In no particular order:1)Internal Medicine Journal has an 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 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 as well as guidelines for palliative care. 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),
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
that the death was preventable."(Thanks to Dr. Bob Arnold for alerting me to these.)3)Annals of Oncology has an interesting look at. It's a German study in which a bunch of hospitalized cancer patients were given the - 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 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. 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 gives space to end-of-life care (it reviews ). So hooray.
The grief experience of clinicians is similar to that of loved ones," is interesting. My oncology group that refers to hospice seems to need as much bereavement services as the family members. Which leads me to feel that the introduction to hospice and palliative care may be introduced much later in the course of treatment - as in the family who denies needing services until the final hours. Any thoughts?
Hi Robin - thanks for your comments. I think you're right. At times clinician guilt/grief can cause appropriate discussions about what's really happening to be delayed/deferred. Not confronting and accomodating our own grief can lead to blurring of boundaries burn out and poor care.
RE: NSAIDs + opioids. There are plenty of theoretical reasons to combine analgesics with differing mechanisms of action as well as some practical ones especially the opioid-sparing effect. You also point out the major draw-back to using an NSAID however: its GI & hematologic toxicity. Not all NSAIDs are created equal though. What hasn't been studied to my knowledge is an NSAID with relatively low GI and hematologic toxicity such as nabumetone (Relafen) or choline magnesium trisalicylate (Trilisate). This study also brings to mind a few articles on adding acetaminophen to even large doses of opioids (probably the most widely read is from JCO a few years ago). NSAIDs and acetaminophen may have somewhat different indications but there is a large overlap in effect. I think NSAIDs can be used (short-term as you say) in selected patients during the titration phase but we should also be thinking about the best way to use acetaminophen for additive analgesia and opioid-sparing.
Hmm. My attempt at finessing the HTML in my previous comment was woefully inadequate. This is the article I tried to get you to: Stockler M et al. Acetaminophen (paracetamol) improves pain and well-being in people with advanced cancer already receiving a strong opioid regimen: a randomized double-blind placebo-controlled cross-over trial. J Clin Oncol. 2004 Aug 15;22(16):3389-94.
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http://www.pallimed.org/2007/09/hematologic-malignancies-lung-cancer.html
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