Abstract
Jordan K, Jahn F, Aapro M: Recent developments in the prevention of chemotherapy-induced nausea and vomiting (CINV): A comprehensive review. Ann Oncol 2015;26:1081–1090.
The prevention of chemotherapy-induced nausea and vomiting (CINV) has been revolutionized over the past 25 years. Guideline-based treatment means that vomiting can be prevented in the majority, but not in all patients. Therefore, antiemetic research continues with the goal of optimizing CINV control for all patients. This comprehensive review summarizes the research efforts in this field over the past few years. Emerging from this research are two new antiemetic agents, netupitant/palonosetron, the first antiemetic combination agent, and rolapitant, a new NK1RA.
In addition, studies have evaluated the benefits of olanzapine and ginger, explored optimal combinations of agents for delayed CINV prevention, confirmed that dexamethasone-sparing regimens are effective, and demonstrated the value of NK1RAs in high-dose chemotherapy settings as well as with certain moderately emetogenic chemotherapies such as carboplatin. Research has also validated the correlation between antiemetic guideline adherence and improved CINV control. Finally, regulatory authorities have used extreme caution in retiring some 5-HT3RAs or decreasing their maximum dose.
Clark JK, Fasciano K: Young adult palliative care challenges and opportunities. Am J Hosp Palliat Med 2015;32:101–111.
Young adulthood is a time of immense growth and possibilities. As a result, it is also a time when serious illness can have profound effects. This review examines the current data pertinent to young adult palliative care and discusses the challenges and opportunities where palliative medicine can enhance the care provided to this growing and vulnerable population. From the data, two primary themes emerged: (1) ongoing young adult development not only generates unique biologic disease burdens and clinical treatment options but also requires frequent assessment and promotion and (2) binary health care systems often leave young adults without access to developmentally appropriate health care. Given its interdisciplinary approach, palliative care is uniquely poised to address the challenges known to caring for the seriously ill young adult.
Longford E, Scott A, Fradsham S, et al.: Malignant bowel obstruction: A systematic literature review and evaluation of current practice. BMJ Support Palliat Care 2015;5:119.
Malignant bowel obstruction (MBO) is a recognized complication of advanced pelvic or abdominal malignancy frequently occurring in advanced stages of illness. Suggested incidences in ovarian carcinoma range from 5.5% to 42% and in colorectal cancer, 4.4% to 24%. Where surgery for MBO is inappropriate, medical management may help bring about resolution of the unpleasant symptoms.
The aim of this review was to evaluate current evidence and opinion on treatment of symptoms associated with MBO. A comprehensive systematic review of the literature was undertaken to evaluate the evidence for the medical management of MBO. A questionnaire-based survey was used to establish professional attitudes and opinions and to review current practice. Following exclusions, 44 relevant papers were systematically appraised.
Results revealed that there is good evidence for the use of octreotide to reduce secretions, and corticosteroids may help bring about resolution of MBO. Ranitidine may also reduce secretions. Venting gastrostomies can alleviate nausea and vomiting with low complication rates and may be considered where prognosis is greater than two weeks. No evidence was found for any specific medication to treat vomiting or pain associated with MBO. In local current practice, hyoscine butyllbromide is used first line to treat colic, cyclizine and/or haloperidol to treat vomiting, with levomepromazine second line. Corticosteroids and octreotide are routinely prescribed. In practice, consideration for referral for venting gastrostomies is guided by local surgical practice. The authors conclude that there is a paucity of evidence with regards to medical management of MBO; much more is required. Subsequent to this review, new local guidelines have been developed.
Morris SM, King C, Turner M, Payne S: Family carers providing support to a person dying in the home setting: A narrative literature review. Palliat Med 2015;29:487–495.
This study is based on people dying at home relying on the care of unpaid family carers. There is growing recognition of the central role that family carers play and the burdens they bear, but knowledge gaps remain around how to best support them. The aim of this study is to review the literature relating to the perspectives of family carers providing support to a person dying at home.
A narrative literature review was chosen to provide an overview and synthesis of findings. The following search terms were used: caregiver, carer, terminal care, supportive care, end of life care, palliative care, domiciliary care AND home AND death OR dying. During April and May 2013, Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO, Pubmed, Cochrane Reviews, and Citation Indexes were searched. Inclusion criteria were as follows: English language, empirical studies and literature reviews, adult carers, perspectives of family carers, articles focusing on family carers providing end-of-life care in the home, and those published between 2000 and 2013. A total of 28 studies were included. The overarching themes were family carers' views on the impact of the home as a setting for end-of-life care, support that made a home death possible, family carer's views on deficits and gaps in support, and transformations to the social and emotional space of the home.
The authors conclude that many studies focus on the support needs of people caring for a dying family member at home, but few studies have considered how the home space is affected. Given the increasing tendency for home deaths, greater understanding of the interplay of factors affecting family carers may help improve community services.
Breuer B, Chang VT, von Roenn JH, et al.: How well do medical oncologists manage chronic cancer pain? A national survey. Oncologist 2015. (E-pub ahead of print.)
Cancer pain is usually managed by oncologists, occasionally with input from specialists in hospice and palliative medicine (PLM) or pain medicine (PMD). The authors evaluated the knowledge of cancer pain management in these three specialty groups (PLM, PMD, and oncology). Eight vignettes depicting challenging scenarios of patients with poorly controlled pain were developed; each had five or six treatment choices. Respondents indicated choices likely to be safe and efficacious as “true” and choices likely to be unsafe or inefficacious as “false.” Two questionnaires were created, each with four vignettes. Three anonymous mailings targeted geographically representative U.S. samples of 570 oncologists, 266 PMD specialists, and 280 PLM specialists, each randomly assigned one version of the questionnaire. Vignette scores were normalized to a 0–100 numeric rating scale (NRS); a score of 50 indicates that the number of correct choices equals the number of incorrect choices (consistent with guessing).
Results demonstrated that the overall response rate was 49% (oncologists, 39%; PMD specialists, 48%; and PLM specialists, 70%). Average vignette score ranges were 53.2–66.5, 45.6–65.6, and 50.8–72.0 for oncologists, PMD specialists, and PLM specialists, respectively. Oncologists scored lower than PLM specialists on both questionnaires and lower than PMD specialists on one. On a 0–10 NRS, oncologists rated their ability to manage pain highly (median 7, with an interquartile range [IQR] of 5–8). Lower ratings were assigned to pain-related training in medical school (median 3, with an IQR of 2–5) and residency/fellowship (median 5, with an IQR of 4–7). Oncologists older than 46–47 years rated their training lower than younger oncologists. The authors conclude that their data suggests that oncologists and other medical specialists who manage cancer pain have knowledge deficiencies in cancer pain management. These gaps help clarify the need for pain management education.
Miller EG, Frizzola MA, Levy C, Greenspan JS: Recent experience establishing a new pediatric palliative care team. J Pediatr 2015;166:4–5.
Pediatric palliative care (PPC) has been growing in the United States over the last decade following calls from the American Academy of Pediatrics and Institute of Medicine to improve the care of children living with life-threatening and life-limiting conditions. Reports regarding program development describe teams that began seeing patients between 1999 and 2009. All reports described variable growth, however, often with an initial period of quiescence followed by a rapid increase in number of patients referred. The authors' team began in 2011, during which they saw an initial large influx of patients, followed by a brief lull and then a plateau. Their results were in direct contrast to the descriptions of other programs. In this article the authors take a closer look at the high rate of palliative care referrals to a new PPC team over the first 24 months of operation.
Leff B, Carlson CM, Saliba D, Ritchie C: The invisible homebound: Setting quality-of-care standards for home-based primary and palliative care. Health Affairs 2015;34:21–29.
Approximately four million adults in the United States are homebound, and many of them cannot access office-based primary care. Home-based medical care can improve outcomes and reduce health care costs, but this care operates in a quality measurement desert, having been largely left out of the national conversation on care quality. To address this shortcoming, two of the authors created the National Home-Based Primary and Palliative Care Network, an organization whose members include exemplary home-based medical practices, professional societies, and patient advocacy groups. This article describes the current status of home-based medical care in the United States and offers a brief narrative of a fictional homebound patient and the health events and fragmented care she faces. The article then describes the network's quality-of-care framework, which includes 10 quality-of-care domains, 32 standards, and 20 quality indicators that are being tested in the field. The same two authors also developed a practice-based registry that will be used for quality-of-care benchmarking, practice-based quality improvement, performance reporting, and comparative effectiveness research. Together, these steps should help bring home-based medical care further into the mainstream of U.S. health care.