The antipsychotic olanzapine trounced standard therapy for breakthrough chemotherapy-induced nausea and vomiting in a clinical trial that could change the way some cancer patients are treated.

In the double-blind phase III study, 30 (71%) of 42 patients, who received olanzapine (Zyprexa) had no emesis, compared with 12 (32%) of 38 patients who received metoclopramide (P less than .01) during a 72-hour observation period after highly emetic chemotherapy.

In addition, 28 (67%) patients on olanzapine had no nausea, compared with 9 (24%) of those patients on metoclopramide (P less than .01), said Dr. Rudolph M. Navari, who presented the study during a press briefing in advance of the annual meeting of American Society of Clinical Oncology, June 1-5, in Chicago. Dr. Navari is the director of the Harper Cancer Institute at Indiana University in South Bend.

ASCO president-elect Dr. Sandra M. Swain, medical director of the Cancer Institute at Washington Hospital Center, called the findings "a great step forward for quality of life for our patients.

"This is a huge advance," said Dr. Swain, a breast cancer expert, who comoderated the teleconference. "We’ve come a long way to really treat and cure these patients ... these side effects can be intolerable to patients. Sometimes patients will opt out of curative treatment, and we certainly don’t want that, when we know we’ve made advances."

The researchers included chemotherapy-naive patients who received highly emetogenic chemotherapy: more than 70 mg/m² cisplatin, or more than 50 mg/m² doxorubicin and more than 600 mg/m² cyclophosphamide.

Patients who developed breakthrough emesis or nausea despite guideline-directed prophylaxis were randomized to receive olanzapine or metoclopramide. Pre-chemotherapy prophylaxis included intravenous dexamethasone (12 mg), intravenous palonosetron (0.25 mg), and intravenous fosaprepitant (150 mg); post-chemotherapy prophylaxis was daily oral dexamethasone (8 mg, days 2-4).

Patients received 10 mg oral olanzapine for 3 days or 10 mg oral metoclopramide three times daily for 3 days. Patients were monitored for emesis and nausea for the 72 hours after the initiation of therapy. In addition, nausea was measured by patients on a visual analog scale (0-10), with 0 being no nausea and 10 being maximal nausea.

Patients in the two groups were similar for age, sex, Eastern Cooperative Oncology Group (ECOG) performance status, and diagnosis (5 bladder cancers, 40 breast cancers, 8 lymphomas, and 27 lung cancers).

"Both olanzapine and metoclopramide were well tolerated with no grade 3 or 4 toxicities," said Dr. Navari. No central nervous system toxicities were observed in either group.

Olanzapine is indicated for treatment of psychosis and is associated with weight gain, but the side effect should not be a problem for cancer patients.

"The side effect of weight gain occurs in patients, who receive the drug for 3 to 6 to 9 months," Dr. Ravari noted. "So using it for a short period of 3-4 days once a month – we did not see that in the current study, nor did we see that in previous studies."

Dr. Navari had previously reported that patients receiving highly emetogenic chemotherapy were about twice as likely not to experience any delayed nausea with an olanzapine regimen compared with a standard aprepitant (Emend) regimen (68% vs. 37%) in a phase III clinical trial. The two regimens worked similarly well for preventing acute nausea and for preventing both acute and delayed vomiting, that study found (Support. Oncol. 2011;9:188-95).

ASCO presented a preview of some meeting highlights with many of the abstracts being posted online as of 6 p.m. EST at www.asco.org.

The authors reported that they have nothing to disclose.

The antipsychotic olanzapine trounced standard therapy for breakthrough chemotherapy-induced nausea and vomiting in a clinical trial that could change the way some cancer patients are treated.

In the double-blind phase III study, 30 (71%) of 42 patients, who received olanzapine (Zyprexa) had no emesis, compared with 12 (32%) of 38 patients who received metoclopramide (P less than .01) during a 72-hour observation period after highly emetic chemotherapy.

In addition, 28 (67%) patients on olanzapine had no nausea, compared with 9 (24%) of those patients on metoclopramide (P less than .01), said Dr. Rudolph M. Navari, who presented the study during a press briefing in advance of the annual meeting of American Society of Clinical Oncology, June 1-5, in Chicago. Dr. Navari is the director of the Harper Cancer Institute at Indiana University in South Bend.

ASCO president-elect Dr. Sandra M. Swain, medical director of the Cancer Institute at Washington Hospital Center, called the findings "a great step forward for quality of life for our patients.

"This is a huge advance," said Dr. Swain, a breast cancer expert, who comoderated the teleconference. "We’ve come a long way to really treat and cure these patients ... these side effects can be intolerable to patients. Sometimes patients will opt out of curative treatment, and we certainly don’t want that, when we know we’ve made advances."

The researchers included chemotherapy-naive patients who received highly emetogenic chemotherapy: more than 70 mg/m² cisplatin, or more than 50 mg/m² doxorubicin and more than 600 mg/m² cyclophosphamide.

Patients who developed breakthrough emesis or nausea despite guideline-directed prophylaxis were randomized to receive olanzapine or metoclopramide. Pre-chemotherapy prophylaxis included intravenous dexamethasone (12 mg), intravenous palonosetron (0.25 mg), and intravenous fosaprepitant (150 mg); post-chemotherapy prophylaxis was daily oral dexamethasone (8 mg, days 2-4).

Patients received 10 mg oral olanzapine for 3 days or 10 mg oral metoclopramide three times daily for 3 days. Patients were monitored for emesis and nausea for the 72 hours after the initiation of therapy. In addition, nausea was measured by patients on a visual analog scale (0-10), with 0 being no nausea and 10 being maximal nausea.

Patients in the two groups were similar for age, sex, Eastern Cooperative Oncology Group (ECOG) performance status, and diagnosis (5 bladder cancers, 40 breast cancers, 8 lymphomas, and 27 lung cancers).

"Both olanzapine and metoclopramide were well tolerated with no grade 3 or 4 toxicities," said Dr. Navari. No central nervous system toxicities were observed in either group.

Olanzapine is indicated for treatment of psychosis and is associated with weight gain, but the side effect should not be a problem for cancer patients.

"The side effect of weight gain occurs in patients, who receive the drug for 3 to 6 to 9 months," Dr. Ravari noted. "So using it for a short period of 3-4 days once a month – we did not see that in the current study, nor did we see that in previous studies."

Dr. Navari had previously reported that patients receiving highly emetogenic chemotherapy were about twice as likely not to experience any delayed nausea with an olanzapine regimen compared with a standard aprepitant (Emend) regimen (68% vs. 37%) in a phase III clinical trial. The two regimens worked similarly well for preventing acute nausea and for preventing both acute and delayed vomiting, that study found (Support. Oncol. 2011;9:188-95).

ASCO presented a preview of some meeting highlights with many of the abstracts being posted online as of 6 p.m. EST at www.asco.org.

The authors reported that they have nothing to disclose.

The antipsychotic olanzapine trounced standard therapy for breakthrough chemotherapy-induced nausea and vomiting in a clinical trial that could change the way some cancer patients are treated.

In the double-blind phase III study, 30 (71%) of 42 patients, who received olanzapine (Zyprexa) had no emesis, compared with 12 (32%) of 38 patients who received metoclopramide (P less than .01) during a 72-hour observation period after highly emetic chemotherapy.

In addition, 28 (67%) patients on olanzapine had no nausea, compared with 9 (24%) of those patients on metoclopramide (P less than .01), said Dr. Rudolph M. Navari, who presented the study during a press briefing in advance of the annual meeting of American Society of Clinical Oncology, June 1-5, in Chicago. Dr. Navari is the director of the Harper Cancer Institute at Indiana University in South Bend.

ASCO president-elect Dr. Sandra M. Swain, medical director of the Cancer Institute at Washington Hospital Center, called the findings "a great step forward for quality of life for our patients.

"This is a huge advance," said Dr. Swain, a breast cancer expert, who comoderated the teleconference. "We’ve come a long way to really treat and cure these patients ... these side effects can be intolerable to patients. Sometimes patients will opt out of curative treatment, and we certainly don’t want that, when we know we’ve made advances."

The researchers included chemotherapy-naive patients who received highly emetogenic chemotherapy: more than 70 mg/m² cisplatin, or more than 50 mg/m² doxorubicin and more than 600 mg/m² cyclophosphamide.

Patients who developed breakthrough emesis or nausea despite guideline-directed prophylaxis were randomized to receive olanzapine or metoclopramide. Pre-chemotherapy prophylaxis included intravenous dexamethasone (12 mg), intravenous palonosetron (0.25 mg), and intravenous fosaprepitant (150 mg); post-chemotherapy prophylaxis was daily oral dexamethasone (8 mg, days 2-4).

Patients received 10 mg oral olanzapine for 3 days or 10 mg oral metoclopramide three times daily for 3 days. Patients were monitored for emesis and nausea for the 72 hours after the initiation of therapy. In addition, nausea was measured by patients on a visual analog scale (0-10), with 0 being no nausea and 10 being maximal nausea.

Patients in the two groups were similar for age, sex, Eastern Cooperative Oncology Group (ECOG) performance status, and diagnosis (5 bladder cancers, 40 breast cancers, 8 lymphomas, and 27 lung cancers).

"Both olanzapine and metoclopramide were well tolerated with no grade 3 or 4 toxicities," said Dr. Navari. No central nervous system toxicities were observed in either group.

Olanzapine is indicated for treatment of psychosis and is associated with weight gain, but the side effect should not be a problem for cancer patients.

"The side effect of weight gain occurs in patients, who receive the drug for 3 to 6 to 9 months," Dr. Ravari noted. "So using it for a short period of 3-4 days once a month – we did not see that in the current study, nor did we see that in previous studies."

Dr. Navari had previously reported that patients receiving highly emetogenic chemotherapy were about twice as likely not to experience any delayed nausea with an olanzapine regimen compared with a standard aprepitant (Emend) regimen (68% vs. 37%) in a phase III clinical trial. The two regimens worked similarly well for preventing acute nausea and for preventing both acute and delayed vomiting, that study found (Support. Oncol. 2011;9:188-95).

ASCO presented a preview of some meeting highlights with many of the abstracts being posted online as of 6 p.m. EST at www.asco.org.

The authors reported that they have nothing to disclose.

Many oncologists are fortunate enough to practice in fine, multidisciplinary cancer centers, where social workers, psychologists, and psychiatrists stand by to assist patients and family members who need professional guidance to help them through despair, family strife, or anxiety interfering with their treatment.

Other oncologists, however, must roll their eyes when practice guidelines, studies, and yes, admittedly, even this blog, recommend referring at-risk patients for specialized psychosocial care. They practice miles from the nearest psychologist with an expertise in psycho-oncology – in counties with no local chapters of the American Cancer Society, Wellness Community cancer programs, or Gilda’s Clubs.

© Nick Smith/iStockphoto

If you’re such an oncologist, you must be asking the Ghostbusters question: Who’m I gonna call?

Okay, get out a pen. Dial toll-free: 1-866-APOS-4-HELP (1-866-276-7443).

That’s the number for the Helpline of the American Psychosocial Oncology Society (APOS), a multidisciplinary organization founded in 1986 by Dr. Jimmie Holland, the indefatigable octogenarian chair of psychiatric oncology at Memorial Sloan-Kettering Medical Center in New York City.

Since 2003, the APOS Helpline has received a total of almost 3,000 calls originating in almost every state.

A recent tally showed that calls came from patients (53.7%), friends and family members (35.3%), healthcare professionals (6.8%), and national and local advocacy organizations serving patients with psychosocial needs beyond their scope (3.2%).

Most often, patients, families, and oncology professionals are directed to counseling resources in their own communities.

When patients cannot pay, or the search for community resources reaches a “dead end,” in the words of Dr. Elizabeth B. Harvey, a New York City psychologist, “We step in and provide temporary support for the patient.”*

In more than 100 calls she has handled as a Helpline counselor, Dr. Harvey has volunteered her time to people such as Bob, a 65-year-old man who was living in seclusion after the death of his wife two years ago. Even if there had been a support group where Bob lived, he was emotionally incapable of making his way to their meetings until phone counseling helped him to “slowly re-enter the world,” she said.

Similarly, when Lucy’s oncologist recommended counseling, the unemployed young mother with metastatic breast cancer and three children to care for had “neither the time nor the money” to investigate resources, wrote Dr. Harvey in a series of vignettes presented to APOS in support of expanding and promoting the Helpline.

People struggling with unsupportive families, housebound due to symptoms, or rurally isolated all have reached out and received help, sometimes by talking to them by phone on a weekly or periodic basis.*

“We have heard some heartbreaking stories,” said Dr. Holland at the annual APOS meeting in Miami.

The APOS members included in the Helpline referral directory reflect the organization’s diversity, coming from the fields of oncology, psychiatry, psychology, social work, nursing, counseling, therapy, and patient advocacy.

Calls are routed through the APOS headquarters in Charlottesville, VA., to Dr. Holland’s office, which contacts trained therapists who are part of the volunteer network.

At the meeting, Helpline coordinators expressed the hope that more professionals, including oncologists, might be made aware of the resource, and that more APOS members might be recruited to serve as counselors.

If you have need to call, please provide your name, phone number, the patient’s city/town and state of residence, and zip code of the location where you need a referral.

Inquiries are generally returned within 24-48 hours.

* CORRECTIONS: Information in these two paragraphs was updated on May 16, 2012.

Many oncologists are fortunate enough to practice in fine, multidisciplinary cancer centers, where social workers, psychologists, and psychiatrists stand by to assist patients and family members who need professional guidance to help them through despair, family strife, or anxiety interfering with their treatment.

Other oncologists, however, must roll their eyes when practice guidelines, studies, and yes, admittedly, even this blog, recommend referring at-risk patients for specialized psychosocial care. They practice miles from the nearest psychologist with an expertise in psycho-oncology – in counties with no local chapters of the American Cancer Society, Wellness Community cancer programs, or Gilda’s Clubs.

© Nick Smith/iStockphoto

If you’re such an oncologist, you must be asking the Ghostbusters question: Who’m I gonna call?

Okay, get out a pen. Dial toll-free: 1-866-APOS-4-HELP (1-866-276-7443).

That’s the number for the Helpline of the American Psychosocial Oncology Society (APOS), a multidisciplinary organization founded in 1986 by Dr. Jimmie Holland, the indefatigable octogenarian chair of psychiatric oncology at Memorial Sloan-Kettering Medical Center in New York City.

Since 2003, the APOS Helpline has received a total of almost 3,000 calls originating in almost every state.

A recent tally showed that calls came from patients (53.7%), friends and family members (35.3%), healthcare professionals (6.8%), and national and local advocacy organizations serving patients with psychosocial needs beyond their scope (3.2%).

Most often, patients, families, and oncology professionals are directed to counseling resources in their own communities.

When patients cannot pay, or the search for community resources reaches a “dead end,” in the words of Dr. Elizabeth B. Harvey, a New York City psychologist, “We step in and provide temporary support for the patient.”*

In more than 100 calls she has handled as a Helpline counselor, Dr. Harvey has volunteered her time to people such as Bob, a 65-year-old man who was living in seclusion after the death of his wife two years ago. Even if there had been a support group where Bob lived, he was emotionally incapable of making his way to their meetings until phone counseling helped him to “slowly re-enter the world,” she said.

Similarly, when Lucy’s oncologist recommended counseling, the unemployed young mother with metastatic breast cancer and three children to care for had “neither the time nor the money” to investigate resources, wrote Dr. Harvey in a series of vignettes presented to APOS in support of expanding and promoting the Helpline.

People struggling with unsupportive families, housebound due to symptoms, or rurally isolated all have reached out and received help, sometimes by talking to them by phone on a weekly or periodic basis.*

“We have heard some heartbreaking stories,” said Dr. Holland at the annual APOS meeting in Miami.

The APOS members included in the Helpline referral directory reflect the organization’s diversity, coming from the fields of oncology, psychiatry, psychology, social work, nursing, counseling, therapy, and patient advocacy.

Calls are routed through the APOS headquarters in Charlottesville, VA., to Dr. Holland’s office, which contacts trained therapists who are part of the volunteer network.

At the meeting, Helpline coordinators expressed the hope that more professionals, including oncologists, might be made aware of the resource, and that more APOS members might be recruited to serve as counselors.

If you have need to call, please provide your name, phone number, the patient’s city/town and state of residence, and zip code of the location where you need a referral.

Inquiries are generally returned within 24-48 hours.

* CORRECTIONS: Information in these two paragraphs was updated on May 16, 2012.

Many oncologists are fortunate enough to practice in fine, multidisciplinary cancer centers, where social workers, psychologists, and psychiatrists stand by to assist patients and family members who need professional guidance to help them through despair, family strife, or anxiety interfering with their treatment.

Other oncologists, however, must roll their eyes when practice guidelines, studies, and yes, admittedly, even this blog, recommend referring at-risk patients for specialized psychosocial care. They practice miles from the nearest psychologist with an expertise in psycho-oncology – in counties with no local chapters of the American Cancer Society, Wellness Community cancer programs, or Gilda’s Clubs.

© Nick Smith/iStockphoto

If you’re such an oncologist, you must be asking the Ghostbusters question: Who’m I gonna call?

Okay, get out a pen. Dial toll-free: 1-866-APOS-4-HELP (1-866-276-7443).

That’s the number for the Helpline of the American Psychosocial Oncology Society (APOS), a multidisciplinary organization founded in 1986 by Dr. Jimmie Holland, the indefatigable octogenarian chair of psychiatric oncology at Memorial Sloan-Kettering Medical Center in New York City.

Since 2003, the APOS Helpline has received a total of almost 3,000 calls originating in almost every state.

A recent tally showed that calls came from patients (53.7%), friends and family members (35.3%), healthcare professionals (6.8%), and national and local advocacy organizations serving patients with psychosocial needs beyond their scope (3.2%).

Most often, patients, families, and oncology professionals are directed to counseling resources in their own communities.

When patients cannot pay, or the search for community resources reaches a “dead end,” in the words of Dr. Elizabeth B. Harvey, a New York City psychologist, “We step in and provide temporary support for the patient.”*

In more than 100 calls she has handled as a Helpline counselor, Dr. Harvey has volunteered her time to people such as Bob, a 65-year-old man who was living in seclusion after the death of his wife two years ago. Even if there had been a support group where Bob lived, he was emotionally incapable of making his way to their meetings until phone counseling helped him to “slowly re-enter the world,” she said.

Similarly, when Lucy’s oncologist recommended counseling, the unemployed young mother with metastatic breast cancer and three children to care for had “neither the time nor the money” to investigate resources, wrote Dr. Harvey in a series of vignettes presented to APOS in support of expanding and promoting the Helpline.

People struggling with unsupportive families, housebound due to symptoms, or rurally isolated all have reached out and received help, sometimes by talking to them by phone on a weekly or periodic basis.*

“We have heard some heartbreaking stories,” said Dr. Holland at the annual APOS meeting in Miami.

The APOS members included in the Helpline referral directory reflect the organization’s diversity, coming from the fields of oncology, psychiatry, psychology, social work, nursing, counseling, therapy, and patient advocacy.

Calls are routed through the APOS headquarters in Charlottesville, VA., to Dr. Holland’s office, which contacts trained therapists who are part of the volunteer network.

At the meeting, Helpline coordinators expressed the hope that more professionals, including oncologists, might be made aware of the resource, and that more APOS members might be recruited to serve as counselors.

If you have need to call, please provide your name, phone number, the patient’s city/town and state of residence, and zip code of the location where you need a referral.

Inquiries are generally returned within 24-48 hours.

* CORRECTIONS: Information in these two paragraphs was updated on May 16, 2012.

MIAMI – Serious psychiatric comorbidities should not deprive cancer patients of life-salvaging or life-enriching therapies, according to two psychiatrists who have helped such patients to achieve successful outcomes with treatment for their physical and mental disorders.

Aggressive psychiatric treatment preserved patients’ eligibility for bone marrow transplantation (BMT) and allowed terminally ill patients to "participate in the important process of saying goodbye," the clinicians reported during separate presentations at the annual meeting of the American Psychosocial Oncology Society.

Bone Marrow Transplantation Feasible

Dr. Isabel Schuermeyer, director of psycho-oncology at the Cleveland Clinic, underscored her contention that even suicidal ideation should not, in most cases, be a contraindication for BMT. She described the case of a 55-year-old mantle cell lymphoma patient with a lengthy history of depression who developed myelodysplastic syndrome following an initial autologous BMT.

"I think there should be no psychiatric contraindication to BMT."

While under consideration for repeat BMT, he developed suicidal ideation, including formulating a plan to drive a car into a wall or poison himself with carbon monoxide. Intensive, collaborative management and a brief inpatient psychiatry admission combined to stabilize the patient on mirtazapine (Remeron) and clonazepam within 2 weeks, she reported. Although rapidly progressive medical complications precluded a second BMT, his psychiatric condition became stable.

A second psychiatric intervention involved a 57-year-old woman with multiple myeloma who drove 1,000 miles without stopping, just to make an appointment at the Cleveland Clinic. This followed her firing of four oncologists in 6 months in her city of origin. Relevant history included an early suicide attempt, alcohol abuse, and anxiety.

On examination, the patient exhibited racing thoughts, a diminished need for sleep, and excessive activity and distractibility. With close follow-up by the psychosocial oncology team and initiation of quetiapine (Seroquel) therapy, the patient’s hypomanic symptoms soon abated, and she was able to safely undergo a transplant.

"She actually did really well and had some insight," Dr. Schuermeyer said in an interview. "She was sleeping 8-9 hours a night."

The literature on psychiatric suitability for BMT is sparse, she noted. In 2006, Foster and colleagues reported (Bone Marrow Transplant. 2006:37:223-8) that nearly 90% of BMT professionals would not transplant a patient with suicidal ideation.

A small case series (Psychiatry Clin. Neurosci. 2003:57:311-5) reported that six of seven patients with psychiatric illnesses were able to undergo BMT with the exception of one patient with borderline personality disorder.

There is a widespread belief that patients with a psychiatric history may not be good candidates for BMT due to concerns about adherence, Dr. Schuermeyer noted. "Everyone wants great outcomes with BMT," she said in an interview.

However, her belief, grounded in experience, is that close collaboration and competent mental health care can overcome psychiatric obstacles in the vast majority of cases. "I think there should be no psychiatric contraindication to BMT. At the end of the day, this is a lifesaving treatment," she said.

Unlike in solid organ transplantation, years of compliance are not required. "Let’s just save peoples’ lives. Let’s be aggressive and work together as a team," she said.

Depression Eased by ECT

Dr. Carlos G. Fernandez-Robles of the psychiatry oncology service at the Massachusetts General Hospital Cancer Center in Boston advocated aggressive treatment of another sort. Using three clinical cases as examples, he outlined the effective use of electroconvulsive therapy in cancer patients with profound treatment-resistant depression that included catatonic symptoms.

Catatonia, he said, is an uncommon entity in general, and even more so in cancer patients; it is likely often unrecognized, however, and can be a manifestation of paraneoplastic encephalopathy, CNS chemotherapy toxicity, or psychiatric in origin.

In one such patient, a 40-year-woman with unresectable T4bN2cM0 maxillary adenoid cystic carcinoma treated with radiation and combination chemotherapy, was admitted to the hospital for failure to thrive, weight loss, and immobility. On examination, she demonstrated mutism, posturing, limb rigidity and mild waxy flexibility, gegenhalten hypertonia, and grasp reflex.

While lorazepam (Ativan) 2 mg IV temporarily resolved her symptoms, the team was unable to achieve any sustained response to psychopharmacologic treatment. The patient responded fully to six treatments with electroconvulsive therapy and was able to complete radiation and chemotherapy, Dr. Fernandez-Robles said.

A second patient with profound depression had complete response to six rounds of ECT after he failed to respond to a variety of medications following resection of right temporal lesions and an anterior temporal lobectomy for multicentric glioblastoma multiforme.

Very few studies have been published of ECT in cancer patients, in large measure because of a stigma not only among members of the general public, but in medical training as well, Dr. Fernandez-Robles said.

 

"Jack Nicholson did for shock therapy what 'Jaws' did for sharks," he wryly paraphrased British psychiatrist Susan Benbow as saying in an allusion to the depiction of ECT in the movie "One Flew Over the Cuckoo’s Nest."

In practice, ECT can reduce emotional suffering and physical pain and can "restore capacity for enjoyment of whatever life remains to be lived," said Dr. Fernandez-Robles.

For terminally ill patients with unremitting depression, it offers hope for engagement "in the important process of saying good-byes and wrapping things up."

Adverse effects can include nausea, headache, postictal delirium, cardiovascular complications, prolonged apnea, and well-known effects on anterograde and recent retrograde memory. Indeed, patients described by Dr. Fernandez-Robles did experience memory-related side effects.

Nonetheless, he said each of the patients had "clear-cut" indications for ECT and their quality of life improved dramatically as a result of the therapy.

"I am really interested in ... the impact of serious mental illness on the quality of care we give to our patients," he said following the meeting.

Neither presenter disclosed any relevant conflicts of interest.

MIAMI – Serious psychiatric comorbidities should not deprive cancer patients of life-salvaging or life-enriching therapies, according to two psychiatrists who have helped such patients to achieve successful outcomes with treatment for their physical and mental disorders.

Aggressive psychiatric treatment preserved patients’ eligibility for bone marrow transplantation (BMT) and allowed terminally ill patients to "participate in the important process of saying goodbye," the clinicians reported during separate presentations at the annual meeting of the American Psychosocial Oncology Society.

Bone Marrow Transplantation Feasible

Dr. Isabel Schuermeyer, director of psycho-oncology at the Cleveland Clinic, underscored her contention that even suicidal ideation should not, in most cases, be a contraindication for BMT. She described the case of a 55-year-old mantle cell lymphoma patient with a lengthy history of depression who developed myelodysplastic syndrome following an initial autologous BMT.

"I think there should be no psychiatric contraindication to BMT."

While under consideration for repeat BMT, he developed suicidal ideation, including formulating a plan to drive a car into a wall or poison himself with carbon monoxide. Intensive, collaborative management and a brief inpatient psychiatry admission combined to stabilize the patient on mirtazapine (Remeron) and clonazepam within 2 weeks, she reported. Although rapidly progressive medical complications precluded a second BMT, his psychiatric condition became stable.

A second psychiatric intervention involved a 57-year-old woman with multiple myeloma who drove 1,000 miles without stopping, just to make an appointment at the Cleveland Clinic. This followed her firing of four oncologists in 6 months in her city of origin. Relevant history included an early suicide attempt, alcohol abuse, and anxiety.

On examination, the patient exhibited racing thoughts, a diminished need for sleep, and excessive activity and distractibility. With close follow-up by the psychosocial oncology team and initiation of quetiapine (Seroquel) therapy, the patient’s hypomanic symptoms soon abated, and she was able to safely undergo a transplant.

"She actually did really well and had some insight," Dr. Schuermeyer said in an interview. "She was sleeping 8-9 hours a night."

The literature on psychiatric suitability for BMT is sparse, she noted. In 2006, Foster and colleagues reported (Bone Marrow Transplant. 2006:37:223-8) that nearly 90% of BMT professionals would not transplant a patient with suicidal ideation.

A small case series (Psychiatry Clin. Neurosci. 2003:57:311-5) reported that six of seven patients with psychiatric illnesses were able to undergo BMT with the exception of one patient with borderline personality disorder.

There is a widespread belief that patients with a psychiatric history may not be good candidates for BMT due to concerns about adherence, Dr. Schuermeyer noted. "Everyone wants great outcomes with BMT," she said in an interview.

However, her belief, grounded in experience, is that close collaboration and competent mental health care can overcome psychiatric obstacles in the vast majority of cases. "I think there should be no psychiatric contraindication to BMT. At the end of the day, this is a lifesaving treatment," she said.

Unlike in solid organ transplantation, years of compliance are not required. "Let’s just save peoples’ lives. Let’s be aggressive and work together as a team," she said.

Depression Eased by ECT

Dr. Carlos G. Fernandez-Robles of the psychiatry oncology service at the Massachusetts General Hospital Cancer Center in Boston advocated aggressive treatment of another sort. Using three clinical cases as examples, he outlined the effective use of electroconvulsive therapy in cancer patients with profound treatment-resistant depression that included catatonic symptoms.

Catatonia, he said, is an uncommon entity in general, and even more so in cancer patients; it is likely often unrecognized, however, and can be a manifestation of paraneoplastic encephalopathy, CNS chemotherapy toxicity, or psychiatric in origin.

In one such patient, a 40-year-woman with unresectable T4bN2cM0 maxillary adenoid cystic carcinoma treated with radiation and combination chemotherapy, was admitted to the hospital for failure to thrive, weight loss, and immobility. On examination, she demonstrated mutism, posturing, limb rigidity and mild waxy flexibility, gegenhalten hypertonia, and grasp reflex.

While lorazepam (Ativan) 2 mg IV temporarily resolved her symptoms, the team was unable to achieve any sustained response to psychopharmacologic treatment. The patient responded fully to six treatments with electroconvulsive therapy and was able to complete radiation and chemotherapy, Dr. Fernandez-Robles said.

A second patient with profound depression had complete response to six rounds of ECT after he failed to respond to a variety of medications following resection of right temporal lesions and an anterior temporal lobectomy for multicentric glioblastoma multiforme.

Very few studies have been published of ECT in cancer patients, in large measure because of a stigma not only among members of the general public, but in medical training as well, Dr. Fernandez-Robles said.

 

"Jack Nicholson did for shock therapy what 'Jaws' did for sharks," he wryly paraphrased British psychiatrist Susan Benbow as saying in an allusion to the depiction of ECT in the movie "One Flew Over the Cuckoo’s Nest."

In practice, ECT can reduce emotional suffering and physical pain and can "restore capacity for enjoyment of whatever life remains to be lived," said Dr. Fernandez-Robles.

For terminally ill patients with unremitting depression, it offers hope for engagement "in the important process of saying good-byes and wrapping things up."

Adverse effects can include nausea, headache, postictal delirium, cardiovascular complications, prolonged apnea, and well-known effects on anterograde and recent retrograde memory. Indeed, patients described by Dr. Fernandez-Robles did experience memory-related side effects.

Nonetheless, he said each of the patients had "clear-cut" indications for ECT and their quality of life improved dramatically as a result of the therapy.

"I am really interested in ... the impact of serious mental illness on the quality of care we give to our patients," he said following the meeting.

Neither presenter disclosed any relevant conflicts of interest.

MIAMI – Serious psychiatric comorbidities should not deprive cancer patients of life-salvaging or life-enriching therapies, according to two psychiatrists who have helped such patients to achieve successful outcomes with treatment for their physical and mental disorders.

Aggressive psychiatric treatment preserved patients’ eligibility for bone marrow transplantation (BMT) and allowed terminally ill patients to "participate in the important process of saying goodbye," the clinicians reported during separate presentations at the annual meeting of the American Psychosocial Oncology Society.

Bone Marrow Transplantation Feasible

Dr. Isabel Schuermeyer, director of psycho-oncology at the Cleveland Clinic, underscored her contention that even suicidal ideation should not, in most cases, be a contraindication for BMT. She described the case of a 55-year-old mantle cell lymphoma patient with a lengthy history of depression who developed myelodysplastic syndrome following an initial autologous BMT.

"I think there should be no psychiatric contraindication to BMT."

While under consideration for repeat BMT, he developed suicidal ideation, including formulating a plan to drive a car into a wall or poison himself with carbon monoxide. Intensive, collaborative management and a brief inpatient psychiatry admission combined to stabilize the patient on mirtazapine (Remeron) and clonazepam within 2 weeks, she reported. Although rapidly progressive medical complications precluded a second BMT, his psychiatric condition became stable.

A second psychiatric intervention involved a 57-year-old woman with multiple myeloma who drove 1,000 miles without stopping, just to make an appointment at the Cleveland Clinic. This followed her firing of four oncologists in 6 months in her city of origin. Relevant history included an early suicide attempt, alcohol abuse, and anxiety.

On examination, the patient exhibited racing thoughts, a diminished need for sleep, and excessive activity and distractibility. With close follow-up by the psychosocial oncology team and initiation of quetiapine (Seroquel) therapy, the patient’s hypomanic symptoms soon abated, and she was able to safely undergo a transplant.

"She actually did really well and had some insight," Dr. Schuermeyer said in an interview. "She was sleeping 8-9 hours a night."

The literature on psychiatric suitability for BMT is sparse, she noted. In 2006, Foster and colleagues reported (Bone Marrow Transplant. 2006:37:223-8) that nearly 90% of BMT professionals would not transplant a patient with suicidal ideation.

A small case series (Psychiatry Clin. Neurosci. 2003:57:311-5) reported that six of seven patients with psychiatric illnesses were able to undergo BMT with the exception of one patient with borderline personality disorder.

There is a widespread belief that patients with a psychiatric history may not be good candidates for BMT due to concerns about adherence, Dr. Schuermeyer noted. "Everyone wants great outcomes with BMT," she said in an interview.

However, her belief, grounded in experience, is that close collaboration and competent mental health care can overcome psychiatric obstacles in the vast majority of cases. "I think there should be no psychiatric contraindication to BMT. At the end of the day, this is a lifesaving treatment," she said.

Unlike in solid organ transplantation, years of compliance are not required. "Let’s just save peoples’ lives. Let’s be aggressive and work together as a team," she said.

Depression Eased by ECT

Dr. Carlos G. Fernandez-Robles of the psychiatry oncology service at the Massachusetts General Hospital Cancer Center in Boston advocated aggressive treatment of another sort. Using three clinical cases as examples, he outlined the effective use of electroconvulsive therapy in cancer patients with profound treatment-resistant depression that included catatonic symptoms.

Catatonia, he said, is an uncommon entity in general, and even more so in cancer patients; it is likely often unrecognized, however, and can be a manifestation of paraneoplastic encephalopathy, CNS chemotherapy toxicity, or psychiatric in origin.

In one such patient, a 40-year-woman with unresectable T4bN2cM0 maxillary adenoid cystic carcinoma treated with radiation and combination chemotherapy, was admitted to the hospital for failure to thrive, weight loss, and immobility. On examination, she demonstrated mutism, posturing, limb rigidity and mild waxy flexibility, gegenhalten hypertonia, and grasp reflex.

While lorazepam (Ativan) 2 mg IV temporarily resolved her symptoms, the team was unable to achieve any sustained response to psychopharmacologic treatment. The patient responded fully to six treatments with electroconvulsive therapy and was able to complete radiation and chemotherapy, Dr. Fernandez-Robles said.

A second patient with profound depression had complete response to six rounds of ECT after he failed to respond to a variety of medications following resection of right temporal lesions and an anterior temporal lobectomy for multicentric glioblastoma multiforme.

Very few studies have been published of ECT in cancer patients, in large measure because of a stigma not only among members of the general public, but in medical training as well, Dr. Fernandez-Robles said.

 

"Jack Nicholson did for shock therapy what 'Jaws' did for sharks," he wryly paraphrased British psychiatrist Susan Benbow as saying in an allusion to the depiction of ECT in the movie "One Flew Over the Cuckoo’s Nest."

In practice, ECT can reduce emotional suffering and physical pain and can "restore capacity for enjoyment of whatever life remains to be lived," said Dr. Fernandez-Robles.

For terminally ill patients with unremitting depression, it offers hope for engagement "in the important process of saying good-byes and wrapping things up."

Adverse effects can include nausea, headache, postictal delirium, cardiovascular complications, prolonged apnea, and well-known effects on anterograde and recent retrograde memory. Indeed, patients described by Dr. Fernandez-Robles did experience memory-related side effects.

Nonetheless, he said each of the patients had "clear-cut" indications for ECT and their quality of life improved dramatically as a result of the therapy.

"I am really interested in ... the impact of serious mental illness on the quality of care we give to our patients," he said following the meeting.

Neither presenter disclosed any relevant conflicts of interest.

Cancer patients deserve to receive aggressive treatment for comorbid depression. Dr. David Spiegel and his team of researchers at Stanford University found that patients with depression may exhibit faster rates of cancer progression. The team found that depression was as dangerous a risk factor for mortality in cancer as it is in cardiovascular disease.

               While depression is often underdiagnosed in cancer patients, Dr. Spiegel said his findings suggests that psychiatrists should view treatment for depression as part of overall cancer treatment. Dr. Spiegel presented his findings at the annual meeting of the American Psychiatric Association. 

Cancer patients deserve to receive aggressive treatment for comorbid depression. Dr. David Spiegel and his team of researchers at Stanford University found that patients with depression may exhibit faster rates of cancer progression. The team found that depression was as dangerous a risk factor for mortality in cancer as it is in cardiovascular disease.

               While depression is often underdiagnosed in cancer patients, Dr. Spiegel said his findings suggests that psychiatrists should view treatment for depression as part of overall cancer treatment. Dr. Spiegel presented his findings at the annual meeting of the American Psychiatric Association. 

Cancer patients deserve to receive aggressive treatment for comorbid depression. Dr. David Spiegel and his team of researchers at Stanford University found that patients with depression may exhibit faster rates of cancer progression. The team found that depression was as dangerous a risk factor for mortality in cancer as it is in cardiovascular disease.

               While depression is often underdiagnosed in cancer patients, Dr. Spiegel said his findings suggests that psychiatrists should view treatment for depression as part of overall cancer treatment. Dr. Spiegel presented his findings at the annual meeting of the American Psychiatric Association. 

DENVER – More than three-quarters of the general public have no idea what palliative care is, according to a national survey. And that, as it turns out, is actually excellent for the field’s future growth prospects, according to one of the nation’s top palliative care specialists.

"This is good news for us. We can create the cognitive frame where there isn’t one already in place," said Dr. Diane E. Meier, director of the Center to Advance Palliative Care and professor of geriatrics and internal medicine at Mount Sinai School of Medicine, New York.

Bruce Jancin/IMNG Medical Media

While the public is largely a blank slate with regard to palliative care, nonpalliative care physicians and other health care professionals tend to believe that palliative care is simply end of life care. Many don’t understand that palliative care is actually about relieving the pain, symptoms, and stress of serious illness in patients of any age and at any stage of disease, and that palliative care can be delivered alongside curative or life-prolonging therapies, Dr. Meier said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The consumer survey sponsored by the Center to Advance Palliative Care and the American Cancer Society involved 800 adults; 70% indicated they were "not at all knowledgeable" about palliative care, and another 8% had never heard of the term. Only 5% were categorized as "very knowledgeable" about palliative care.

Once they were informed about what palliative care truly is, however, survey participants of all political persuasions were very positive about it.

For example, once they were educated about palliative care, 95% of those surveyed said it’s important for patients with serious illnesses and their families to learn about palliative care. Most (92%) indicated they would likely consider it for themselves or a loved one, and an equal percentage said it’s important that palliative care services be available at all hospitals, Dr. Meier reported.

She and other leaders in the palliative care field are now seeking funding for an ambitious 5-year, multimillion-dollar social marketing campaign to increase public awareness regarding palliative care.

"We’ve recognized that we’re not going to see policy change without public support," Dr. Meier said.

Among the policy changes she and her colleagues seek is a big boost in the palliative care workforce, which at present is so small as to constitute a major barrier to access. While there is one oncologist for every 145 patients in the United States with a new cancer diagnosis, and one cardiologist for every 71 patients who have a myocardial infarction, there is just one palliative care specialist for every 1,300 people with a serious illness. And in nearly half of the states, no postgraduate training in palliative care is available.

Dr. Meier would like to see an increased number of physician and nurse practitioner fellowship programs established in palliative care. Another priority is to develop a midcareer board certification track in palliative care across all medical disciplines.

"We have a lot of people coming in from oncology, surgery, and other fields who are seeking work with meaning and purpose," she observed.

Starting in 2013, the specialty will require fellowship training for board certification in palliative care. "Grandfathering in" will no longer be possible.

Dr. Meier reported having no financial conflicts.

DENVER – More than three-quarters of the general public have no idea what palliative care is, according to a national survey. And that, as it turns out, is actually excellent for the field’s future growth prospects, according to one of the nation’s top palliative care specialists.

"This is good news for us. We can create the cognitive frame where there isn’t one already in place," said Dr. Diane E. Meier, director of the Center to Advance Palliative Care and professor of geriatrics and internal medicine at Mount Sinai School of Medicine, New York.

Bruce Jancin/IMNG Medical Media

While the public is largely a blank slate with regard to palliative care, nonpalliative care physicians and other health care professionals tend to believe that palliative care is simply end of life care. Many don’t understand that palliative care is actually about relieving the pain, symptoms, and stress of serious illness in patients of any age and at any stage of disease, and that palliative care can be delivered alongside curative or life-prolonging therapies, Dr. Meier said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The consumer survey sponsored by the Center to Advance Palliative Care and the American Cancer Society involved 800 adults; 70% indicated they were "not at all knowledgeable" about palliative care, and another 8% had never heard of the term. Only 5% were categorized as "very knowledgeable" about palliative care.

Once they were informed about what palliative care truly is, however, survey participants of all political persuasions were very positive about it.

For example, once they were educated about palliative care, 95% of those surveyed said it’s important for patients with serious illnesses and their families to learn about palliative care. Most (92%) indicated they would likely consider it for themselves or a loved one, and an equal percentage said it’s important that palliative care services be available at all hospitals, Dr. Meier reported.

She and other leaders in the palliative care field are now seeking funding for an ambitious 5-year, multimillion-dollar social marketing campaign to increase public awareness regarding palliative care.

"We’ve recognized that we’re not going to see policy change without public support," Dr. Meier said.

Among the policy changes she and her colleagues seek is a big boost in the palliative care workforce, which at present is so small as to constitute a major barrier to access. While there is one oncologist for every 145 patients in the United States with a new cancer diagnosis, and one cardiologist for every 71 patients who have a myocardial infarction, there is just one palliative care specialist for every 1,300 people with a serious illness. And in nearly half of the states, no postgraduate training in palliative care is available.

Dr. Meier would like to see an increased number of physician and nurse practitioner fellowship programs established in palliative care. Another priority is to develop a midcareer board certification track in palliative care across all medical disciplines.

"We have a lot of people coming in from oncology, surgery, and other fields who are seeking work with meaning and purpose," she observed.

Starting in 2013, the specialty will require fellowship training for board certification in palliative care. "Grandfathering in" will no longer be possible.

Dr. Meier reported having no financial conflicts.

DENVER – More than three-quarters of the general public have no idea what palliative care is, according to a national survey. And that, as it turns out, is actually excellent for the field’s future growth prospects, according to one of the nation’s top palliative care specialists.

"This is good news for us. We can create the cognitive frame where there isn’t one already in place," said Dr. Diane E. Meier, director of the Center to Advance Palliative Care and professor of geriatrics and internal medicine at Mount Sinai School of Medicine, New York.

Bruce Jancin/IMNG Medical Media

While the public is largely a blank slate with regard to palliative care, nonpalliative care physicians and other health care professionals tend to believe that palliative care is simply end of life care. Many don’t understand that palliative care is actually about relieving the pain, symptoms, and stress of serious illness in patients of any age and at any stage of disease, and that palliative care can be delivered alongside curative or life-prolonging therapies, Dr. Meier said at the annual meeting of the American Academy of Hospice and Palliative Medicine.

The consumer survey sponsored by the Center to Advance Palliative Care and the American Cancer Society involved 800 adults; 70% indicated they were "not at all knowledgeable" about palliative care, and another 8% had never heard of the term. Only 5% were categorized as "very knowledgeable" about palliative care.

Once they were informed about what palliative care truly is, however, survey participants of all political persuasions were very positive about it.

For example, once they were educated about palliative care, 95% of those surveyed said it’s important for patients with serious illnesses and their families to learn about palliative care. Most (92%) indicated they would likely consider it for themselves or a loved one, and an equal percentage said it’s important that palliative care services be available at all hospitals, Dr. Meier reported.

She and other leaders in the palliative care field are now seeking funding for an ambitious 5-year, multimillion-dollar social marketing campaign to increase public awareness regarding palliative care.

"We’ve recognized that we’re not going to see policy change without public support," Dr. Meier said.

Among the policy changes she and her colleagues seek is a big boost in the palliative care workforce, which at present is so small as to constitute a major barrier to access. While there is one oncologist for every 145 patients in the United States with a new cancer diagnosis, and one cardiologist for every 71 patients who have a myocardial infarction, there is just one palliative care specialist for every 1,300 people with a serious illness. And in nearly half of the states, no postgraduate training in palliative care is available.

Dr. Meier would like to see an increased number of physician and nurse practitioner fellowship programs established in palliative care. Another priority is to develop a midcareer board certification track in palliative care across all medical disciplines.

"We have a lot of people coming in from oncology, surgery, and other fields who are seeking work with meaning and purpose," she observed.

Starting in 2013, the specialty will require fellowship training for board certification in palliative care. "Grandfathering in" will no longer be possible.

Dr. Meier reported having no financial conflicts.