Monday, January 11, 2010

JCO round-up

In addition to my prior post, a handful of additional articles from recent Journal of Clinical Oncology issues:

JCO has a paper on video-assisted advance care planning for cancer patients (see here for a prior post; see here for lots more). This study involved outpatients with aggressive brain cancers (n=50, mean age in 50s, over 3/4 rated their current health status as good or better, about 50% reported they would not want CPR at baseline) who were randomly assigned to either a verbal description of advanced cancer and different treatment options or that plus a short video showing the different treatment options in real life. Advanced cancer "was defined to participants as being "very sick" in a situation where they may or may not be able to speak for themselves" (as far as I can tell no discussion of time-based prognosis or inevitability of death). The treatment options given were 'comfort care,' 'basic medical care' (essentially life-prolonging treatments short of ICU-level care), and 'life-prolonging care' (everything including ICU level care, CPR, mechanical ventilation, etc.).

The video (no sample available unfortunately**) is described as the following:

In the video, life-prolonging care images included: an intensive care unit with a ventilated patient being tended to by respiratory therapists; a simulated code with clinicians illustrating CPR and intubation; and various intravenous medications including vasopressors administered through a venous catheter. Visual images to depict basic medical care included: a patient getting antibiotics via a peripheral intravenous catheter; scenes from a typical medical ward service; and a patient wearing a nasal cannula. The video depiction of comfort care included: a patient on home hospice care receiving pain medications; a patient with a nasal cannula comfortable on oxygen at home; and a medical attendant assisting a patient with self-care.
There were marked differences in levels of care that the patients said they'd wish for themselves: for the verbal-only patients 22% said they'd prefer comfort care, 52% basic care, and 26% full life prolonging care. For the video patients, 91% said they'd prefer comfort care, 4% basic, and one uncertain. More patients changed their mind about CPR in the video group as well (48% declined it at baseline, wheras 91% declined it after the video). (Yes this means the patient who wanted basic care also said, presumably, they wanted CPR.)

**Angelo Volandes, the senior author of the article, has a website with his videos, but they are behind what I think is a paywall. I've seen one of his early videos on advanced dementia and it is very reasonable and well-balanced.

There is an updated clinical practice guideline on chemotherapy for stage IV non-small cell lung cancer (free full-text here). It's an interesting read for, in particular, beginning fellows who need some sort of introduction to the anti-neoplastic approach to this cancer we see all too-commonly in palliative care practice settings. Note that this is a CPB about chemotherapy for NSCLC, and basically ignores other aspects of care. It does represent a concise summary of the benefits (such as they are) of newer, targeted agents (erlotinib, etc.). On the ASCO website there is an unabridged version of the recommendations (pdf here) which ends with a few pages on discussion chemotherapy with patients, including how to discuss risks and benefits, which also specifically mentions the problems with discussing median survival data (using the infamous bevacizumab example - which is basically that most patients got no benefit, but the percent who did got a lot of benefit/life-prolongation, meaning that the median survival for the study population increased by 2 months but that is an incredibly poor way of actually communicating to patients what they can expect).
Although most clinical trials report the median survival time of the control arm and the experimental arm, it is the consensus of the Update Committee that quoting comparative median survival times to a patient can be misleading. For example, a patient who is considering whether to take bevacizumab with carboplatin/paclitaxel may learn that bevacizumab improves median survival by 2 months (from 10.3 to 12.3 months). A common misconception of an individual patient is that taking bevacizumab will allow him or her to live 2 months longer. On the contrary, some patients experience treatment- related death related to bevacizumab, whereas other patients may live many months longer as a result of the beneficial effects of the drug. Patients who request statistics must be reminded that these numbers are based on the experience of thousands of patients, with median survival time representing the experience of the majority of patients. Physicians can explain what median survival time means—that is, half of the patients live longer, and half die sooner. However, there are patients who live much longer or much shorter than the median survival time.
There's a review of depression screening/diagnosis instruments in geriatric cancer patients. Believe it or not, 'there are insufficient data to...' etc. etc. It's a tidy overview however of many of the most common scales, and how they've been evaluated. Anyone out there using a specific scale for older cancer patients?

There's a look at emotional distress experienced by bereaved family members of patients who died in Japanese palliative care units. There's an interesting finding that overhearing conversations between medical staff outside the room at the time of the patient's death was one of the strongest predictors of 'high level distress' in bereaved family members. I'm curious as to why they chose to even ask that question (they describe how their questionnaire was created but it's not clear where individual questions came from).

There is an exploratory study of parents of children with cancer who were likely to die and nearing death (the parents had made a decision for either enrollment in a phase I study, a DNR order, and or initiated a plan for end of life care) - looking into how these parents conceptualized being a 'good parent' as they made these decisions.

And finally, a few supportive care articles I'll mention in passing: one on case management (and related) programs for symptom surveillance (didn't do much); another on a home nursing program to monitor symptoms for patients on oral chemotherapy which seemed to be helpful; and another on the frequency of insomnia in cancer patients on therapy.