Abstract
Fede A, Miranda M, Antonangelo D, et al. Use of unnecessary medications by patients with advanced cancer: Cross-sectional survey. Support Care Cancer 2011;19: 1313–1318.
Cancer patients at the end of life not infrequently take numerous medications. However, it has not been assessed what proportion of patients take unnecessary medications and which patients are at risk for doing so. In this cross-sectional survey of medications, the authors attempted to evaluate medications utilized by terminally ill ambulatory cancer patients, with the aim of identifying medications considered unnecessary. Results demonstrated that among 87 patients, 21 (24%, 95% confidence interval [CI] 15.6%–34.5%) were taking at least one unnecessary medication, the most common being gastric protectors. In multivariable analyses, patients with Charlson Comobidity Index ≤1 (odds ratio [OR]: 4.49, CI 95% 1.32–15.26; p=0.01) or whose medication list had not been reconciled by physicians (OR: 6.38, CI 95% 1.21–33.40; p=0.02) were more likely to use an unnecessary medication. The authors concluded that patients with advanced cancer take many medications considered unnecessary, and that medication reconciliation should be performed routinely for these patients.
Hayes RD, Lee W, Rayner L, et al. Gender differences in prevalence of depression among patients receiving palliative care: The role of dependency. Palliat Med 2011. (Online ahead of print publication)
In community studies the prevalence of depression is higher in women than men; however, in palliative care settings this relationship is usually less strong, absent, or even reversed. In this cross-sectional study, the authors attempted to identify reasons for excess depression among men receiving palliative care. Three-hundred patients recruited from a large hospice in South East London were studied. Depression was measured using the Primary Care Evaluation of Mental Disorder. Results demonstrated the higher prevalence of depression among men was not explained by a higher prevalence of particular types of cancer nor confounding by other covariates. Possible effect modifiers were examined. Depending on others for help with basic tasks (eating, dressing, washing, or using the toilet) was a risk factor for depression in men only, with 37.8% of dependent men being depressed compared with 2.4% of similarly affected women (OR=24.3, 3.1–193.2, p=0.003). A dose-response effect between the level of dependency and depression in men (p for trend=0.01) was also observed. The authors conclude that depending on others for help with basic tasks appears to contribute to the burden of depression among men with terminal illness. This gender-specific association may explain why the usual gender differences in depression prevalence are not observed in palliative care.
Banerjee S, Hellier J, Dewey M, et al. Sertraline or mirtazepine for depression in dementia (HTA-SADD): A randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011;378:403–411.
Depression is common in dementia but the evidence base for appropriate drug treatment is sparse and at best equivocal. In this parallel-group, double-blind, placebo-controlled study, the authors attempted to assess efficacy and safety of two of the most commonly prescribed antidepressant drugs, sertraline and mirtazapine, compared with placebo. Study participants were recruited from old-age psychiatry services in nine centers in England. Participants were eligible if they had probable or possible Alzheimer's disease, depression (lasting ≥4 weeks), and a Cornell scale for depression in dementia (CSDD) score of 8 or more. Participants were ineligible if they were clinically critical (e.g., suicide risk), contraindicated to study drugs, on antidepressants, in another trial, or had no caregiver. The clinical trials unit at King's College London (UK) randomly allocated participants with a computer-generated block randomization sequence, stratified by center, with varying block sizes, in a 1:1:1 ratio to receive sertraline (target dose 150 mg per day), mirtazapine (45 mg), or placebo (control group), all with standard care. The primary outcome was reduction in depression (CSDD score) at 13 weeks (outcomes to 39 weeks were also assessed), assessed with a mixed linear-regression model adjusted for baseline CSDD, time, and treatment center. Results demonstrated that decreases in depression scores at 13 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (mean difference 1.17, 95% CI −0.23 to 2.58; p=0.10) or mirtazapine (0.01, −1.37 to 1.38; p=0.99), or between participants in the mirtazapine and sertraline groups (1.16, −0.25 to 2.57; p=0.11); these findings persisted to 39 weeks. Fewer controls had adverse reactions (29 of 111 [26%]) than did participants in the sertraline group (46 of 107, 43%; p=0.010) or mirtazapine group (44 of 108, 41%; p=0.031), and fewer serious adverse events rated as severe (p=0.003). Five patients in every group died by week 39. The authors conclude that because of the absence of benefit compared with placebo and increased risk of adverse events, the present practice of use of these antidepressants for first-line treatment of depression in Alzheimer's disease should be reconsidered.
Shah H, Gemmete JJ, Chaudhary N, et al. Acute life-threatening hemorrhage in patients with head and neck cancer presenting with carotid blowout syndrome: Follow-up results after initial hemostasis with covered-stent placement. Am J Neuroradiol 2011;32:743–747.
Covered stent placement (CSP) in patients with head and neck cancer (HNC) presenting with carotid blowout syndrome (CBS) can provide immediate hemostasis to prevent exsanguination. The authors evaluated the safety and efficacy of CSP to control acute life-threatening hemorrhage in patients with HNC presenting with CBS by retrospectively reviewing 10 patients (7 men, 3 women; mean age, 59 years) with HNC presenting with acute life-threatening hemorrhage from CBS that was treated with CSP. The authors studied patient demographics, presentations, procedures, initial and delayed complications, and technical and clinical outcomes on follow-up. Results demonstrated that all patients achieved immediate hemostasis following CSP. Periprocedural complications consisted of groin hematomas (n=2), acute limb ischemia requiring thrombectomy, and an asymptomatic temporal lobe hemorrhage. Imaging and clinical follow-up were available for a mean of 17.7 months (range, 1–60 months). Two patients remained asymptomatic with a patent stent and no evidence of rebleeding at 17 and 21 months, respectively. Recurrent hemorrhages requiring retreatment were encountered in 3 patients secondary to stent infections (30%) at mean duration of 8 months. Neurologic morbidity resulted from stent thrombosis and stroke at 8 months in a single patient. Mortality was unrelated to CSP but was a result of palliative hospice care (n=3) at a mean of 2 months or natural disease progression (n=1) with documented patency of the stent at 6 months. The authors conclude that acute life-threatening hemorrhage from CBS related to advanced HNC can be safely and effectively treated with CSP. However, potential delayed ischemic or infectious complications are common in the exposed or infected neck.
Heffner JE. Advance care planning in chronic obstructive pulmonary disease: Barriers and opportunities. Curr Opin Pulm Med 2011;17:103–109.
Experts in palliative care have increasingly recognized the global epidemic of chronic obstructive pulmonary disease (COPD), its astonishing rise in prevalence, and its profound impact on patients' quality of life and functional capacity. Unfortunately, patients with COPD receive less advance care planning (ACP) and palliative care when compared with patients with other diseases with similar prognoses. In this review, the author highlighted recent advances in identifying barriers to ACP and opportunities for providing more effective and timely palliative care. For example, patients with COPD identify dyspnea as their most disabling symptom, with disease-directed care providing only partial relief, and with dyspnea eventually becoming refractory and requiring transition to palliative care. Throughout all stages of COPD, however, integrating palliative care with disease-directed treatments improves patients' well-being and functional capacities. Because of the unique disease trajectory of COPD, professional groups have proposed new models for palliative care specifically tailored to COPD, as patients benefit from better integration of palliative and disease-specific care throughout the course of their disease from diagnosis to death, not just at the end of life. Pulmonary rehabilitation may provide a platform for coordinating integrated care. Moreover, health agencies will increasingly expect better coordination of services for patients with this progressive, disabling, and eventually terminal disease.
Campos MP, Hassan BJ, Riechelmann R, Del Giglio A. Cancer-related fatigue: A practical review. Ann Oncol 2011;22:1273–1279.
Fatigue is an exceedingly common and often treatable problem in cancer patients that profoundly affects all aspects of quality of life. Prevalence estimates have ranged from 50% to 90% of cancer patients overall. After addressing reversible or treatable contributing factors, such as hypothyroidism, anemia, sleep disturbance, pain, emotional distress, climacterium, medication adverse events, metabolic disturbances, or organ dysfunction such as heart failure, myopathy, and pulmonary fibrosis, patients may be screened with a brief fatigue self-assessment tool. All cancer patients should be screened regularly for fatigue. Those with moderate or severe fatigue may benefit from both pharmacologic and nonpharmacologic interventions, whereas mild fatigue that does not interfere with quality of life can be treated with nonpharmacologic measures alone. Physicians often have insufficient knowledge about fatigue and its treatments or underestimate the impact of fatigue on quality of life, whereas patients may consider it an unavoidable and untreatable side-effect and fear that reporting it may incite a change toward less aggressive cancer treatment. This practical review may be useful to health care professionals in order to avoid the common barriers to its treatment that exist on the sides of both physicians and patients.