Wednesday, March 28, 2007

Fatigue & QOL in cancer; Bleeding in head & neck cancer; Perception of pain control; Palliative feel-goodery in the ICU


1)
Annals of Oncology has an article examining fatigue and quality of life in cancer patients receiving radiation therapy. It looked at 70 patients (breast or lung cancer, average age 64, ECOG mostly 0-1, about half had received chemotherapy) receiving curative-intent radiation. The data comes from a single administration of the ubiquitous EORTC QLQ-C30. Basically they found that fatigue had the highest correlation with quality of life (r of -0.76); fatigue's premiere importance to predicting quality of life withstood multivariate analysis, more than any other single symptom or group of symptoms.

It's long been recognized that fatigue is routinely found to be the most prevalent symptom reported by cancer patients (pretty much in any stage of their disease--even those who are years out from curative therapy). This study finds fatigue is the most important predictor of health related quality of life--at least in this group of cancer patients. The question, for me, is what is fatigue? Is it a discreet symptom (which then has discreet symptom-specific therapy like pain, vomiting, pruritis, constipation, edema, etc.) or is it something else? Because one interpretation of this study is that patients saying they are fatigued is sort of the same thing as them saying "my health related quality of life is bad." "I, globally, don't feel well or whole." This, is a different thing than, say, announcing, "I itch." What all this means, I don't know.

2)
Supportive Care in Cancer has an article looking at the natural history of patients who receive transcutaneous arterial embolization for massive bleeding in head and neck cancer. It reviews the experience of ~60 patients at a single center in Taiwan who received angiography and if possible TAE (which involves femoral artery --> carotid artery catheterization and then embolization with foam, alcohol, or coils to try to stop the hemorrhaging) after 'conservative measures' failed to control their bleeding. Median survival was 16 days and over a quarter of patients died within 48 hours of angiography. Patients who were able to receive TAE lived a median of 26 days vs. 8 days for those who didn't receive TAE. It would have been interesting if they presented the survival of patients who presented hemorrhaging but didn't receive angiography at all but oh well. For me this was an interesting piece of research insofar as it documents the natural history of these unfortunate patients with intractable hemorrhage: it is astonishgly dismal. These uncontrolled data suggest TAE prolongs life (triples median survival in fact) which is notable, but what those extra 18 days were like is unclear to me.

3)
Pain has an article about perception & pain in cancer patients with pain. It looked at ~300 adult cancer outpatients with pain (mean 6.7 on a 0-10 NRS)--they answered questionnaires about their pain. 90% of this group felt that their pain could be controlled & 70% felt like it currently was controlled. The researchers did some fancy statistical modeling (which I didn't understand at all) and conclude that their data suggest that: patients' perceived control over their pain was related to their symptom distress level (but not to their functional status). The authors seem to conclude that their findings suggest that patients' sense of control over their pain can be an important tool to decrease their distress from the pain. Perhaps true, but I remained unconvinced that what they were finding was anything other than a simple relationship: pain poorly controlled/pain causing much distress --> patients' 'perceived control' over their pain was diminished (or its inverse: pain well controlled --> patients feel they have control over their pain). This is distinctly different than concluding that perception of control leads to lower symptom distress. The fact that I remain unconvinced of this of course doesn't mean I'm right--maybe I just don't understand their model.

4)
Quality and Safety in Health Care recently had an article about the development of a 'palliative care bundle' in the ICU. The background on this is that a lot of the quality improvement initiatives in the ICU have been around 'bundles'--a set of practices (ideally evidenced based) designed to improve care/reduce complications/etc. in the ICU. Classic ones are the "ventilator bundle" (semi-recumbent positioning, daily awakenings, dvt prophylaxis, etc.) and the "central line bundle." This group developed their recommendations based on several sources (mostly expert opinion) and proposed their bundle (which includes triggers for communication/family meetings/discussing patient values/wishes/and goals of care, pain and symptom assessments, emotional and spiritual support). They even gathered baseline data in several ICUs to see how well these things were already being done in these units (very mixed results). Who knows where this will go but it is exciting. There certainly does seem to be a growing awareness, coming from within the critical care community itself (as evidenced by the growing amount of palliative care "flavored" research being done in ICUs, issues being devoted to palliative and terminal care in ICU journals, etc.), that great improvements can be made in 1) care of the dying in ICUs and 2) 'humanizing' the ICU experience, in general, for patients and families. This bundle project is very much a part of this trend. The article however also highlights how hard it is to find quality outcome research to base these guidelines in--there's a lot of opinion and experience to base things on but in order for practice to change frequently you need outcome evidence as well--so you can say "See, this really does make a difference. We are not just promoting a lot of empty feel-goodery." Thus, the importance of research like this.

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