I probably should have blogged these before but haven't.  The AAHPM for the last couple of months has been publishing "PC-FACS"--brief, critical summaries & appraisals of palliative care related articles (based on the POEMS or CAT EBM models of summarizing evidence).  Clearly this is something after my own heart.  This month's includes a review of the Lancet early decompressive surgery for malignant cord compression trial I blogged a while back.

This is the website's description of the PC-FACS:
PC-FACS (F ast Article Critical Summaries for Clinicians in Palliative C are), a new electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 30 medical and scientific journals. Each month, systematic reviews and insightful commentary on 3-4 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice.  In its first year of publication, PC-FACS is being e-mailed to AAHPM members as a benefit of membership. Comments from readers are welcomed at resources@aahpm.org.

Reviews of the more vicious cancers keep on coming out in the general journals, this time a "seminar" on small cell lung cancer in Lancet.  Not much to say about this but I am finding these reviews quite helpful as a non-oncologist.  This one has a middle section about the history of various chemotherapy regimens for small cell which is pretty interesting.  But I have to point out that even though this article doesn't have pretenses of "medical progress" like the NEJM one, there is not even a nod here to supportive--let alone palliative--care for this routinely lethal disease.  Not a peep.

September's J of Pain & Symptom Management has a couple of letters I wanted to highlight.  The edition as a whole has, as usual, a bunch of interesting articles (including one examining a switch from reservoir to matrix fentanyl patches) but 2 letters struck me.  One is about nicotine withdrawal in the palliative care setting.  It introduced to me the small body of literature about nicotine withdrawal & delirium.  As a relucatant ex-smoker I was somewhat disappointed in reading this letter & the problems patients have smoking due to physical disability or facility restrictions--I had always planned on lighting up again the moment I checked myself into the hospice but it looks like this may not happen.  The other letter is a case report on a young woman with cancer who ended up on 10 lidocaine patches at a time for 24hrs a day for many months & had no problems with this & still had systemic lidocaine levels that were far from cardiotoxic.

J Clinical Oncology has pre-released an article on-line about the effects of defining cancer patients as 'terminal.'  It looks at a Danish population of deceased cancer patients and compares those who were labelled 'terminal' vs. those who weren't.  Apparently, in Denmark, a physician can make a 'terminal declaration' about a patient--that they have less than 6 months to live.  With the terminal declaration a patient can get increased reimbursement for medication expenses, home care services, and informal caregivers can receive compensation (so, akin to the timing of hospice referral in the US, the timing of the terminal declaration may have as much to do with specific patient/caregiver needs as with actual recognition on the part of the patient or physician about the terminal nature of the illness).  Essentially, the authors looked at everyone in an area who died of cancer & compared those with the official terminal declaration vs. those without.  They found a few differences in the groups based on type of cancer etc. as well as a marked difference in rate of hospitalization and place of death (39% of terminal diagnosis patients died in a hospital vs. 65% of those without).  This is, unfortunately, as far as they looked.  Obviously there are major problems here--not least being that probably some significant portion of the "non-terminal-declaration" patients weren't terminally ill prior to an acute event that killed them.  However this article struck me because 1) this terminal declaration business is potentially a mother-lode of information & one hopes these Danish researchers & others keep mining it & 2) it's another drop in the bucket of information suggesting that defining the dying early, referring dying people for services early (hospice or otherwise) is beneficial to our patients.

BMJ has published a review of opioids for cancer pain which is really an introduction to the use of opioids for cancer pain.  It's pretty simple & simplistic, and actually it's somewhat disheartening--but probably not unrealistic--that the editors of BMJ felt that their readers needed something like this.  It may be useful as a teaching aide. 

The current Lancet has a review of cholangiocarcinoma, unfortunately an over-represented disease for us in palliative care.  I personally found it very helpful.  The news isn't good:  intrahepatic cholangiocarcinoma is becoming more common & mortality hasn't improved in the last 30 years.  The last few sections of the review cover palliative therapies** including the role of biliary stenting & photodynamic therapy which I've been reading about for a bit but have yet to see used although, per this reviewer, it sounds quite helpful:

In this novel treatment, the photosensitiser sodium porfimer (which localises to mitochondria) is given intravenously and localises preferentially in tumour tissue over 24–48 h. This process is followed by endoscopic direct illumination of the tumour bed with a specific wavelength of light resulting in the activation of the porfimer, generating oxygen free radicals and leading to ischaemic cancer cell death. This technique has been shown to regress carcinomas of the skin, lungs, pharynx, oesophagus, and stomach. The tumoricidal tissue penetration achieved is a depth of 4 mm and hence it is regarded as a palliative option. The estimated time to tumour progression is about 6 months, meaning that photodynamic therapy is needed twice yearly.
In a prospective study, 39 patients with Bismuth III/IV cholangiocarcinomas were randomised to treatment with either biliary stenting plus photodynamic therapy or stenting alone. The photodynamic therapy group had higher median survival (493 days vs 98 days), less cholestasis, better quality of life scores, and better stabilisation of Karnofsky performance status than did the stenting group. The improved survival was probably secondary to relief of obstruction rather than a reduction in tumour mass.   Further studies are needed, especially of photodynamic therapy in combination with radiation or chemotherapy, or both.
 
**"Palliative" in this article means all non-curative interventions.  The authors unfortunately perpetuate the confusion surrounding the use of "palliative" by including both life-prolonging but non-curative interventions & interventions that are only intended to improve quality of life.  By this logic ACE-inhibitors for heart failure & insulin for diabetes are palliative therapies. 

It is not news to report that today Oregon's physician assisted suicide law was argued in front of the Supreme Court. I will probably write about it in the coming weeks, but I thought Slate.com's round-up of the hearings today & a brief history of the case was particularly informative.

The current Pain has an curious article about the cognitive effects of morphine. It's a small study (n=14) of patients on chronic long acting opioids (average MEDD of 190mg) who require minimal breathrough. They are given their usual breakthrough dose (avg. 20mg) or placebo & a bunch of cognitive tests are run. The next day they get the other treatment and more tests are run. Interestingly the VAS pain scores weren't much different but those who received morphine reported substantially more pain "relief." There were no differences in sedation. Anyway, the patients experienced more anterograde and retrograde memory loss after the morphine dose than placebo; other than that other cognitive domains were intact. This study is clearly very small & limited & I don't think any clinical implications can be made; nevertheless it looks at a practice which is probably second nature to most of us (the use of breakthrough short acting opioids in patients on long acting opioids) & asks what are some of the drawbacks. The authors warn of quality of life problems based on their findings however they didn't measure quality of life & I wager there would be quality of life problems with not having as needed analgesia....

(There is also an interesting case report of a woman with congenital insensitivity to pain whose first painful experience was a tension headache after a traumatic emotional event.)