The journal of supportive oncology最新文献

Oncology quality measurement programs should include measures in key domains of palliative care and supportive oncology. This article describes an approach to quality measurement in these areas including the key steps of defining the quality measurement goal; identifying stakeholders and audiences; defining the population and setting (including potential characteristics of interest, such as specific conditions or disparities); and choosing the domain, target, and steps in the process of care, such as assessment and treatment. Other key steps include choosing or adapting measures that have been evaluated in other settings or are in widespread use; identifying data sources or collection needs; and considering issues of scientific acceptability, such as evidence to support process-outcome relationships. Other quality measurement considerations include the challenges of measurement, particularly in important domains such as communication and spiritual care, variation in patient preferences, or inconsistent documentation. In addition, potential unintended consequences, such as measurement burden and overemphasis of checklist care, may reduce patient-centeredness and attention to important patient concerns not addressed by quality measures.

Background: Routine symptom and health-related quality of life (HRQOL) assessments can engage patients, give provider feedback, and improve doctor/patient communication.

Objective: We compared the impact of a technology-assisted symptom monitoring system versus usual care on HRQOL and doctor/patient communication in early-stage prostate cancer (PCa) survivors.

Methods: Men (N = 94) were on average 62-years old, mostly African American (AA; 61.7%), and 10-19 months post-treatment. They were randomized to symptom monitoring plus feedback (SM + F; n = 49) or usual care (UC; n = 45). SM+F participants completed a 12-item telephoneassisted monitoring intervention. All participants completed a baseline and 2 follow-up interviews.

Results: Among the SM+F participants, perceptions of the monitoring system were positive: 97.1% endorsed it as easy/very easy to use and 85% felt all patients could benefit from it. At baseline, men reported favorable general and cancer-specific HRQOL and doctor/patient communication, but poorer urinary and sexual function. Although there was no overall impact of the intervention, post hoc exploratory analyses indicated that among AA men, those who received SM+F improved relative to UC on doctor/patient communication (P < .05), general HRQOL (P < .06), and sexual function (P < .05).

Limitations: Variability in survivor follow-up care, limited access to eligible participants, and minimal physician training in the use of reports likely decreased physician investment.

Conclusion: Overall, PCa survivors were receptive to this monitoring system. Exploratory analyses suggest that this technology-assisted monitoring system may be of particular benefit to African American men. Additional studies with larger samples, more intervention time-points, and increased physician training are needed to strengthen the intervention's impact.

Background: Patients with late-stage cancer are living longer, making it important to understand factors that contribute to maintaining quality of life (QOL) and completing advanced illness behaviors (eg, advance directives).

Objective: To examine whether illness perceptions-the cognitive beliefs that patients form about their cancer-may be more important guides to adjustment than clinical characteristics of the cancer.

Methods: In a cross-sectional study, 105 female patients diagnosed with stage III (n = 66) or IV (n = 39) breast (n = 44), gynecological (n = 38), or lung (n = 23) cancer completed self-report measures of illness perceptions, QOL, and advanced illness behaviors. Clinical data was obtained from medical records.

Results: Despite modest associations, patients' beliefs about the cancer were clearly unique from the clinical characteristics of the cancer. Illness perception variables accounted for a large portion of the variance (PS < .01) for QOL and advanced illness behaviors, whereas clinical characteristics did not. QOL scores were predicted by patients' reports of experiencing more cancer related symptoms (ie, illness identity), believing that their cancer is central to their self-identity, and higher income. Higher completion of advanced illness behaviors was predicted by higher income, the cancer being recurrent, and participants perceiving their cancer as more severe but also more understandable.

Limitations: This study was limited by a cross-sectional design, small sample size, and focus on female patients.

Conclusion: Addressing patients' beliefs about their cancer diagnosis may provide important targets for intervention to improve QOL and illness behaviors in patients with late-stage cancer.

Background: Patients with brain metastases from solid tumors can be subdivided by characteristics into separate prognostic groups, such as the Radiation Therapy Oncology Group's Recursive Partitioning Analysis (RPA) or the Graded Prognostic Assessment (GPA). At our institution, patients falling into the poorest prognostic groups are often treated with whole brain radiotherapy (WBRT).

Objective: To determine if observed survival of poor prognosis patients treated with WBRT for brain metastases at our institution matches the survival predicted by RPA and GPA prognostic indices.

Methods: The charts of 101 consecutive patients with newly diagnosed brain metastases from solid tumors who received WBRT were retrospectively reviewed. We calculated each patient's RPA and GPA and compiled treatment and survival data. Observed median survival was compared to that predicted by the RPA and GPA prognostic indices.

Results: RPA III patients (n = 25) had a median survival of 2.4 months in our study. GPA 0.0-1.0 patients (n = 35) had a median survival of 2.4 months in our study. These values did not vary significantly from those predicted by the respective indices.

Limitations: This is a retrospective analysis and subject to selection bias.

Conclusion: Given the delivery time for WBRT and the potential side effects associated with the treatment, the predictably short overall survival in poor prognosis patients calls into question the value of WBRT in this patient subgroup.

Background: Skin reactions and pain are commonly reported side effects of radiation therapy (RT).

Objective: To characterize RT-induced symptoms according to treatment site subgroups and identify skin symptoms that correlate with pain.

Methods: A self-report survey-adapted from the MD Anderson Symptom Inventory and the McGill Pain Questionnaire--assessed RT-induced skin problems, pain, and specific skin symptoms. Wilcoxon Sign Ranked tests compared mean severity or pre- and post-RT pain and skin problems within each RT-site subgroup. Multiple linear regression (MLR) investigated associations between skin symptoms and pain.

Results: Survey respondents (N = 106) were 58% female and on average 64 years old. RT sites included lung, breast, lower abdomen, head/neck/brain, and upper abdomen. Only patients receiving breast RT reported significant increases in treatment site pain and skin problems (P < or = .007). Patients receiving head/neck/brain RT reported increased skin problems (P < .0009). MLR showed that post-RT skin tenderness and tightness were most strongly associated with post-RT pain (P = .066 and P = .122, respectively).

Limitations: Small sample size, exploratory analyses, and nonvalidated measure.

Conclusions: Only patients receiving breast RT reported significant increases in pain and skin problems at the RT site while patients receiving head/neck/brain RT had increased skin problems but not pain. These findings suggest that the severity of skin problems is not the only factor that contributes to pain and that interventions should be tailored to specifically target pain at the RT site, possibly by targeting tenderness and tightness. These findings should be confirmed in a larger sampling of RT patients.

There are a number of challenges facing head and neck cancer patients who present with metastatic or locally recurrent head and neck cancer; such as, limited treatment options, overall poor prognosis, and high symptom burden secondary to tumor and treatment. Disease and symptom management can be difficult, and requires that the potential benefits versus the adverse effects of systemic therapy be weighed very carefully. Individual patient characteristics including performance status, weight loss, symptom burden, comorbidities, and social supports must be taken into consideration. Unfortunately, reliable data describing the impact of therapy on symptom burden and quality of life (QOL) is lacking. Recently completed randomized phase III treatment trials have demonstrated the feasibility of incorporating patient reported outcome measures to assess symptoms and QOL into clinical studies. Nonetheless, obstacles to accurate and thorough QOL reporting remain. Development of tools directed at symptom burden and functional impairment in the metastatic or recurrent head and neck cancer population is needed. Such tools would enhance our ability to assess the impact of treatment, thus optimizing treatment decisions for patients with recurrent and/or metastatic head and neck cancer.

Background: Symptom management medications are often compounded into topical gel formulations providing an alternative route of administration for hospice and palliative care patients. Though commonly used, transdermal absorption and bioavailability studies of these gel products are lacking. Chlorpromazine was studied because it is FDA approved for treatment of nausea and vomiting and is used off-label for treatment of agitation and delirium.

Objective: The objective of this study is to determine the transdermal absorption of chlorpromazine PLO gel in healthy adults.

Methods: Twenty-five milligrams of chlorpromazine in PLO gel was applied to 10 subjects' wrists and 100 mg was applied to 1 subject's wrist. Blood draws were completed preapplication and 1, 2, and 4 hours postapplication. This single-center unblinded study recruited healthy adults between 18 and 70 years of age. Participants were not pregnant, did not have an allergy to any component of the study medication, and were not taking a phenothiazine medication.

Results: Chlorpromazine was undetected in any of the 11 subjects' blood samples.

Limitations: There is an assumption of equivalent medication absorption in healthy patients and palliative care or hospice patients.

Conclusion: Rapid relief of symptoms at end of life is essential. Chlorpromazine in PLO gel may not be an effective treatment option since blood levels were undetectable at 1, 2, and 4 hours after topical application.

Cancer is the leading cause of disease-related death in children and adolescents. Pediatric patients with cancer suffer greatly at the end of life. However, palliative care interventions can reduce suffering and significantly improve the care of these patients and their families. A large percentage of pediatric deaths occur outside of the hospital setting where pediatric palliative resources may not be readily available. Patients in the home setting may be cared for by community hospice programs, which are typically staffed for adult populations. Increasingly, nonpediatric providers are asked to provide palliative care for children and adolescents at the end of life, yet they receive little formal training in this area. This review focuses on the principles of best practice in the provision of palliative care for children and adolescents with cancer. Our intent is to aid clinical providers in delivering optimal care to this patient population. Topics unique to pediatric palliative care that are addressed include: providing pain and symptom management in the broad pediatric range from neonate to adolescent; caring for and interacting with developmentally distinct groups; engaging in shared decision making with parents and adolescents; providing accommodations for prognoses that are often more uncertain than in adult patients; and delivering concurrent disease-directed therapy with palliative care.