[Experiences of cancer patients with breakthrough pain and pharmacological treatments]

BACKGROUND

of cancer patients receiving palliative care, 80% suffer from cancer pain, and again 80% of these patients report breakthrough pain. This study explores the patients' perception of breakthrough pain, their experiences with existing therapeutic regimens and their expectations regarding an ideal breakthrough pain medication.

METHOD

from November 2008 to February 2010 two German palliative care units recruited 80 in- or outpatient cancer patients who completed a standardized questionnaire on breakthrough pain characteristics, analgesic medication, attitudes towards new treatment approaches for breakthrough pain, and experiences with alternative routes of drug administration as part of the "European Survey of Oncology Patients' Experience of Breakthrough Pain".

RESULTS

the study participants suffered from 1-12 episodes of either incident (47.5%) or spontaneous pain (37.5%) per day which were perceived as "severe" in 71% of all cases. These exacerbations highly interfered with the patients' general activity, mood, walking ability, and normal work. Overall, 64% of the patients reported alleviation from pharmacological (26%) and non-pharmacological (73%) interventions. Subcutaneous (40%) and oral (39%) routes were used frequently; intranasal (1.25%) and intrapulmonary (1.25%) routes were used rarely. Only 64% of all participants stated an overall satisfaction with their breakthrough analgesia.

CONCLUSION

the diagnosis and treatment of breakthrough pain seems to be conducted in a suboptimal manner, and standard recommendations on breakthrough pain relief are not implemented consistently. Possible causes of pain should be taken into account as well as multi-professional treatment interventions and alternative routes of administration of fast onset, effective drugs should be considered.

[Validation of the new version of the minimal documentation system (MIDOS) for patients in palliative care : the German version of the edmonton symptom assessment scale (ESAS)]

BACKGROUND

repeated self-assessment of symptoms and problems of patients is required for quality assurance in palliative care. In Germany, the Minimal Documentation System (MIDOS) has been designed specifically for palliative care patients. To adapt MIDOS as a German version of the Edmonton Symptom Assessment Scale (ESAS) a revised version of MIDOS(2) has now been validated. Two original items on average and highest pain intensity (11-step NRS) were replaced by one item on pain intensity on a 4-step VRS and the assessment of vomitus, lack of appetite and depressive mood were added to the assessment of nausea, dyspnoea, constipation, weakness, tiredness, anxiety, others and well-being which were already part of the original version.

METHOD

all patients admitted to the palliative care unit were asked to participate voluntarily in this study. MIDOS(2), the German versions of the ESAS and the quality of life questionnaire EORTC QLQ-C15-Pal were completed on the same day during their inpatient stay. MIDOS(2) was repeated on the next day.

RESULTS

from August 2009 to March 2010, 60 patients (55% men, 45% women; mean age = 64.3, range = 23.6-92.4 years) treated in the palliative care unit completed the study. Self-assessment with MIDOS(2) was reported to burden the patients only slightly (mean burden = 1.1, range: 0 = no to 10 = maximum burden on a NRS), application of MIDOS(2) took between 1 and 7 min (mean duration = 2.4 min) and 61.7% of the patients preferred MIDOS(2) (with VRS) to ESAS (30%) (with NRS) for routine daily documentation. External criterion validity by inter-item correlations of MIDOS(2) with ESAS varied between r = .533 (anxiety) and .881 (nausea) and between r = .348 (depressive mood) and .717 (constipation) for the corresponding items of the EORTC QLQ-C15-Pal. Test-retest reliability between the sum scores of symptoms and problems reported in MIDOS(2) on the first day and on the second day was .688, and r = .573 for well-being.

CONCLUSION

MIDOS(2) can be recommended for routine daily documentation in palliative care because of low burden, little expenditure of time and high participation of patients. Statistical evaluation indicated good external validity and reliability.

Content development for EUROPEAN GUIDELINES on the use of opioids for cancer pain: a systematic review and Expert Consensus Study

Workpackage 3.1 (WP 3.1), within the European Palliative Research Collaborative (EPCRC), was aimed at critically revising and updating the European Association for Palliative Care recommendations on cancer pain management. The aim of this paper is to report the results of the first phase in the revision process which consists of a literature review and an expert consensus about the contents to be considered relevant in the development of the new guidelines. A systematic literature search was carried out from 2001 to 2008 through various databases including Medline, Cinahl, Cochrane Database of Systematic Reviews, Embase and Google. Through this process, guideline quality was evaluated, content was compared with EAPC recommendations and a first set of key-points was developed. A modified two-round Delphi method was applied to choose the most relevant topics for future systematic literature reviews. Fourteen guidelines on cancer pain management, published or updated after 2000, were retrieved. A comparison of these guidelines with the EAPC recommendations led to the formulation of 37 key-points, which were submitted to a panel of experts through a Delphi method. Through the responses given by the experts (25 after the first round and 19 after the second) and after a revision by the WP 3.1 local and steering committees, a final list of 22 topics was generated to answer all identified key-points. Each of these topics will be the object of systematic literature reviews. The final version of the "Evidence-based guidelines for the use of opioid analgesics in the treatment of cancer pain: the EAPC recommendations" will be based on the results of the 22 systematic literature reviews.

[A wish to hasten death : what is behind it]

"There's nothing more to do, so let's come to an end, Doc!" A request for euthanasia or physician-assisted suicide is a dramatic expression of patients' suffering and causes difficulties for staff members to react to these questions. Great efforts have been made in the last two centuries to gain a deeper understanding of the wish for hastened death of terminally ill patients and to develop conclusions for the management of these situations. This article presents differences in international legislation on euthanasia and summarises the ethical background. The current results from the literature according to motivations for the wish for hastened death, communicative functions of the request, attitudes and practices of physicians and their willingness to accompany the patient in euthanasia as well as practical implications for clinical practice are discussed.

[Evaluation of the need for communication training of ophthalmologists for gaining telephone consent for cornea donation]

INTRODUCTION

Because of the gap between the high need for cornea tissue for transplantation and the current lower numbers of donors, there is high pressure to succeed in telephone calls to relatives of deceased for obtaining consent. Besides the attempt to increase the rate of donors, these telephone calls should be gentle for relatives and not overstrain professionals. This study assesses the need and expectations of physicians towards communication training in preparation for their task.

METHODS

In September-October 2009 a needs assessment for communication training among physicians who currently work or have worked for the eye bank took place. Personal data were recorded and their estimate of the perceived burden as well as needs and potential benefits from a specific communication training for obtaining consent for cornea donation by telephone were assessed using numeric rating scales between 1 (minimum) and 10 (maximum). Results were expressed as mean and range.

RESULTS

The participants felt only moderately prepared for the task regarding information content, their emotions and personal convictions. They considered a specific training to be highly meaningful, necessary and helpful. Their highest burden during telephone calls previously experienced was documented as 8.4 and the average burden as 6.3. Accordingly, their willingness to continue working at an eye bank after their rotation was moderate.

DISCUSSION

Physicians involved in obtaining consent for cornea donation by telephone feel highly stressed and only moderately prepared for fulfilling the task both for the information content and on the emotional level. Accordingly, specific communication training is perceived as highly meaningful, necessary and helpful. An educational program was developed to meet the needs and expectations of physicians.

Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative

BACKGROUND

Many patients in Europe do not receive adequate relief of pain because of excessive regulatory restrictions on the availability and accessibility of opioids. This is a major public health problem. The aim of the study is to evaluate and report on opioid availability and the legal and regulatory barriers to accessibility across the countries of Europe.

METHODS

European Society for Medical Oncology and European Association for Palliative Care national representatives reported data regarding survey of opioid availability and accessibility. Formulary adequacy is evaluated relative to the World Health Organization (WHO) essential drugs list and the International Association for Hospice and Palliative Care list of essential medicines for palliative care. Overregulation is evaluated according to the guidelines for assessment of national opioid regulations of the WHO.

RESULTS

Data were reported on the availability and accessibility of opioids for the management of cancer pain in 21 Eastern European countries and 20 Western European countries. Results are presented describing the availability and cost of opioids for cancer pain in each surveyed country and nine forms of regulatory restrictions.

CONCLUSIONS

Using standards derived from the WHO and International Narcotics Control Board, this survey has exposed formulary deficiencies and excessive regulatory barriers that interfere with appropriate patient care in many European countries. There is an ethical and public health imperative to address these issues.

[Problems and deficits in the transition from inpatient and outpatient care of cancer patients. A qualitative analysis]

INTRODUCTION

Problems and deficits in the transition between hospital-based and outpatient care of cancer patients were evaluated. The project was initiated by the Public Health Department of the City of Aachen and was carried out with cooperation from all hospitals in the urban areas.

METHOD

From September 2002 to April 2003 a total of 145 cancer patients fulfilling the inclusion criteria from 4 regional hospitals were documented at 4 time points within a period of 6-8 weeks by questionnaires, telephone and personal interviews. Aspects of interest were disease type, symptom burden, well-being, the homecare situation and medical aids required.

RESULTS

Patients and their relatives reported on inadequate pain management, insufficient preparation of transition, problems in information flow, organisational problems, lack of attention and humaneness, deficiency of care, delay of diagnosis, inadequate access to services, insufficient prescription of drugs and adjuvants, financial problems and quarrels with the health insurance company on payment of aid devices. Coping strategies were mostly non-functional and not problem-orientated.

DISCUSSION

Special attention should be paid to psychosocial and interpersonal needs of patients. Volunteers may have an important role in the care of patients and relatives. The introduction of case managers might lead to an advancement of care. Sensitisation of physicians, nurses and other caregivers for deficits in transition of patients is needed and should be covered in palliative care education and training.

A comparison of intranasal fentanyl spray with oral transmucosal fentanyl citrate for the treatment of breakthrough cancer pain: an open-label, randomised, crossover trial

OBJECTIVE

The efficacy of intranasal fentanyl spray (INFS) was compared with that of oral transmucosal fentanyl citrate (OTFC) for the relief of cancer-related breakthrough pain (BTP) in an open-label, crossover trial.

METHODS

Adult cancer patients receiving stable background opioid treatment and experiencing BTP episodes were recruited from 44 study centres in seven European countries (Austria, France, Germany, Italy, Poland, Spain and the United Kingdom); of the 196 patients enrolled, 139 were randomised to receive INFS followed by OTFC, or vice versa. Patients were titrated to an effective dose of one agent (50, 100 or 200 microg INFS; 200, 400, 600, 800, 1200 or 1600 microg OTFC) to treat six BTP episodes, then titration and treatment were repeated with the other agent. The primary outcome was patient-recorded time to onset of 'meaningful' pain relief. Secondary outcomes included pain intensity difference (PID) at 10 and 30 minutes (PID(10), PID(30)), sum of PID at 15 and 60 minutes (SPID(0-15), SPID(0-60)), ease of administration, treatment preference and relationship between background opioid dose and effective INFS dose. Additional outcome measures included proportions of episodes with > or =33% and > or =50% pain intensity (PI) reduction, and PID at additional time points.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00496392.

RESULTS

Among the intention-to-treat population (n = 139), median time to onset of 'meaningful' pain relief was 11 minutes with INFS versus 16 minutes with OTFC; 65.7% of patients attained faster time to 'meaningful' pain-relief onset with INFS (p < 0.001). PID was statistically significantly greater for INFS than OTFC from 5 minutes post-dosing. Significantly more INFS-treated breakthrough pain episodes achieved clinically important pain relief (> or =33% and > or =50% PI reduction) up to 30 minutes post-dosing. The proportions of episodes treated with INFS and OTFC achieving a PI reduction of > or =33% at 5 minutes were 25.3% versus 6.8% (p < 0.001), and at 10 minutes were 51.0% versus 23.6% (p < 0.001), respectively; the proportions of episodes treated with INFS and OTFC achieving a > or =50% PI reduction at 5 minutes were 12.8% versus 2.1% (p < 0.001), and at 10 minutes were 36.9% versus 9.7% (p < 0.001), respectively. Higher SPID(0-15) and SPID(0-60) scores were achieved with INFS (p < 0.001). More patients preferred INFS than OTFC (p < 0.001) and more patients found it very easy/easy to use. Both treatments were well tolerated. In the safety population (n = 139), 56.8% (n = 79) of patients experienced > or =1 AE during the trial. The only AE that occurred in > or =5% of patients in either treatment group was nausea. Among those patients who experienced serious AEs (13.7%, n = 19), none were considered to be related to either study medication. There was a weak correlation between effective INFS doses and background opioid doses.

CONCLUSION

In this open-label, randomised, crossover trial, significantly more patients attained faster 'meaningful' pain relief with INFS than OTFC, and more patients preferred INFS to OTFC.

Evaluation and comparison of two prognostic scores and the physicians’ estimate of survival in terminally ill patients

Background

Method

Results

Discussion

[Treatment discontinuation and obligation to treat: an extended model for the decision-making process]

Social developments and medical progress in the last decades have led to a significant change of values in medicine, which spans from the cornerstone of the patient's autonomy to the increasingly difficult decision-making process related to available medical treatments. This conflict exaggerates with end-of-life situations, where a purely palliative approach to the therapy is applied, or in cases of reduced ability for patient's consent. From a legal point of view, many uncertainties have been clarified in recent years. The patient's autonomy has been strengthened, however, the law requires the doctor to review and carefully balance the treatment options so that a new and modified patient-doctor relationship is often necessary in this difficult decision-making process. The doctor should no longer retreat into the classical role of a neutral advisor and leave the complete responsibility of medical decisions to the patient. Instead, in order for the patient to be able to make a balanced and individually tailored autonomous decision, the doctor needs to bring in his medical expertise along with his own personal experiences and personal opinions, as long as he clearly differentiates between personal and professional views. This way the patient will be empowered to make complex medical decisions, considering his personal situation and previous experiences as well as his own set of values. For complex situations medical practitioners can find support from reflection within the treatment team, or through an external ethical advisory panel. Algorithms can be helpful to illustrate the steps in a decision-making process and thus support medical staff in situations of difficult medical decisions.

A matter of definition--key elements identified in a discourse analysis of definitions of palliative care

For more than 30 years, the term "palliative care" has been used. From the outset, the term has undergone a series of transformations in its definitions and consequently in its tasks and goals. There remains a lack of consensus on a definition. The aim of this article is to analyse the definitions of palliative care in the specialist literature and to identify the key elements of palliative care using discourse analysis: a qualitative methodology. The literature search focused on definitions of the term 'palliative medicine' and 'palliative care' in the World Wide Web and medical reference books in English and German. A total of 37 English and 26 German definitions were identified and analysed. Our study confirmed the lack of a consistent meaning concerning the investigated terms, reflecting on-going discussion about the nature of the field among palliative care practitioners. Several common key elements were identified. Four main categories emerged from the discourse analysis of the definition of palliative care: target groups, structure, tasks and expertise. In addition, the theoretical principles and goals of palliative care were discussed and found to be key elements, with relief and prevention of suffering and improvement of quality of life as main goals. The identified key elements can contribute to the definition of the concept 'palliative care'. Our study confirms the importance of semantic and ethical influences on palliative care that should be considered in future research on semantics in different languages.

Criteria for successful multiprofessional cooperation in palliative care teams

INTRODUCTION

Team work is considered a central component of palliative care. Within this comparatively young field of medicine, the emergence of new institutions (eg, palliative care units) highlights the challenge of establishing a completely new team.

METHODS

This study focuses on the factors, which enhance both the success and outcome criteria of good team work from the perception of team members in a palliative care unit. The palliative care team at the University Hospital of Aachen (n = 19) was interviewed 1 year after the unit's startup by the means of semistructured interviews. Interview texts were analysed using qualitative content analysis.

RESULTS

Factors crucial to cooperation in the team members' views were close communication, team philosophy, good interpersonal relationships, high team commitment, autonomy and the ability to deal with death and dying. Moreover, close communication was by far the most frequently mentioned criteria for cooperation. Team performance, good coordination of workflow and mutual trust underpin the evaluation of efficient team work. Inefficient team work is associated with the absence of clear goals, tasks and role delegation, as well as a lack of team commitment.

CONCLUSION

In a new team, close communication is particularly important for staff as they reorientate themselves to the dynamics of a new peer group. The results confirm the overwhelming importance of clarity, commitment and close, positive exchange among team members for successful team work.

[Efficacy of opioid analgesia at the superior cervical ganglion in neuropathic head and facial pain]

The efficacy of ganglionic local opioid analgesia (GLOA) at the superior cervical ganglion (SCG) was retrospectively investigated in 74 consecutive patients with neuropathic pain in the head and face region. It was possible to retrospectively analyze the short-term and medium-term treatment results in 64 of 74 patients. The long-term effect was subsequently determined using a standardized questionnaire. The short-term analgesic effect of the first blockade by GLOA was significant with a mean pain reduction of 52% (p < 0.001). Within a span of 20 min the mean pain intensity decreased from 65 to 28 on a visual analogue scale. A clinically relevant pain reduction (> or = 30%) was observed in 73% of the patients. The proportion of responders (pain reduction > or = 50%) was 59% after the first blockade. Patients with zoster or trigeminal neuralgia experienced greater pain relief than patients with atypical facial pain or longer lasting postzoster neuralgia. During the course of the blockade series with an average duration of 33 days, a significant medium-term pain reduction of 30% was noted. In the first 3 treatment days, the level of continuous pain declined from 6.3 to 4.3 on a numerical rating scale. Short-term responders reported a better medium-term pain reduction than nonresponders. After 3 years (range: 5 months to 6 years), 21% of 52 patients remained free of pain. The other patients reported often only minimal residual pain or a decrease of pain severity and duration. According to these results, GLOA at the SCG can represent a suitable and simple treatment option for neuropathic facial pain.

Assessing cognition and psychomotor function under long-term treatment with controlled release oxycodone in non-cancer pain patients

BACKGROUND

The therapeutic use of opioids can be associated with altered cognition and impaired psychomotor function. Several studies have demonstrated the impact of opioid therapy on psychomotor performance and cognition, but no data exist about the effect of long-term treatment with controlled release oxycodone (CRO) on driving ability.

METHODS

Thirty patients suffering from chronic non-cancer pain who had been treated with stable doses of CRO where included in a prospective trial and compared with 90 healthy volunteers (matched pairs). A computerized test battery that was developed to assess the driving ability of traffic delinquents in Germany was employed. Attention reaction, visual orientation, motor coordination and vigilance were evaluated. The data from a total of 11 parameters were assessed and for each test a relevant score was defined. As the primary endpoint the sum score of the three relevant scores was determined. A weaker statistical means to assess the patients' performance is to compare the test results with an age-independent control group. Individuals performing worse than the 16th percentile of this control group are considered to be unable to drive according to German legislation.

RESULTS

Significant non-inferiority could not be demonstrated for the primary endpoint. However, driving ability as defined as a result above the 16th percentile did not differ significantly between the patients receiving CRO and the age-independent control group.

CONCLUSION

The use of CRO does not prohibit driving, but individual assessment is necessary.

Therapie chronischer Schmerzen mit oralem retardiertem Oxycodon

Oral controlled-release oxycodone has been available for the treatment of chronic pain in Germany since 1998. Controlled trials have shown good clinical efficacy and tolerability. This survey reports results from six open prospective multicenter trials. In these trials 4196 patients suffering from cancer pain and non-cancer-related pain with inadequate pain relief were treated with oral controlled-release oxycodone for 3-4 weeks. Only a few participating physicians were pain specialists. A total of 356 patients suffering from pain of the musculoskeletal system and receiving oxycodone therapy were monitored for 6 months. Exclusion from the studies was due mainly to inadequate analgesia, side effects, and noncompliance. The efficacy of oxycodone was rated to be better than moderate by most of the patients, quality of life parameters increased significantly, and patient satisfaction was high. The treatment with oral controlled-release oxycodone was a safe and effective option even when used by nonspecialized physicians.

Palliative Schmerztherapie, Cannabinoide

Cancer pain treatment should follow the recommendations of the World Health Organisation. Treatment should be with oral application, regular application times and following the analgesic step-ladder. Non-opioids such as dipyrone or non-steroids are used for slight to moderate pain, step-2 opioids such as tramadol or tilidine/naloxone for moderate pain and step-3 opioids such as morphine, oxycodone or hydromorphone for severe pain. Transdermal application of fentanyl or buprenorphine offer a non-invasive parenteral alternative for patients with stable pain syndromes. Cannabinoids such as tetrahydrocannabinol offer a valuable add-on option for cancer patients with refractory pain, spasticity, nausea or appetite loss.

Intravenous versus Subcutaneous Morphine Titration in Patients with Persisting Exacerbation of Cancer Pain

BACKGROUND

Patients with cancer pain with initially adequate analgesia under oral sustained-release opioid medication may suffer from persisting pain exacerbations. Sometimes even fast help is needed and then optimally performed by intravenous application (IVA) of immediate-release (IR) opioids. This IVA, however, may only be performed by physicians in Germany.

OBJECTIVE

We wanted to find out if subcutaneous application of IR-opioids might be an adequate alternative to IVA in persisting pain exacerbations of patients with cancer pain because this could be performed by the nursing staff in Germany as well.

DESIGN

An open randomized controlled trial was used to compare intravenous versus subcutaneous morphine titration in persisting pain exacerbations in patients with cancer pain.

SETTING/SUBJECTS

Thirty-nine patients with cancer (21 intravenously, 18 subcutaneously) of the pain management department of the university hospital of Cologne, Germany were included into the study.

MEASUREMENTS

Calculated from preexisting analgesic medication boli of morphine were given every 5 minutes (intravenously) or 30 minutes (subcutaneously) up to adequate analgesia or intolerable side effects. Pain intensity, nausea, sedation, and some vital parameters were documented before the start, after each application and at the end of titration.

RESULTS

Thirty-five patients were pretreated with oral opioids, 4 patients with nonopioid analgesics. Six patients stopped titration because of intolerable side effects (sedation, vomiting). Thirty patients (77%) reported at least sufficient pain reduction, 3 patients were free of pain (intravenously). Mean pain intensity decreased on a visual analogue scale (VAS, 0-100) from 83 to 32 (intravenously) and from 68 to 42 (subcutaneously). Morphine doses ranged from 4 mg to 32 mg (intravenously; mean, 18.5 +/- 9.2 mg) and from 10 mg to 200 mg (subcutaneously mean, 57.9 +/- 59.6 mg). Mean time up to adequate analgesia was 53 (intravenously) 77 min (subcutaneously), respectively. There was no change in vital parameters but an increase of sedation in both groups. The adaptation of the continuous analgesic medication resulted in a stable and lasting pain relief after 4 days in both groups.

CONCLUSIONS

Intravenous and subcutaneous-morphine titration are adequate to antagonize persisting pain exacerbations in cancer pain patients quickly and to adapt the continuous opioid analgesic medication.

[What is the profile of palliative care in Germany. Results of a representative survey]

Since 1996 a working group of palliative care physicians has been developing a core documentation for palliative facilities. The data on a total of 1304 patients were collected in 2001. Treatment in palliative care units was provided for 531 patients until their death (Pat-V), 604 patients could be discharged home, and 169 patients were transferred to other facilities (Pat-E). Infusion therapy, physical therapy, positioning and mobilization, together with counseling and social services were initiated in more than 30% of the patients, while specific measures such as ascites or pleura puncture were instituted in less than 10%. Chemotherapy, radiotherapy, immunotherapy, urinary catheter, physical therapy, mobilization, positioning, psychotherapy, and social services were documented more frequently in the Pat-E group than in the Pat-V group. Chemotherapy was started in only 35 patients and radiotherapy in only 31 patients while they were in the palliative care unit. Parenteral nutrition, infusion therapy, wound management, and counseling were documented more frequently in the Pat-V group. Advanced directives were available for 9,9% of the patients omission or discontinuation of therapies was documented for 28,1%. Specific indications for the quality of palliative care provided could not be identified with the documentation instruments applied. The core documentation does however furnish data from a representative sample of in-patient palliative care in Germany, which can be used as a comparative data pool for other studies and quality assurance measures.

[Review of cannabinoids in the treatment of nausea and vomiting]

Cannabinoids are used to treat nausea and vomiting. The effect appears to be mediated by cannabinoid receptors in the nucleus tractus solitarius. Results are available from studies on the use of cannabinoids to manage nausea and vomiting after chemotherapy. None of these studies, however, compared cannabinoids with the newer serotonin antagonists. The antiemetic efficacy of cannabinoids for other indications has not yet been studied sufficiently. Most of the studies report significantly more or stronger side effects with cannabinoid medication in comparison to similar medication. In some of the studies on treatment after chemotherapy or radiotherapy, the patients terminated the cannabinoid therapy more frequently due to side effects. Although clinical studies have provided clear evidence for the antiemetic efficacy of cannabinoids, the frequency and severity of side effects argue against their use as the method of first choice. For patients who cannot be adequately treated with conventional antiemetic agents, cannabinoids can represent a valuable adjunct to the antiemetic regimen.