Comments on Pallimed: A Hospice & Palliative Medicine Blog: Sertraline is not good for what ails you; Palliati...

Props also to Charles Wessel a librarian at Pitt w...

2007-07-20T08:52:35.075-05:00

Props also to Charles Wessel a librarian at Pitt who did this for Dr. Arnold and who provided two further systematic reviews on the subject:

One in Palliative Medicine

One in Br J CA

Note that neither of the 3 systematic reviews mentioned are specifically about advanced cancer and what there is about advanced cancer is mentioned in prior comments.

Thanks again Bob & Charles.

Here are the links from Drew's Post above with hyp...

2007-07-19T21:22:13.065-05:00

Here are the links from Drew's Post above with hyperlink

Number 1

Number 2

Number 3

Number 4

In response to my querying about good data support...

2007-07-19T17:07:00.558-05:00

In response to my querying about good data supporting antidepressant use in advanced cancer Dr. Bob Arnold asked one of his librarians to kindly run a search on this which he forwarded to me. My gloss: there aren't a lot of good data supporting SSRI use. As far as controlled trials go it looks like there have been 2 specifically evaluating fluoxetine in advanced cancer & both of these support its use. (cut & paste these into your browser address window if you want the link).

http://jco.ascopubs.org/cgi/content/abstract/21/10/1937

http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=9741068

There have been a couple other trials which included advanced cancer patients which were negative (didn't support antidepressant use).

There has been a recent systematic review of depression treatment in cancer which includes these two articles also. I blogged about it briefly here: http://www.pallimed.org/2006/11/advanced-directives-in-ny-times.html

And here is the original link: http://www.ingentaconnect.com/content/klu/520/2007/00000015/00000002/00000145

Anyway it seems the issues are multifold:
1) a lack of controlled trials in general.
2) a particular lack of controlled trials in advanced cancer patients
3) non-uniformity in definitions of advanced cancer patients, but this plagues a lot of cancer research
4) what evidence there is supports fluoexetine - it's unclear whether we can assume there is a 'class effect' here - whether we can generalize from fluoxetine to all SSRI's (like sertraline). on the one hand they are in fact all different agents, with different pharmacokinetics, and receptor affinities etc. on the other hand in depression in otherwise healthy adults they all seem equally efficacious (supporting a true class effect). someone tell me if this is wrong. it's reasonable to assume that depression in advanced cancer is different from depression in healthy adults.

So that's where things stand. None of this is to say we shouldn't be trying these drugs, we really don't know, and like most other things in palliative medicine sometimes they seem to help but often they don't. That, at least, is my experience.

Curious what others' thoughts are.

Anyway, Bob, thanks for the info.

While I agree with your first paragraph - drawing ...

2007-07-18T09:28:00.484-05:00

While I agree with your first paragraph - drawing on all the resources - the question is how much benefit does that provide our advanced cancer patients? Doing things, many things, doesn't mean we're helping....

Radionucleotide therapies are used at my institution for sure. Rarely, but that's because the indication for them seems relatively tight: multiple painful sites not feasibly or safely treated with external beam radiation. The research supporting them is relatively solid though. If radium turns out to be an effective antitumor/life prolonging therapy in hormone refractory prostate cancer we may be seeing much more of these.

I like your use of the phrase "quality of life boo...

2007-07-17T21:24:26.648-05:00

I like your use of the phrase "quality of life booster." Depression and end of life issues seem to get lumped together so easily, that SSRI's may often get started just for that reason, when a good clinical evaluation for depression may be required. It is important to draw on all the social resources that may be available to oncologists, and palliative care providers including social workers, chaplains, psychiatrists, psychologists, expressive therapies (art, music, and others). And then come up with a cohesive plan to address the multifactorial casues of depressive symptoms. Meds are not always the trick, but too often are they used in isolation.

I would love to see a raise of hands of how many physicians have ever prescribed or been involved with a patient who is actively receiving a radionucleotide. It may just be my geographical locations, or something else, but for as much as I read about radionucleotides in articles/textbooks, I have yet to see them used clinically. Anybody else feel this way? If not, tell me why I should be seeing/using them more.

Nice Coda.