Sunday, September 23, 2007

Hematologic malignancies; Lung cancer guidelines; Screening for depression; NSAIDs & opioids

In no particular order:

1)
Internal Medicine Journal has an editorial calling for closer integration of palliative care into the care of people with hematologic malignancies. It's from an Australian perspective although seems to be broadly relevant internationally and speaks to some of the issues I see in my own practice:

"The unique biology of blood cancers has traditionally been seen as one of the key obstacles to the integration of palliative care. It is now understood that it is the varying professional perspectives, rather than the unique biological circumstances of haematology, that makes the difference. There are indeed special considerations for haematology patients, which can include factors such as the high-tech and invasive nature of treatments offered that at times are myeloblative and may involve transient bone marrow failure; the speed of change to a terminal event; the need for blood products and the possibility of catastrophic bleeds. At times there can be a blurring of the distinction between the curative and palliative phase. However, evidence indicates that in most cases there are clear indications that the terminal stage has been reached."

At least in the US - the 'hospice model' doesn't work well for some patients in the terminal phases of hematologic malignancies - especially those that remain ambulatory (and many do) and continue to benefit from blood products, antimicrobials, and even myelosuppressive therapies. However, part of the impetus for palliative care in the US has been to provide 'hospice-like' care to those who (due to prognosis, goals, or - frankly - cost) are not 'hospice-appropriate' and it would seem this is a prime patient population for this.

(This editorial was prompted by a report which is supposedly found at this website but I can't find it. Leave a comment (with link) if you find it.)

2)
Chest has published the ACCP evidence-based guidelines for palliative care for lung cancer patients as well as guidelines for palliative care consultation, quality of life measurement, and bereavement.

The first is mostly a comprehensive, summative review of the literature for symptom control & supportive care of the lung cancer patient. It's quite long & a good one for the teaching file, and very much comes from a 'chest physician' (pulmonologist, thoracic surgeon) perspective. For me its sections on bronchoscopic palliative procedures, hemoptysis management, tracheoesophageal fistula management, effusion management, etc. are the most interesting and worth a read.

The second does the same thing but talks about the role of palliative care consultation, qol stuff, and psychosocial/familial/bereavement aspects of caring for lung cancer patients. It gives the following recommendation grade I-C evidence (meaning there's pretty good data to support it):

"For all patients with advanced lung cancer (and their families), it is recommended that palliative care be integrated into their treatment, including those pursuing curative or life-prolonging therapies. "

Most notable, however, is the column-space this article gives to bereavement - including clinician bereavement. I practically wept when I realized these formal, professional-society based, evidence-based guidelines gave (not insubstantial) space to these matters. There's nothing earth shattering here - it's just the fact that the topic is taken seriously that makes me slightly hopeful for medicine in the 21st century. This is how it starts:

"The grief experience of clinicians is similar to that of loved ones, in quality if not in severity, but the term disenfranchised has been applied to the grief of clinicians because it seems somehow less legitimate than the grief of family and friends. There are additional challenges that involve issues of professional maturity, competence, integrity, and interprofessional friction that may contribute to special difficulties for clinicians. Of particular note is the tendency of clinicians to blame themselves for imagined failures; grief may be more intense if it is believed that the death was preventable."

(Thanks to Dr. Bob Arnold for alerting me to these.)

3)
Annals of Oncology has an interesting look at screening for depression in cancer patients. It's a German study in which a bunch of hospitalized cancer patients were given the Beck Depression Inventory - the authors looked to see how many patients screened positive for depression based on somatic symptoms vs. affective symptoms. The study involved prospectively evaluating ~200 adult cancer patients (mean age 57 years, all hospitalized with newly diagnosed cancers to receive first line chemotherapy) with the BDI. They found that 8% had 'clinically relevant depression' (defined as a score of at least 18 on the BDI) but that most of these this was due to somatic symptoms (fatigue, sleep disturbance, etc.) and not affective symptoms (anhedonia, hopelessness, helplessness, etc.). Using only affective symptoms they suggest only 3% of the population would have 'clinically relevant' depression. Besides the fact that these figures all seem generally low, this study more or less confirms what we already know - the somatic symptoms of cancer interfere with the diagnosis of depression, we have to be quite careful particularly before instituting pharmacologic therapy, and the BDI is an inappropriate diagnostic aid in cancer patients. I realize there is some controversy around this - how much somatic symptoms should be weighed in our diagnosis of depression in cancer. I've always stuck to the affective symptoms only, but would like to hear other perspectives if you've got them - leave a comment.

4)
Supportive Care in Cancer has an article (a randomized trial) of starting an NSAID along with morphine for cancer pain. It's a small Brazilian trial, and involves dipyrone, an NSAID not available in the US. It randomized 34 cancer patients (opioid naive, with a variety of pain syndromes) with baseline pain scores ~7/10 to morphine 10mg q4 hours scheduled plus either scheduled dipyrone or placebo. Patients received this for 48 hours then crossed over (to either placebo or dipyrone) and followed for another 48 hours. Dipyrone patients did better: achieved analgesia faster. In fact, the placebo group had basically no analgesic response until dipyrone was added after 48 hours which, besides the very small N and the fact that I think the cross over time of 48 hours is too short, is the major concern I have with this. The morphine-only-first group didn't respond at all to their morphine (for whatever reason): this indicates to me they weren't getting morphine dosed appropriately - they weren't going through a dose-titration phase - and so at best one could argue that dipyrone is effective when added to fixed-dose morphine. A hypothesis-generating aspect of the study, though, was that those patients who received the NSAID initially, even after it was switched to placebo, had a sustained analgesic reponse from it (they continued to do better than those who were started on dipyrone at 48 hours). I'm often reluctant to use NSAIDs for many cancer patients due to comorbidity and bleeding risk (especially those who are or who will soon be undergoing chemotherapy or procedures): this study raises the possibility that it might benefit patients to give them short-term NSAID therapy along with the opioid.

(Thanks to Dr. Sean Marks who presented this paper at our group's journal club.)

5)
And finally, in line with #2 above, Annals of Internal Medicine's recent clinical update in critical care medicine gives space to end-of-life care (it reviews this article). So hooray.

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