Wednesday, November 28, 2007

Desire for prognostic information; BPR3; Trolling/Kevorkian; More

Blogging on Peer-Reviewed Research1)
Journal of Clinical Oncology
has a paper on elderly cancer patients' desire for information and involvement in treatment decisions. The study involved 75 (out of ~250 originally screened) patients over 70 years old and within a few months of a diagnosis of metastatic colorectal cancer. 80% had ECOG performance statuses of 0 or 1 (no symptoms or mild symptoms without disability). The patients were asked a variety of questions about their understanding of the cancer/prognosis; wish for prognostic information; how they make decisions; etc. Their physicians were also asked questions about what they thought their patients preferences were.

The major findings were: only 44% of patients wanted prognostic information (about survival); males were more likely to want prognostic information but no other demographic or disease characteristic predicted wanting to know prognosis; there was an even split between patients who wanted more active/collaborative vs. more passive treatment.

The really, really interesting findings were: 1) only 25% of patients had received prognostic information on survival from their physicians - including most of those who wanted it, 2) 'most' (the authors frustratingly don't give a number on this) patients reported that they believed 'chemotherapy was somewhat likely or very likely to cure their cancer,' and 3) patients who actually had received prognostic info from their docs were less likely to believe #2. And, consistent with previous research findings, physicians were overall very poor predictors of which patients wanted prognostic info or what the patients' decision-making preferences were.

The abstract to this article initially caught my eye because the 44% wanting prognostic information struck me as really low - many other studies have found that the vast majority of advanced cancer patients want this information (at least in the US and Australia). Reading the paper, however, and realizing that over half of these patients (96% of whom were starting chemotherapy) mistakenly thought that the chemo had a decent chance of curing them. These, then, were people who did not necessarily perceive that they had a life-limiting (and by all reasonable definitions terminal) illness and may not even realize that discussions of prognosis/time were, potentially, timely. (Desire for prognostic information has been closely correlated with perceived survival - the sicker you are the more likely you are to want to talk time.)

The clinical message here is pretty simple - talk to your patients about what they want to know and how they want to make decisions (this is all very consonant with comments on a recent post about never assuming anything about your patients). The other issue is the persistent and repeated finding in many different studies that a substantial number of patients with incurable cancers seem to think they're receiving potentially curative therapy. In this study, in particular, the numbers are so high (over 50% - my memory tells me the figure is usually a third) - despite the relatively really high educational level of the patients - over 60% had post-high school education which is quite high for most studies like this. It strikes me that this question, itself, is worthy of a study - how much of this is people choosing to believe what they want to believe vs. unclear communication with the oncologist vs. other factors?

(Full reference: Elkin EB et al. Desire for information and involvement in treatment decisions: elderly cancer patients' preferences and their physicians' perceptions. J Clin Oncol. 2007;25:5275-80. DOI: 10.1200/JCO.2007.11.1922)

Well what is that 'blogging on peer-reviewed research' icon at the top of the post all about? Click on it to find out. It's from the Bloggers for Peer-Reviewed Research Reporting (BPR3) project which is, among other things, a way of marking and sharing blog posts which seriously discuss peer-reviewed research:

"Bloggers for Peer-Reviewed Research Reporting strives to identify serious academic blog posts about peer-reviewed research by offering an icon and an aggregation site where others can look to find the best academic blogging on the Net."

This is something which we have been striving to do at Pallimed from the beginning (although certainly not with all our posts) and we were pretty excited about the project when we heard about it.

Placing the 'blogging on peer reviewed' research icon on a post is not just a vanity plate on a blog post - it enables the post to be identified through search functions as a BPR3 post, and eventually there will be an aggregator site collecting/sorting all the BPR3 posts (this is still in the works - you can sort of do it now at Technorati). So, we're joining the movement, and hope that it thrives.

The only difference you'll likely notice - besides the icon on those posts - is that we will start placing the full article reference (& doi if available) per the BPR3 posting guidelines.

A nod to Christian for finding out about this and suggesting we do it - thanks.


Archives of Internal Medicine has a paper on depression in COPD patients (common and undertreated although not convincingly/strongly predictive of hospitalization or morality).

Journal of Supportive Oncology has a fascinating article describing an 'oral PCA' system for cancer patients (abstract here - JSO always has free full-text available). Basically it's a bedside device for dispensing a patient's oral breakthrough meds (with a lock-out - e.g. no more than 2 pills in 4 hours etc.) without the involvement of a nurse or someone else to dispense it. It uses a radiofrequency tag technology to prevent anyone besides the patient from accessing it. The study more or less presents acceptibility/feasibility data from a pilot trial.

My initial reactions. Pro: patients don't have to wait for nurses to dispense the drug which is good; patient control is a nice idea. (Potential) cons: could decrease pain assessment; divertable. The real question is: what is the problem this is trying to fix? It may be a legitimate one but if the purpose is to improve pain management the problem in hospitals is not due to a dispensing delay of oral analgesics....

And finally, Christian got really annoyed with this recent NY Times article about the whole so-called Medicare 'hospice cap' situation and since he is not going to post for a few days I offered to post it.

How about this nugget:

'Some providers have survived only by aggressively recruiting new patients, using this year’s Medicare reimbursements to pay off last year’s cap charges, while stalling for Congressional relief. Ms. Youngblood, the Hometown Hospice nurse, said that after she visited her charges — doling out their pills, and turning the sweet potatoes in their ovens — she trolled for new patients at nursing homes and senior centers.

At the small hospital here, she said, the nurses joke about her “marketing” forays: “They’ll say, ‘Here comes Nurse Kevorkian. She has no shame.’ And I’ll say, ‘Look, I have to have a paycheck, too.’”

When 'trolling' and 'Kevorkian' are one sentence that's the face of hospice I love to see in the media.

I actually had been unaware of the hospice cap issue until the Hospice Guy began posting about it recently (see his last 4 or 5 posts here at Hospice Blog for an indepth discussion of it).

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