Tuesday, April 10, 2007

Proxies; Single-fraction radiotherapy; Cancer symptom research; We are responsible for all the ills of the 20th century


Several things, relatively briefly:

1)
The latest JCO has a couple of articles to note. First presents some research looking at if female cancer patients identify different individuals as their health care proxies and primary caregivers. It is from a survey of older women with cancer and finds that only about half of them name the same person to be their health care proxy decision maker, emergency contact, as well as their primary support person/caregiver. This finding was true even for women in partnered relationships. The second is a systematic review of radiotherapy for analgesia of painful bone metastases, specifically looking at single vs. multiple fraction radiotherapy. It confirms the consensus: they are about equally effective in providing analgesia, toxicity is about the same, but people receiving single-fraction are distinctly more likely to need re-treatment.

2)
March's Journal of Supportive Oncology has a few articles to note (several don't have abstracts; table of contents here; pdf's are available free even for those without abstracts). First is a review on warfarin use (and the many, many ways it can go wrong) in cancer patients: a good all around primer/review on the subject. Next is a narrative summary of 20 years worth of cancer symptom research by the NCI & the North Central Cancer Treatment Group (Mayo). By narrative I mean a rapid fire review of the supportive cancer/symptom research of this group touching on everything from pain to mucositis to anorexia to hot flashes. It's the sort of article to keep handy as a quick evidence based reference list for cancer symptom research--i.e. it's got a killer bibliography. It also points to the frequency but importance of negative research--research that indicates the intervention in question isn't helpful. Without it we'd all be peddling pentoxifylline for anorexia. There's a supporting editorial by Charles von Gunten wondering why the NCCTG's cancer symptom research hasn't been replicated elsewhere--why there is such a dearth of organized, sustained symptom research elsewhere, like by ECOG or SWOG? His assessment: lack of money and lack of leadership, although NPCRC is a good sign.

3)
Internal Medicine News recently had a few of articles about palliative medicine. First is one overviewing quality/performance measures in palliative care. It mostly focuses on the work of the National Quality Forum. Another discusses the American Osteopathic Association's approval of palliative medicine as a subspecialty under their board (this is not big news; it was expected to have happened and I guess it did in February). The final one is an editorial which seems to have a bone to pick with hospice/palliative medicine as a subspecialty. Sort of. I think you'll see what I mean if you read it. It seems to criticize HPM for being a 'place' based speciality (hospice) although, clearly, it isn't. Then it criticizes HPM for the following reasons:

"There is a special peculiarity to end-of-life care, in that it may be applied to a patient of any age, of either sex, of one of many cultures and beliefs, and with one of any number of physical conditions. The “dying process” is sometimes viewed as if it were a single definable and predictable process for all who are dying, as opposed to a unique individual experience shaped by the terminal disease and by the attitudes and circumstances of the patient's entire life.
In hospice, system requisites—not individual patient requisites—are applied to the dying at enrollment: the defined “time taken for dying” criteria for entry (occasionally resulting in the discharge of a patient who doesn't die fast enough); mandated concurrence with a Do Not Resuscitate order (despite the desire of some people to fight to the bitter end); and favored diagnostic categories (with cancer patients, for example, often getting preference over equally ill emphysema patients)."

As for the first point, we, as a profession, seem to be very aware of death being a unique individual experience etc. etc.; that is why, among other things, we are deliberately & self-consciously inter- & multi-disciplinary because individual patients and families have needs that are complex, unique, and usually beyond the skill set of any one profession, let alone individual. The second set of critiques, about hospice system requisites are either 1) inaccurate (the DNR bit), 2) descriptions of poor care, or 3) well-recognized limitations of the (at least U.S.) model of hospice care as defined by Medicare. Hospice isn't for everyone; most palliative care professionals would be the first to tell you that. I'm picking on the parts of the editorial which galled me; many other points were welcome, particularly about problems with further fracturing patients' care with another subspeciality thrown in the mix. However, by the time it came to its last sentence I frankly had no clue what the editorialist was talking about:

"As we know from the lamentable history of the 20th century, when the system becomes the patient, terrible things can happen. This frightens me and should frighten us all."

Huh?

(IMN's website currently appears to be allowing free access to articles for everyone; it's usually free for those who sign-up. I've found it a little testy today however but hopefully it won't give readers major trouble--the March 15th issue is what you want.)

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