conflicts of interest.
This study has provided evidence of the risk of strategic failure for those receiving disease-directed treatment for advanced cancer. In my practice as a surgeon wearing my other hat as a palliative medicine consultant in a critical care unit, I frequently see the "red flag" of ongoing cytotoxic chemotherapy for patients with advanced cancer now admitted for critical illness. Rarely, in my experience, has an ICU admission contributed much in the way of future quality of life or survival. Even more rarely has there been a previous detailed discussion with health care providers about the rainy day scenario of how to manage a grave complication of treatment or an illness. In the name of hope we often avoid the inevitable with tedious negotiations about tactical distractions - more consultants, more scans, more procedures. Adding to the confusion is the gulf separating critical care from oncology. Their respective worldviews are strikingly different.
The study also raises two other questions: What do we mean when we say "terminal"? Do we really understand the difference between palliative treatment and noncurative treatment? The current consensus definition of "palliative" emphasizes quality of life as the primary goal of care and sees life prolongation as a secondary benefit. Dr. Thomas Miner, an oncologic surgeon, framed it well: "Palliative treatment is not the opposite of cure; it has its own distinct indications and goals and should be evaluated independently" (Ann. Surg. Oncol. 2002;9:696-703). To prevent the tragic outcome for oncology patients of "ICU to nowhere," patients, families, and practitioners should consider taking the time and resources such as a palliative care team to have the strategic discussion much earlier in the course of oncologic illness.
Geoffrey P. Dunn, M.D., an ACS Fellow based in Erie, Pa., is chair of the American College of Surgeons Surgical Palliative Care Task Force.
This study has provided evidence of the risk of strategic failure for those receiving disease-directed treatment for advanced cancer. In my practice as a surgeon wearing my other hat as a palliative medicine consultant in a critical care unit, I frequently see the "red flag" of ongoing cytotoxic chemotherapy for patients with advanced cancer now admitted for critical illness. Rarely, in my experience, has an ICU admission contributed much in the way of future quality of life or survival. Even more rarely has there been a previous detailed discussion with health care providers about the rainy day scenario of how to manage a grave complication of treatment or an illness. In the name of hope we often avoid the inevitable with tedious negotiations about tactical distractions - more consultants, more scans, more procedures. Adding to the confusion is the gulf separating critical care from oncology. Their respective worldviews are strikingly different.
The study also raises two other questions: What do we mean when we say "terminal"? Do we really understand the difference between palliative treatment and noncurative treatment? The current consensus definition of "palliative" emphasizes quality of life as the primary goal of care and sees life prolongation as a secondary benefit. Dr. Thomas Miner, an oncologic surgeon, framed it well: "Palliative treatment is not the opposite of cure; it has its own distinct indications and goals and should be evaluated independently" (Ann. Surg. Oncol. 2002;9:696-703). To prevent the tragic outcome for oncology patients of "ICU to nowhere," patients, families, and practitioners should consider taking the time and resources such as a palliative care team to have the strategic discussion much earlier in the course of oncologic illness.
Geoffrey P. Dunn, M.D., an ACS Fellow based in Erie, Pa., is chair of the American College of Surgeons Surgical Palliative Care Task Force.
This study has provided evidence of the risk of strategic failure for those receiving disease-directed treatment for advanced cancer. In my practice as a surgeon wearing my other hat as a palliative medicine consultant in a critical care unit, I frequently see the "red flag" of ongoing cytotoxic chemotherapy for patients with advanced cancer now admitted for critical illness. Rarely, in my experience, has an ICU admission contributed much in the way of future quality of life or survival. Even more rarely has there been a previous detailed discussion with health care providers about the rainy day scenario of how to manage a grave complication of treatment or an illness. In the name of hope we often avoid the inevitable with tedious negotiations about tactical distractions - more consultants, more scans, more procedures. Adding to the confusion is the gulf separating critical care from oncology. Their respective worldviews are strikingly different.
The study also raises two other questions: What do we mean when we say "terminal"? Do we really understand the difference between palliative treatment and noncurative treatment? The current consensus definition of "palliative" emphasizes quality of life as the primary goal of care and sees life prolongation as a secondary benefit. Dr. Thomas Miner, an oncologic surgeon, framed it well: "Palliative treatment is not the opposite of cure; it has its own distinct indications and goals and should be evaluated independently" (Ann. Surg. Oncol. 2002;9:696-703). To prevent the tragic outcome for oncology patients of "ICU to nowhere," patients, families, and practitioners should consider taking the time and resources such as a palliative care team to have the strategic discussion much earlier in the course of oncologic illness.
Geoffrey P. Dunn, M.D., an ACS Fellow based in Erie, Pa., is chair of the American College of Surgeons Surgical Palliative Care Task Force.
Cancer patients who received palliative chemotherapy at the end of life were significantly more likely to undergo intensive medical care and to die in an ICU, according to researchers.
These patients were also significantly more likely to be referred late to hospice care compared with terminal patients who did not receive palliative chemotherapy, said Dr. Holly Prigerson of Weill Cornell Medical College, New York, and her associates.
The prospective, multicenter cohort study enrolled 386 adults with metastatic cancers refractory to at least one chemotherapy regimen. Patients were terminally ill at enrollment. In all, 216 (56%) were receiving palliative chemotherapy when they enrolled a median of 4 months before death.
Fourteen percent of patients receiving palliative chemotherapy underwent mechanical ventilation, cardiopulmonary resuscitation, or both in the week before death, compared with 2% of patients not receiving palliative chemotherapy. The adjusted difference in risk was 10.5%. Since events were rare, adjusted risk differences were calculated and reported instead of odds ratios, as odds ratios might have exaggerated actual risk, the investigators noted.
Patients receiving palliative chemotherapy were less likely to acknowledge that their illness was terminal (35% vs. 49%, P = .04) and to report having discussed their end-of-life wishes with a physician (37% vs. 48%, P = .03. They were also less likely to have completed a do-not-resuscitate order compared with patients not receiving palliative chemotherapy (36% vs. 49%, P less than .05), the investigators reported (BMJ 2014 [doi: 10.1136/bmj.g1219]).
There was no significant difference in overall survival between patients who received palliative chemotherapy and those who did not (hazard ratio 1.11), the investigators said.
The findings show that "end of life discussions may be particularly important for patients receiving palliative chemotherapy, who should be informed by data on the likely outcomes associated with its use," the researchers said.
The study was nonrandomized, and therefore patients who received palliative chemotherapy could have differed in terms of unmeasured factors such as disease duration, the investigators noted. They recommended larger studies to confirm their findings.
The authors received research support from the National Institute of Mental Health, the National Cancer Institute, the American Cancer Society, and the Conquer Cancer Foundation. No authors reported conflicts of interest.
Cancer patients who received palliative chemotherapy at the end of life were significantly more likely to undergo intensive medical care and to die in an ICU, according to researchers.
These patients were also significantly more likely to be referred late to hospice care compared with terminal patients who did not receive palliative chemotherapy, said Dr. Holly Prigerson of Weill Cornell Medical College, New York, and her associates.
The prospective, multicenter cohort study enrolled 386 adults with metastatic cancers refractory to at least one chemotherapy regimen. Patients were terminally ill at enrollment. In all, 216 (56%) were receiving palliative chemotherapy when they enrolled a median of 4 months before death.
Fourteen percent of patients receiving palliative chemotherapy underwent mechanical ventilation, cardiopulmonary resuscitation, or both in the week before death, compared with 2% of patients not receiving palliative chemotherapy. The adjusted difference in risk was 10.5%. Since events were rare, adjusted risk differences were calculated and reported instead of odds ratios, as odds ratios might have exaggerated actual risk, the investigators noted.
Patients receiving palliative chemotherapy were less likely to acknowledge that their illness was terminal (35% vs. 49%, P = .04) and to report having discussed their end-of-life wishes with a physician (37% vs. 48%, P = .03. They were also less likely to have completed a do-not-resuscitate order compared with patients not receiving palliative chemotherapy (36% vs. 49%, P less than .05), the investigators reported (BMJ 2014 [doi: 10.1136/bmj.g1219]).
There was no significant difference in overall survival between patients who received palliative chemotherapy and those who did not (hazard ratio 1.11), the investigators said.
The findings show that "end of life discussions may be particularly important for patients receiving palliative chemotherapy, who should be informed by data on the likely outcomes associated with its use," the researchers said.
The study was nonrandomized, and therefore patients who received palliative chemotherapy could have differed in terms of unmeasured factors such as disease duration, the investigators noted. They recommended larger studies to confirm their findings.
The authors received research support from the National Institute of Mental Health, the National Cancer Institute, the American Cancer Society, and the Conquer Cancer Foundation. No authors reported conflicts of interest.
FROM BMJ
Major Finding: Patients receiving palliative chemotherapy were more likely to undergo mechanical ventilation, cardiopulmonary resuscitation, or both in the week before death, compared with patients not receiving palliative chemotherapy (14% vs. 2%) and were less likely to die at home (47% vs. 66%).
Data Source: Prospective, multicenter cohort study of 386 adults who had metastatic cancers refractory to at least one chemotherapy regimen, and who were considered terminally ill at enrollment.
Disclosures: The authors received research support from the National Institute of Mental Health, the National Cancer Institute, the American Cancer Society, and the Conquer Cancer Foundation. No authors reported conflicts of interest.
Targeted cancer therapies pose unique perioperative challenges
SCOTTSDALE, ARIZ. – Patients on targeted cancer therapies require special handling in the perioperative period, according to oncologist Sunil K. Sahai.
In addition to the known cardiotoxic side effects of DNA-damaging chemotherapy drugs such as anthracyclines and alkylating agents, newer drugs directed toward specific molecular targets on cancerous tumors have their own side effects that can complicate surgery or recovery, said Dr. Sahai of the University of Texas M.D. Anderson Cancer Center in Houston.
It can be a challenge even for oncologists to stay current with new cancer therapies and their side effect profiles, Dr. Sahai said at a meeting on perioperative medicine sponsored by the University of Miami.
"When M.D. Anderson was founded in the 1940s as the Texas Tumor Institute, there were three chemotherapy drugs on the market. Last year our formulary had 150 different chemotherapy drugs, " he said.
There are four major classes of targeted agents, each with its own associated adverse effects:
• Selective estrogen receptor modulators, such as tamoxifen and toremifene.
• Aromatase inhibitors – letrozole, anastrozole, and exemestane.
• Monoclonal antibodies – cetuximab, bevacizumab, trastuzumab, and others.
• Tyrosine kinase inhibitors (TKIs) – imatinib, dasatinib, sunitinib, and others.
Dr. Sahai presented case examples to illustrate the challenges of perioperative management of patients on targeted therapies. When a 67-year-old morbidly obese woman taking tamoxifen for the prevention of breast cancer presents with acute cholecystitis requiring urgent laparoscopic surgery, for example, Dr. Sahai said he would recommend 30 days of postoperative low-molecular-weight heparin injections to prevent venous thromboembolic events (VTEs).
"Patients who are on tamoxifen have a [baseline] relative risk of a VTE of between 3 and 7," he noted.
The combination of tamoxifen, obesity, and a history of breast cancer in a patient undergoing abdominal surgery suggests a high risk for VTE and a need for prophylaxis, he said.
He said he would not, however, recommend stopping tamoxifen without a documented discussion between the oncologist and the patient.
"Most oncologists are okay with stopping tamoxifen for 5-7 days during a procedure, but most of them are not willing to go for more than 14 days of stopping it," he said.
There are no data to support the practice; rather, it’s a matter of personal preference, he added.
Cardiotoxic agents
The cardiotoxic effects of older chemotherapy agents such as the anthracycline doxorubicin are well known, but newer agents, such as the monoclonal antibody trastuzumab (Herceptin) also have documented cardiotoxicities, although their long-term effects will not be known until the drugs have been on the market longer, Dr. Sahai pointed out.
Thus, a patient with colorectal cancer treated with an anthracycline is at increased risk for cardiomyopathy and heart failure, and if he receives a monoclonal antibody, he is at increased risk for ischemic cardiomyopathy. The combination of an anthracycline and trastuzumab (also used to treat gastric cancers) can increase the risk for heart failure by up to 28%, Dr. Sahai noted.
He also advised his colleagues to monitor patients receiving TKIs (most frequently prescribed for hematologic malignancies) for cardiac rhythm disturbances and drug interactions.
TKIs can prolong the QTc interval, predisposing patients to torsades de pointes, a form of ventricular tachycardia that can cause sudden death.
In addition, TKIs can cause pleural effusions, and are associated with difficult-to-control hypertension, Dr. Sahai said.
Decisions, decisions
If patients treated for cancer present for evaluation before noncardiac surgery with symptoms of cardiovascular disease such as chest pain, shortness of breath, or dyspnea on exertion, the clinician should first determine whether the symptoms appeared before, during, or after cancer therapy.
If the symptoms appeared before treatment, the patients should be evaluated for cardiovascular disease according to 2007 American College of Cardiology/American Heart Association perioperative evaluation guidelines, Dr. Sahai said.
If the cancer therapy included radiation or chemotherapy known to have cardiovascular side effects, patients should be tested for conditions that are most likely associated with their treatment history, whether myocardial ischemia, cardiomyopathies, arrhythmias, valvular disease, or a combination, he advised.
Dr. Sahai reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – Patients on targeted cancer therapies require special handling in the perioperative period, according to oncologist Sunil K. Sahai.
In addition to the known cardiotoxic side effects of DNA-damaging chemotherapy drugs such as anthracyclines and alkylating agents, newer drugs directed toward specific molecular targets on cancerous tumors have their own side effects that can complicate surgery or recovery, said Dr. Sahai of the University of Texas M.D. Anderson Cancer Center in Houston.
It can be a challenge even for oncologists to stay current with new cancer therapies and their side effect profiles, Dr. Sahai said at a meeting on perioperative medicine sponsored by the University of Miami.
"When M.D. Anderson was founded in the 1940s as the Texas Tumor Institute, there were three chemotherapy drugs on the market. Last year our formulary had 150 different chemotherapy drugs, " he said.
There are four major classes of targeted agents, each with its own associated adverse effects:
• Selective estrogen receptor modulators, such as tamoxifen and toremifene.
• Aromatase inhibitors – letrozole, anastrozole, and exemestane.
• Monoclonal antibodies – cetuximab, bevacizumab, trastuzumab, and others.
• Tyrosine kinase inhibitors (TKIs) – imatinib, dasatinib, sunitinib, and others.
Dr. Sahai presented case examples to illustrate the challenges of perioperative management of patients on targeted therapies. When a 67-year-old morbidly obese woman taking tamoxifen for the prevention of breast cancer presents with acute cholecystitis requiring urgent laparoscopic surgery, for example, Dr. Sahai said he would recommend 30 days of postoperative low-molecular-weight heparin injections to prevent venous thromboembolic events (VTEs).
"Patients who are on tamoxifen have a [baseline] relative risk of a VTE of between 3 and 7," he noted.
The combination of tamoxifen, obesity, and a history of breast cancer in a patient undergoing abdominal surgery suggests a high risk for VTE and a need for prophylaxis, he said.
He said he would not, however, recommend stopping tamoxifen without a documented discussion between the oncologist and the patient.
"Most oncologists are okay with stopping tamoxifen for 5-7 days during a procedure, but most of them are not willing to go for more than 14 days of stopping it," he said.
There are no data to support the practice; rather, it’s a matter of personal preference, he added.
Cardiotoxic agents
The cardiotoxic effects of older chemotherapy agents such as the anthracycline doxorubicin are well known, but newer agents, such as the monoclonal antibody trastuzumab (Herceptin) also have documented cardiotoxicities, although their long-term effects will not be known until the drugs have been on the market longer, Dr. Sahai pointed out.
Thus, a patient with colorectal cancer treated with an anthracycline is at increased risk for cardiomyopathy and heart failure, and if he receives a monoclonal antibody, he is at increased risk for ischemic cardiomyopathy. The combination of an anthracycline and trastuzumab (also used to treat gastric cancers) can increase the risk for heart failure by up to 28%, Dr. Sahai noted.
He also advised his colleagues to monitor patients receiving TKIs (most frequently prescribed for hematologic malignancies) for cardiac rhythm disturbances and drug interactions.
TKIs can prolong the QTc interval, predisposing patients to torsades de pointes, a form of ventricular tachycardia that can cause sudden death.
In addition, TKIs can cause pleural effusions, and are associated with difficult-to-control hypertension, Dr. Sahai said.
Decisions, decisions
If patients treated for cancer present for evaluation before noncardiac surgery with symptoms of cardiovascular disease such as chest pain, shortness of breath, or dyspnea on exertion, the clinician should first determine whether the symptoms appeared before, during, or after cancer therapy.
If the symptoms appeared before treatment, the patients should be evaluated for cardiovascular disease according to 2007 American College of Cardiology/American Heart Association perioperative evaluation guidelines, Dr. Sahai said.
If the cancer therapy included radiation or chemotherapy known to have cardiovascular side effects, patients should be tested for conditions that are most likely associated with their treatment history, whether myocardial ischemia, cardiomyopathies, arrhythmias, valvular disease, or a combination, he advised.
Dr. Sahai reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – Patients on targeted cancer therapies require special handling in the perioperative period, according to oncologist Sunil K. Sahai.
In addition to the known cardiotoxic side effects of DNA-damaging chemotherapy drugs such as anthracyclines and alkylating agents, newer drugs directed toward specific molecular targets on cancerous tumors have their own side effects that can complicate surgery or recovery, said Dr. Sahai of the University of Texas M.D. Anderson Cancer Center in Houston.
It can be a challenge even for oncologists to stay current with new cancer therapies and their side effect profiles, Dr. Sahai said at a meeting on perioperative medicine sponsored by the University of Miami.
"When M.D. Anderson was founded in the 1940s as the Texas Tumor Institute, there were three chemotherapy drugs on the market. Last year our formulary had 150 different chemotherapy drugs, " he said.
There are four major classes of targeted agents, each with its own associated adverse effects:
• Selective estrogen receptor modulators, such as tamoxifen and toremifene.
• Aromatase inhibitors – letrozole, anastrozole, and exemestane.
• Monoclonal antibodies – cetuximab, bevacizumab, trastuzumab, and others.
• Tyrosine kinase inhibitors (TKIs) – imatinib, dasatinib, sunitinib, and others.
Dr. Sahai presented case examples to illustrate the challenges of perioperative management of patients on targeted therapies. When a 67-year-old morbidly obese woman taking tamoxifen for the prevention of breast cancer presents with acute cholecystitis requiring urgent laparoscopic surgery, for example, Dr. Sahai said he would recommend 30 days of postoperative low-molecular-weight heparin injections to prevent venous thromboembolic events (VTEs).
"Patients who are on tamoxifen have a [baseline] relative risk of a VTE of between 3 and 7," he noted.
The combination of tamoxifen, obesity, and a history of breast cancer in a patient undergoing abdominal surgery suggests a high risk for VTE and a need for prophylaxis, he said.
He said he would not, however, recommend stopping tamoxifen without a documented discussion between the oncologist and the patient.
"Most oncologists are okay with stopping tamoxifen for 5-7 days during a procedure, but most of them are not willing to go for more than 14 days of stopping it," he said.
There are no data to support the practice; rather, it’s a matter of personal preference, he added.
Cardiotoxic agents
The cardiotoxic effects of older chemotherapy agents such as the anthracycline doxorubicin are well known, but newer agents, such as the monoclonal antibody trastuzumab (Herceptin) also have documented cardiotoxicities, although their long-term effects will not be known until the drugs have been on the market longer, Dr. Sahai pointed out.
Thus, a patient with colorectal cancer treated with an anthracycline is at increased risk for cardiomyopathy and heart failure, and if he receives a monoclonal antibody, he is at increased risk for ischemic cardiomyopathy. The combination of an anthracycline and trastuzumab (also used to treat gastric cancers) can increase the risk for heart failure by up to 28%, Dr. Sahai noted.
He also advised his colleagues to monitor patients receiving TKIs (most frequently prescribed for hematologic malignancies) for cardiac rhythm disturbances and drug interactions.
TKIs can prolong the QTc interval, predisposing patients to torsades de pointes, a form of ventricular tachycardia that can cause sudden death.
In addition, TKIs can cause pleural effusions, and are associated with difficult-to-control hypertension, Dr. Sahai said.
Decisions, decisions
If patients treated for cancer present for evaluation before noncardiac surgery with symptoms of cardiovascular disease such as chest pain, shortness of breath, or dyspnea on exertion, the clinician should first determine whether the symptoms appeared before, during, or after cancer therapy.
If the symptoms appeared before treatment, the patients should be evaluated for cardiovascular disease according to 2007 American College of Cardiology/American Heart Association perioperative evaluation guidelines, Dr. Sahai said.
If the cancer therapy included radiation or chemotherapy known to have cardiovascular side effects, patients should be tested for conditions that are most likely associated with their treatment history, whether myocardial ischemia, cardiomyopathies, arrhythmias, valvular disease, or a combination, he advised.
Dr. Sahai reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM THE PERIOPERATIVE MEDICINE SUMMIT