Monday, September 3, 2007

Hypercalemia of malignancy; Palliative care for prisoners

Happy Labor Day.

Supportive Care in Cancer has an article about the natural history of hypercalcemia of malignancy in the age of bisphosphonates. The patients were 260 consecutive patients presenting to a cancer center in France with solid tumors, no prior history of hypercalemia, and who received bisphosphonate therapy. Median corrected calcium levels were 2.83 mmol/L (~11.32 mg/dL) and half the patients had either head & neck or breast cancer. Median survival was 60 days across the cohort. The authors looked at patient characteristics associated with worse prognosis and the following ones survived multivariate analysis: corrected calcium over 2.83, hypoalbuminemia (<3.5 g/dL), squamous-cell histology, bone mets, and liver mets. Of note, women lived twice as long as men (94 vs 45 days), and one wonders if this was due to a preponderance of breast cancer in these patients, although this sex difference didn't survive multivariate analysis and survival based on underlying prognosis was not broken out.

This is an interesting article for a couple of reasons. Various sources have quoted for years that prognosis in the setting of hypercalemia of malignancy is dismal, but the last time I did a literature review on this it seemed that most of the studies (and there are only a few) were old (1980's, early 1990's), had relatively small N's, and were done prior to the use of bisphosphonates. So this recent data (which is, to be sure, from a single institution, although it does have a decent N for this type of study) is an important addition and, unfortunately, demonstrates that prognosis remains dismal for these patients, despite the availability of bisphosphonates.

2) JAMA continues their 'perspectives on care at the close of life' series with one on palliative care for prison inmates. It's a general overview, and well written. This is a topic I really have known nothing about and found it quite interesting. There are many differences in care between the civilian and prison worlds although, as the following he said/she said suggests, some things are exactly the same:

"DR V:
Mr L gets MS Contin, I believe 90 mg every 8 hours. He can have Vicodin at pill call for breakthrough pain. . . . When I ask him about pain, he says it's fine. I have no reason to doubt him.

MR L: [The pain] gets pretty out of hand sometimes. . . . If you can catch the right nurse or the right doctor, they can situate you where they can help you some. If you were to gauge my pain on a scale of 1 to 10 right now, it would be about 8.5. I’ve learned to deal with that kind of pain. I don't want to be totally out of pain because then I won't know what I'm really going through."

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