Characteristics and correlates of dyspnea in patients with advanced cancer

Dyspnea-Related Dimensions And Self-Efficacy: Associations With Well-Being in Advanced Lung Cancer

CONTEXT

Dyspnea is a complex, multidimensional symptom comprising sensory-perceptual, affective, and functional domains that commonly persists in patients with lung cancer and impairs mental health and quality of life (QOL). However, data are lacking on how dyspnea's dimensions or self-efficacy to manage dyspnea are associated with patient outcomes.

OBJECTIVES

To assess the associations of dyspnea dimensions (dyspnea-related sensory-perceptual experience, affective distress, and functional impact) and dyspnea self-efficacy with depression, anxiety, and QOL in patients with advanced lung cancer reporting dyspnea.

METHODS

We conducted a secondary analysis of baseline clinical trial data testing a supportive care intervention for dyspnea. Patients with advanced lung cancer reporting at least moderate dyspnea (≥2 on the Modified Medical Research Council Dyspnea Scale) self-reported dyspnea and patient outcome measures. Hierarchical regressions tested the associations of the dyspnea dimensions with depressive and anxiety symptoms (Hospital Anxiety and Depression Scale) and QOL (Functional Assessment of Cancer Therapy-Lung) while adjusting for variables known to affect these outcomes.

RESULTS

The sensory-perceptual experience of dyspnea (effort) was associated with worse depressive symptoms (b = 0.21, P < 0.01) and QOL (b = -0.53, P = 0.01). Dyspnea self-efficacy was associated with improved depressive (b = -1.26, P < 0.01) and anxiety symptoms (b = -1.72, P < 0.01) and QOL (b = 3.66, P < 0.01). The affective and functional dimensions of dyspnea were not associated with the patient outcomes in the final models.

CONCLUSIONS

Dyspnea-related sensory-perceptual experience and self-efficacy were associated with mental health and QOL outcomes in patients with lung cancer. Examining the individual contributions of dyspnea's multiple dimensions provides a nuanced understanding of its patient impact.

Common and distinct risk factors that influence more severe and distressing shortness of breath profiles in oncology outpatients

BACKGROUND

Shortness of breath occurs in 10%-70% of oncology patients. Very little is known about interindividual variability in its severity and distress and associated risk factors. Using latent profile analyses (LPAs), purpose was to identify subgroups of patients with distinct severity and distress profiles for shortness of breath as single symptom dimensions. In addition, a joint LPA was done using patients' severity AND distress ratings. For each of the three LPAs, differences among the shortness of breath classes in demographic, clinical, symptom, stress, and resilience characteristics were evaluated.

METHODS

Patients completed ratings of severity and distress from shortness of breath a total of six times over two cycles of chemotherapy. All of the other measures were completed at enrollment (i.e., prior to the second or third cycle of chemotherapy). Separate LPAs were done using ratings of severity and distress, as well as a joint analysis using severity AND distress ratings. Differences among the latent classes were evaluated using parametric and nonparametric tests.

RESULTS

For severity, two classes were identified (Slight to Moderate [91.6%] and Moderate to Severe [8.4%]). For distress, two classes were identified (A Little Bit to Somewhat [83.9%] and Somewhat to Quite a Bit [16.1%]). For the joint LPA, two classes were identified (Lower Severity and Distress [79.9%] and Higher Severity and Distress [20.1%]). While distinct risk factors were associated with each of the LPAs, across the three LPAs, the common risk factors associated with membership in the worse class included: a past or current history of smoking, poorer functional status, and higher comorbidity burden. In addition, these patients had a higher symptom burden and higher levels of cancer-specific stress.

CONCLUSIONS

Clinicians can use the information provided in this study to identify high-risk patients and develop individualized interventions.

Episodic breathlessness in patients with cancer: definition, terminology, clinical features - integrative systematic review

PURPOSE

Breatlessness flares directly impair quality of life of patients with cancer. The aim of this review was to analyse and synthesise the available information related to its terminology, definition and clinical features in patients with cancer.

METHODS

Integrative systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Literature search was conducted in MEDLINE PubMed, CINAHLPlus, Web of Science, Cochrane Central Register Controlled Trials CENTRAL, Scopus and OpenAire.

RESULTS

Data from 1065 patients with cancer included in 12 studies were analysed. The preferred term for breathlessness flares was episodic dyspnoea (ED). The reported frequency of ED was 20.4% (70.9% in patients reporting background dyspnoea (BD)). ED intensity was moderate to severe with short duration (<10 min) in >80% of patients. The most common trigger was exertion (>90%) followed by emotional or environmental factors. ED management consisted mainly of pharmacological and non-pharmacological measures.

CONCLUSIONS

This systematic review shows that ED is common in patients with cancer, especially in those with BD. Further studies are urgently needed to better understand this condition and to develop specific therapeutic management.

PROSPERO REGISTRATION NUMBER

CRD42019126708.

Higher Lifetime Stress and Symptom Burden Contribute to the Occurrence of Shortness of Breath

OBJECTIVES

Among four classes of patients with distinct shortness of breath profiles, evaluate for differences in levels of global, cancer-specific, and cumulative life stress, as well as resilience; evaluate for differences in the occurrence rates for various stressful life events, and evaluate for differences in the severity of common co-occurring symptoms.

DATA SOURCES

Outpatients (N = 1338) completed questionnaires six times over two cycles of chemotherapy. The occurrence of shortness of breath was assessed using the Memorial Symptom Assessment Scale. Latent class analysis was used to identify subgroups of patients with distinct shortness of breath profiles. Differences among the classes were evaluated using parametric and nonparametric tests.

CONCLUSION

Shortness of breath classes were labeled based on their distinct occurrence trajectories: None (70.5%), Decreasing (8.2%), Increasing (7.8%), and High (13.5%). Compared to None class, Decreasing and High classes had higher global and cancer-specific stress scores. The High class reported higher occurrence rates for several adverse childhood experiences. Compared to None class, Decreasing and High classes had higher depression, anxiety, and morning fatigue scores and lower morning energy and cognitive function scores.

IMPLICATIONS FOR NURSING PRACTICE

Given the additive or synergistic relationships between stress, co-occurring symptoms, and shortness of breath, multimodal interventions that include stress management, exercise training, and/or symptom management may decrease shortness of breath in oncology patients.

Current Management Options for Dyspnea in Cancer Patients

OPINION STATEMENT

Dyspnea is one of the most frequent and distressing symptoms in patients with advanced cancer. As dyspnea deteriorates patients' quality of life markedly and tends to worsen as the disease progresses, comprehensive assessment and timely treatment of the underlying etiologies are essential. International guidelines recommend various non-pharmacological and pharmacological management options. However, there is a scarcity of confirmatory clinical trials on cancer dyspnea, and the overall level of evidence is weak. Recently, observational and survey studies indicated a wide range of practice patterns of palliative care specialists, providing important insight into the real-world management of dyspnea. In this paper, we summarize current management options for dyspnea in cancer patients, highlight major controversies in the literature, and propose future research directions toward quality care for patients with dyspnea and their families.

Surveillance of Symptom Burden Using the Patient-Reported Outcome Version of the Common Terminology Criteria for Adverse Events in Patients With Various Types of Cancers During Chemoradiation Therapy: Real-World Study

BACKGROUND

Over 90% of patients with cancer experience 1 or more symptoms caused directly by cancer or its treatment. These symptoms negatively impact on the completion of planned treatment as well as patients' health-related quality of life (HRQoL). It often results in serious complications and even life-threatening outcomes. Thus, it has been recommended that surveillance of symptom burden should be performed and managed during cancer treatment. However, differences in symptom profiles in various patients with cancer have not been fully elucidated for use in performing surveillance in the real world.

OBJECTIVE

This study aims to evaluate the burden of symptoms in patients with various types of cancers during chemotherapy or radiation therapy using the PRO-CTCAE (Patient-Reported Outcome Version of the Common Terminology Criteria for Adverse Events) and its impact on quality of life.

METHODS

We performed a cross-sectional study of patients undergoing outpatient-based chemotherapy, radiation therapy, or both at the National Cancer Center at Goyang or at the Samsung Medical Center in Seoul, Korea between December 2017 and January 2018. To evaluate cancer-specific symptom burden, we developed 10 subsets for using the PRO-CTCAE-Korean. To measure HRQoL, we used the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). Participants answered questions prior to their clinic appointments on tablets. Multivariable linear regression was used to analyze symptoms based on cancer type and to evaluate the association between the PRO-CTCAE items and the EORTC QLQ-C30 summary score.

RESULTS

The mean age (SD) of the patients was 55.0 (11.9) years, and 39.94% (540/1352) were male. Overall, symptoms in the gastrointestinal category were the most dominant in all cancers. Fatigue (1034/1352, 76.48%), decreased appetite (884/1352, 65.38%), and numbness and tingling (778/1352, 57.54%) were the most frequently reported. Patients reported more local symptoms caused by a specific cancer. In terms of nonsite-specific symptoms, patients commonly reported concentration (587/1352, 43.42%), anxiety (647/1352, 47.86%), and general pain (605/1352, 44.75%). More than 50% of patients with colorectal (69/127, 54.3%), gynecologic (63/112, 56.3%), breast (252/411, 61.3%), and lung cancers (121/234, 51.7%) experienced decreased libido, whereas 67/112 (59.8%) patients with gynecologic cancer and lymphoma/myeloma reported pain during sexual intercourse. Patients with breast, gastric, and liver cancers were more likely to have the hand-foot syndrome. Worsening PRO-CTCAE scores were associated with poor HRQoL (eg, fatigue: coefficient -8.15; 95% CI -9.32 to -6.97), difficulty in achieving and maintaining erection (coefficient -8.07; 95% CI -14.52 to -1.61), poor concentration (coefficient -7.54; 95% CI -9.06 to -6.01), and dizziness (coefficient -7.24; 95% CI -8.92 to -5.55).

CONCLUSIONS

The frequency and severity of symptoms differed by cancer types. Higher symptom burden was associated with poor HRQoL, which suggests the importance of appropriate surveillance of PRO symptoms during cancer treatment. Considering patients had comprehensive symptoms, it is necessary to include a holistic approach in the symptom monitoring and management strategies based on comprehensive patient-reported outcome measurements.

Distinct Shortness of Breath Profiles in Oncology Outpatients Undergoing Chemotherapy

CONTEXT

Shortness of breath is a distressing symptom that occurs in 10% to 70% of oncology patients. Despite this broad range in its occurrence, little is known about inter-individual variability in shortness of breath and associated risk factors among patients receiving chemotherapy.

OBJECTIVES

Identify subgroups of patients with distinct shortness of breath profiles; evaluate for differences among these subgroups in demographic and clinical characteristics; evaluate for differences among symptom dimensions of shortness of breath, and evaluate for differences in quality of life outcomes.

METHODS

Outpatients (n=1338) completed questionnaires six times over two chemotherapy cycles. Occurrence of shortness of breath was assessed using the Memorial Symptom Assessment Scale. Latent class analysis was used to identify subgroups of patients with distinct shortness of breath profiles.

RESULTS

Four distinct shortness of breath profiles were identified (None [70.5%], Decreasing [8.2%], Increasing [7.8%], High [13.5%]). Risk factors for membership in High class included: history of smoking, self-reported diagnosis of lung disease, having lung cancer, and receipt of a higher number of cancer treatments. Compared to the None class, High class reported poorer physical, psychological, and social functioning.

CONCLUSIONS

Almost 14% of patients with heterogeneous types of cancer receiving chemotherapy had persistently high occurrence rates of shortness of breath for almost two months. In addition, compared to the Decreasing and Increasing classes, the High class' episodes of shortness of breath were more frequent and more severe. Clinicians need to assess all oncology patients for shortness of breath and provide targeted interventions.

Dyspnea in Oncological Patients: a Brain Teaser

Dyspnea is one of the most common symptoms in oncological patients with greater prevalence in lung cancer and advanced disease states. Causes of dyspnea can be directly or indirectly associated with cancer, anti-neoplastic therapies and comorbidities unrelated to cancer. Routine screening of dyspnea is suggested for all oncological patients by using unidimensional, simple scales and multidimensional tools to capture more domains affected by this symptom and to assess the effectiveness of interventions. The first step in the treatment algorithm of dyspnea is the identification of potentially reversible causes; if no specific cause is depicted, symptomatic treatment with non-pharmacological and pharmacological interventions is suggested. Referral to palliative care and continuous palliative sedation are the last resort in patients with a very limited life expectancy of not more than a few days for symptomatic relief and to decrease of the distress of patients and caregivers.

Effect of Dexmedetomidine for Palliative Sedation for Refractory Dyspnoea in Patients with Terminal-Stage Cancer

Background

Dyspnoea affects a considerable percentage of patients with terminal-stage cancer, and clinical guidelines recommend palliative sedation for patients with refractory dyspnoea. Midazolam is currently the most commonly used sedative; however, it can cause serious adverse reactions, such as respiratory/circulatory depression. Hence, there is a need for an alternative sedative. Dexmedetomidine (DEX) is a promising alternative as its "awake sedation" effect; however, little is known regarding its use in patients with end-stage dyspnoea. Therefore, the aim of this study was to determine the safety and usefulness of DEX for palliative sedation of patients with refractory dyspnoea.

Methods

This retrospective study included patients with terminal-stage cancer who received DEX for palliative sedation owing to refractory dyspnoea in the hospice ward from January 2018 to October 2022. We analysed their general data, dyspnoea conditions, sedation details, sedative treatment effect, dyspnoea relief, and changes in vital signs before and after sedation, via paired t-tests.

Results

We included 17 patients with terminal-stage cancer who received DEX palliative sedation at a dose of 0.2-0.9 µg/kg·h for refractory dyspnoea, among whom 6 (35%) received a loading dose of 1 µg/kg in 10 min. After 1 h of sedation and at the maximum sedation dose, the Respiratory Distress Observation Scale and Richmond Agitation-Sedation Scale scores decreased significantly compared with those before sedation (all P<0.001), as did the respiratory rate (P=0.024 and P=0.008, respectively). The heart rate and blood oxygen saturation did not significantly change, whereas the systolic and diastolic blood pressure after 1 h of sedation were significantly lower than those before sedation (both P=0.015).

Conclusion

DEX is a promising palliative sedative for patients with terminal-stage cancer, as it safely relieved the symptoms of refractory dyspnoea without inducing serious adverse reactions. Therefore, DEX may greatly enhance the quality of life for patients with terminal-stage cancer.

Systematic review of the literature on the occurrence and characteristics of dyspnea in oncology patients

BACKGROUND

Dyspnea is a common and distressing symptom for oncology patients.However, dyspnea is not well-characterized and often underestimated by clinicians. This systematic review summarizes the prevalence, intensity, distress, and impact of dyspnea in oncology patients and identifies research gaps.

METHODS

A search of all of the relevant databases was done from 2009 to May 2022. A qualitative synthesis of the extant literature was performed using established guidelines.

RESULTS

One hundred-seventeen studies met inclusion criteria. Weighted grand mean prevalence of dyspnea in patients with advanced cancer was 58.0%. Intensity of dyspnea was most common dimension evaluated, followed by the impact and distress. Depression and anxiety were the most common symptoms that co-occurred with dyspnea.

CONCLUSION

Numerous methodologic challenges were evident across studies. Future studies need to use valid and reliable measures; evaluate the impact of dyspnea; and determine biomarkers for dyspnea.

Prevalence of dyspnoea and usage of opioids in managing dyspnoea in advanced cancer patients: a longitudinal observational multi-centre study from India

Context

Breathlessness is one of the devastating symptoms experienced by patients with advanced cancer and can be very challenging to manage.

Objectives

To find the point prevalence of dyspnoea in advanced cancer patients presenting to palliative care out-patient clinics, and the usage of opioids in palliation of dyspnoea.

Methods

We conducted a prospective observational study among all consecutive patients presenting to the outpatient clinics of six cancer centres in India from different parts of the country. In addition to routinely documented demographic and clinical data from patient charts, study investigators collected information on the Edmonton Symptom Assessment System, Cancer Dyspnoea Scale (CDS) and European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core 15 Palliative Care. We calculated the prevalence of dyspnoea and documented the usage of opioids in palliation of dyspnoea using tests of differences across patient characteristics.

Results

Between May 1, 2019, and April 30, 2020, 5,541 patients were screened for eligibility, and 288 were enrolled (48 patients from each of the six centres). We analysed the data of 288 patients, of which 36.4% had dyspnoea, with 28.5% with moderate to a severe degree (>4/10). Tiredness and loss of appetite were found to have associations with dyspnoea which were statistically significant on multivariate analysis. Standard palliative care management and routine usage of opioids preceded improvement in dyspnoea scores, CDS scores and quality of life scores throughout 7 days.

Conclusion

Dyspnoea is a common symptom in advanced cancer patients, presenting to outpatient clinics, and routine documentation of dyspnoea with appropriate usage of opioids helps in mitigation.

Key message

The article suggests that breathlessness is a common problem in advanced cancer patients and opioid prescription preceded symptom improvements in such patients.

Effect of dexamethasone on dyspnoea in patients with cancer (ABCD): a parallel-group, double-blind, randomised, controlled trial

BACKGROUND

Systemic corticosteroids are commonly prescribed for palliation of dyspnoea in patients with cancer, despite scarce evidence to support their use. We aimed to assess the effect of high-dose dexamethasone versus placebo on cancer-related dyspnoea.

METHODS

The parallel-group, double-blind, randomised, controlled ABCD (Alleviating Breathlessness in Cancer Patients with Dexamethasone) trial was done at the at the University of Texas MD Anderson Cancer Center and the general oncology clinic at Lyndon B Johnson General Hospital (both in Houston, TX, USA). Ambulatory patients with cancer, aged 18 years or older, and with an average dyspnoea intensity score on an 11-point numerical rating scale (NRS; 0=none, 10=worst) over the past week of 4 or higher were randomly assigned (2:1) to receive dexamethasone 8 mg orally every 12 h for 7 days followed by 4 mg orally every 12 h for 7 days, or matching placebo capsules for 14 days. Pharmacists did permuted block randomisation with a block size of six, and patients were stratified by baseline dyspnoea score (4-6 vs 7-10) and study site. Patients, research staff, and clinicians were masked to group assignment. The primary outcome was change in dyspnoea NRS intensity over the past 24 h from baseline to day 7 (±2 days). Analyses were done by modified intention-to-treat (ie, including all patients who were randomly assigned and started the study treatment, regardless of whether they completed the study). Enrolment was stopped after the second preplanned interim analysis, when the futility criterion was met. This study is registered with ClinicalTrials.gov (NCT03367156) and is now completed.

FINDINGS

Between Jan 11, 2018, and April 23, 2021, we screened 2867 patients, enrolled 149 patients, and randomly assigned 128 to dexamethasone (n=85) or placebo (n=43). The mean change in dyspnoea NRS intensity from baseline to day 7 (±2 days) was -1·6 (95% CI -2·0 to -1·2) in the dexamethasone group and -1·6 (-2·3 to -0·9) in the placebo group, with no significant between-group difference (mean 0 [95% CI -0·8 to 0·7]; p=0·48). The most common all-cause grade 3-4 adverse events were infections (nine [11%] of 85 patients in the dexamethasone group vs three [7%] of 43 in the placebo group), insomnia (seven [8%] vs one [2%]), and neuropsychiatric symptoms (three [4%] vs none [0%]). Serious adverse events, all resulting in hospital admissions, were reported in 24 (28%) of 85 patients in the dexamethasone group and in three (7%) of 43 patients in the placebo group. No treatment-related deaths occurred in either group.

INTERPRETATION

High-dose dexamethasone did not improve dyspnoea in patients with cancer more effectively than placebo and was associated with a higher frequency of adverse events. These data suggest that dexamethasone should not be routinely given to unselected patients with cancer for palliation of dyspnoea.

FUNDING

US National Cancer Institute.

Effect of heated humidified high-flow nasal cannula (HFNC) oxygen therapy in dyspnea patients with advanced cancer, a randomized controlled clinical trial

PURPOSE

Heated humidified high-flow nasal cannula (HFNC) oxygen therapy is one of the most important oxygen therapy methods, which are commonly applied to relieve dyspnea in advanced cancer patients. Our study aims to observe the efficacy and safety of HFNC oxygen therapy on dyspnea patients with advanced cancer and explore the clinical application.

METHODS

Sixty subjects with advanced cancer requiring oxygen therapy from a grade 3, class A hospital in China were recruited and randomized (1:1) to traditional nasal catheter oxygen therapy or HFNC. Primary outcomes were dyspnea, oral dryness, and sleep condition, which were recorded after 72-h treatment. Secondary outcomes were heart rate (HR), respiration rate (RR), S_pO₂, P_aO₂, and P_aCO₂, which were recorded after 2, 6, 24, and 72 h treatment.

RESULTS

Seventy-two hours after treatment, there were significant improvements in all primary outcomes (P < 0.001). P_aO₂ and RR were statistically changed 2 h after HFNC treatment (P < 0.001). P_aCO₂ and HR were statistically changed 24 h after HFNC treatment (P < 0.001).

CONCLUSION

HFNC oxygen therapy has good effect, high safety, and is easy to be accepted by dyspnea patients with advanced cancer. It can be used as the first choice of oxygen therapy for these patients and has broad clinical prospects.

TRIAL REGISTRATION

This work was retrospectively registered in the Chinese Clinical Trials Registry (ChiCTR2100049582) on August 4, 2021.

SINFONIA study protocol: a phase II/III randomised controlled trial examining benefits of guided online group singing in people with chronic obstructive pulmonary disease and interstitial lung disease and their carers

Background

Chronic obstructive pulmonary disease (COPD) and interstital lung disease (ILD) are incurable conditions characterised by airflow limitation, persisting respiratory symptoms, and progressive respiratory failure. People living with COPD or ILD often suffer from chronic and severe breathlessness, with limited treatment options and low engagement rates with current therapies. Group singing represents a potential community-based therapy to improve quality of life for patients with COPD or ILD and breathlessness.

Methods

This protocol papers describes SINFONIA, a parallel, double-arm, randomised, blinded-analysis, mixed-methods phase II/III trial of guided, online group singing that will be conducted over 24 months. Adults with confirmed COPD or ILD, on stable treatment for at least four weeks at time of recruitment, with a modified Medical Research Council (mMRC) dyspnoea score of two or greater, who are capable and willing to give consent, and not currently participating in pulmonary rehabilitation will be eligible to participate. Carers may optionally enrol in the trial. Data will be collected on quality of life, anxiety and depression, breathlessness, mastery of breathing, exercise tolerance, loneliness, healthcare utilisation, and carer quality of life (optional). Participants will be randomised 1:1 to intervention or control arms with intervention arm attending one 90 min, guided, online, group singing session per week for 12 weeks and control arm continuing routine care. Phase II of the trial aims to determine the feasibility and acceptability of guided, online group singing and will collect preliminary data on effectiveness. Phase III aims to determine whether guided, online group singing has an effect on quality of life with the primary outcome being a between arm difference in quality of life (36-item Short Form Survey) measured at 12 weeks.

Discussion

SINFONIA is the first study is the first of its kind in Australia and to our knowledge, the first to deliver the singing intervention program entirely online. Determining the feasibility, acceptability, and effectiveness of guided, online group singing is an important step towards improving low-cost, low-risk, community-based therapeutic options for patients living with COPD or ILD and breathlessness.

Trial registration: Phase II—ACTRN12621001274864, registered 20th September 2021; Phase III—ACTRN12621001280897, registered 22nd September 2021.

Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life

Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.

Unmet mental health needs in patients with advanced B-cell lymphomas

CONTEXT

Existing research on psychological distress and mental health service utilization has focused on common types of solid tumor cancers, leaving significant gaps in our understanding of patients experiencing rare forms of hematologic cancers.

OBJECTIVE

To examine distress, quality of life, and mental health service utilization among patients with aggressive, refractory B-cell lymphomas.

METHOD

Patients (n = 26) with B-cell lymphomas that relapsed after first- or second-line treatment completed self-report measures of distress (Hospital Anxiety and Depression Scale) and quality of life (Short-Form Health Survey, SF-12). Patients also reported whether they had utilized mental health treatment since their cancer diagnosis.

RESULTS

Approximately 42% (n = 11) of patients reported elevated levels of psychological distress. Of patients with elevated distress, only one quarter (27.2%; n = 3) received mental health treatment, while more than half did not receive mental health treatment (54.5%; n = 6), and 18.1% (n = 2) did not want treatment. Patients with elevated distress reported lower mental quality of life than patients without elevated distress [F (1, 25) = 15.32, p = 0.001].

SIGNIFICANCE OF THE RESULTS

A significant proportion of patients with advanced, progressive, B-cell lymphomas may experience elevated levels of distress. Yet, few of these distressed patients receive mental health treatment. Findings highlight the need to better identify and address barriers to mental health service utilization among patients with B-cell lymphoma, including among distressed patients who decline treatment.

Prevalence, Clinical Characteristics, and Management of Episodic Dyspnea in Advanced Lung Cancer Outpatients: A Multicenter Nationwide Study-The INSPIRA-DOS Study

Background: Episodic dyspnea (ED) is a common problem in patients with advanced lung cancer (LC). However, the prevalence of ED and other related aspects in this patient population is not known. Objectives: To assess and describe the prevalence, clinical features, treatment, and risk factors for ED in outpatients with advanced LC. Design: Multicenter cross-sectional study. Subjects: Consecutive sample of adult outpatients with advanced LC. Measurements: We assessed background dyspnea (BD), the characteristics, triggers, and management of ED. Potential ED risk factors were assessed through multivariate logistic regression. Results: A total of 366 patients were surveyed. Overall, the prevalence of ED was 31.9% (90% in patients reporting BD). Patients reported a median of one episode per day (interquartile range [IQR]: 1-2), with a median intensity of 7/10 (IQR: 5-8.25). ED triggers were identified in 89.9% of patients. ED was significantly associated with chronic obstructive pulmonary disease (p = 0.011), pulmonary vascular disease (p = 0.003), cachexia (p = 0.002), and palliative care (p < 0.001). Continuous oxygen use was associated with higher risk of ED (odds ratio: 9.89; p < 0.001). Opioids were used by 44% patients with ED. Conclusions: ED is highly prevalent and severe in outpatients with advanced LC experiencing BD. The association between intrathoracic comorbidities and oxygen therapy points to alveolar oxygen exchange failure having a potential etiopathogenic role in ED in this population. Further studies are needed to better characterize ED in LC to better inform treatments and trial protocols.

Multi-Dimensional Dyspnea-Related Scales Validated in Individuals With Cardio-Respiratory and Cancer Diseases. A Systematic Review of Psychometric Properties

CONTEXT

In order to examine the multi-dimensional nature of dyspnea and its impact on the activities of daily living (ADLs) in patients with cardio-respiratory and cancer diseases, validated measures are needed.

OBJECTIVES

Our aim was to identify all the multi-dimensional clinical scales assessing dyspnea and its impact on ADLs in patients with cardio-respiratory and cancer diseases, and to critically appraise their psychometric properties.

METHODS

Five databases were systematically searched up to July 2020. Eligible criteria were: the examination of at least one psychometric property, and the recruitment of adults with a cardio-respiratory or cancer disease in non-emergency settings. The characteristics and psychometric properties of the studies included were presented through a narrative synthesis. The methodological quality of the studies and evidence synthesis were rated using the "COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)" criteria.

RESULTS

Forty-three studies, for which eight assessment scales had been identified, were included in the review. At the time of the review, three multi-dimensional assessment scales were available for assessing dyspnea symptoms, and five multi-dimensional scales were available to examine the impact of dyspnea on ADLs. Although the use of these scales has rapidly grown, evidence of psychometric properties has been reported as limited in most of the scales.

CONCLUSION

Despite the potential of the identified scales, further studies are needed to strength evidence on the validity and reliability of the multi-dimensional dyspnea scales. Furthermore, more studies appraising the content validity and responsiveness of the scales are specifically recommended.

Intranasal Fentanyl Versus Placebo for Treatment of Episodic Breathlessness in Hospice Patients With Advanced Nonmalignant Diseases

CONTEXT

Episodic breathlessness is a distressing and difficult to treat symptom because of its short duration. Fast actioned intranasal fentanyl (INF) is potentially more suitable than oral opioids.

OBJECTIVES

To examine the feasibility, preliminary efficacy, and safety of INF for the treatment of episodic breathlessness from advanced nonmalignant conditions in hospice patients.

METHODS

Phase IIB, double-blind, randomized controlled, multisite, INF citrate solution vs. placebo crossover feasibility study. Opioid-tolerant patients were to treat six episodes of breathlessness using INF spray. The primary outcome was change in the Visual Analogue Scale for dyspnea (VAS-D) score from baseline to 15 minutes after study drug's administration (VAS-D₁₅). Other outcomes were to collect demographic data and determine the use of rescue medications, safety, and feasibility of the study design.

RESULTS

Twenty-one of 49 eligible patients were enrolled, and 19 (90%) patients completed the study. The mean difference in VAS-D₁₅ between fentanyl and placebo was -3.37 mm (95% CI = -10.35 to 3.61 mm; P = 0.337). There was no statistically significant or clinically meaningful difference between INF and placebo in relieving the sensation of discomfort in episodic breathlessness. No significant drug-related adverse event or detrimental effect on vital signs was observed.

CONCLUSION

We found no difference between INF and placebo in relieving episodic breathlessness in nonmalignant conditions. INF was well tolerated, and the study design proved to be feasible in hospice patients with advanced diseases. Future study using higher concentration of fentanyl solution may be warranted.

Management of Dyspnea in Advanced Cancer: ASCO Guideline

PURPOSE

To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer.

METHODS

ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020.

RESULTS

The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea.

RECOMMENDATIONS

A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .

Managing Anxiety from Cancer (MAC): A pilot randomized controlled trial of an anxiety intervention for older adults with cancer and their caregivers

OBJECTIVE

Anxiety is common in older adults with cancer (OACs) and their caregivers and is associated with poor outcomes including worse physical symptoms, poor treatment adherence and response, and longer hospitalizations. This study examined the feasibility, acceptability, adherence, and preliminary efficacy of a cognitive-behavioral therapy (CBT) intervention for OACs and their caregivers.

METHOD

Patients with active cancer age 65 years and older and their caregivers were randomized to Managing Anxiety from Cancer (MAC), a seven-session CBT-based psychotherapy intervention delivered over the telephone or usual care. Patients and caregivers completed the intervention separately with licensed social workers. Self-report measures of anxiety, depression, and quality of life were administered after randomization and following intervention completion. Analyses were conducted separately for patients and caregivers and at the dyad level. Hierarchical Linear Modeling accounted for the within-dyad intraclass correlation coefficients (ICCs) by random intercepts associated with the dyads.

RESULTS

Twenty-nine dyads were randomized; 28 (96.6%) patients and 26 (89.7%) caregivers completed all study procedures. Of dyads randomized to MAC, 85.7% (n = 12) of patients and caregivers completed all seven sessions. Most patients (≥50%) and over 80% of caregivers rated the overall intervention and intervention components as "moderately" to "very" helpful. MAC was associated with a greater reduction in anxiety among dyads than usual care, the effect of MAC was greater in caregivers than in patients, and improvement in patient anxiety was associated with the reduction in caregiver anxiety. However, these results did not reach statistical significance.

SIGNIFICANCE OF RESULTS

This pilot study demonstrates the feasibility of MAC and suggests strategies for improving acceptability, with a focus on adherence. Furthermore, these results indicate that MAC is promising for the reduction of anxiety in OAC-caregiver dyads and may be particularly beneficial for OAC caregivers. Larger randomized controlled trials are needed to evaluate the efficacy of MAC.

Functional impairment, symptom severity, and overall quality of life in patients with advanced lung or colorectal cancer in six European countries: baseline findings from the ACTION study

BACKGROUND

People with advanced cancer often suffer from various symptoms, which can arise from the cancer itself and its treatment, the illness experience, and/or co-morbid conditions. Important patient-reported outcomes such as functional status, symptom severity, and quality of life (QoL) might differ between countries, as countries vary with regard to contextual factors such as their healthcare system.

PURPOSE

To assess self-reported emotional functioning, physical functioning, symptoms, and overall QoL in patients with advanced lung or colorectal cancer from six European countries, particularly in relation to their country of residence.

METHODS

We used baseline patient data from the ACTION trial, including socio-demographic and clinical data as well as patient-reported data regarding functioning, symptoms, and overall QoL (EORTC QLQ-C15-PAL).

RESULTS

Data from 1117 patients (55% lung cancer stage III/IV, 45% colorectal cancer stage IV) were used. The highest (worst) average symptom score was found for fatigue. We found similarities but also important differences in the outcomes across countries. The best scores (the highest for emotional functioning and QoL, the lowest for symptoms) were reported by Dutch and Danish patients. Belgian patients reported relatively low emotional functioning.

CONCLUSION

The optimization of functioning, symptom relief, and overall QoL should be important objectives of healthcare professionals who take care of patients with advanced cancer. There are similarities, but also substantial differences across countries in functional status, symptoms, and overall QoL. Policymakers should take these differences into account and invest in offering health care catered to the needs of their population.

Nonpharmacological Interventions for Managing Breathlessness in Patients With Advanced Cancer: A Systematic Review

Importance

Breathlessness is a frequent and debilitating symptom in patients with advanced cancer. Often, in the context of breathlessness, aggressive cancer treatment is not beneficial, feasible, or aligned with goals of care. Targeted symptom-focused interventions may be helpful in this scenario.

Objective

To evaluate the advantages and harms of nonpharmacological interventions for managing breathlessness in adults with advanced cancer.

Evidence Review

PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception through May 2020 for published randomized clinical trials (RCTs), nonrandomized controlled trials, and observational studies of the advantages and/or harms of nonpharmacological interventions on alleviating breathlessness in adults with advanced cancer. Only English-language studies were screened for eligibility, titles, abstracts, and full text. Risk of bias and strength of evidence (SOE) were independently assessed. The key outcomes reported in studies were breathlessness, anxiety, exercise capacity, health-related quality of life, and harms. Data were analyzed from October 1, 2019, to June 30, 2020.

Findings

A total of 29 RCTs (2423 participants) were included. These RCTs evaluated various types of interventions, such as respiratory (9 RCTs), activity and rehabilitation (7 RCTs), behavioral and psychoeducational (3 RCTs), integrative medicine (4 RCTs), and multicomponent (6 RCTs). Several nonpharmacological interventions were associated with improved breathlessness, including fan therapy (standardized mean difference [SMD], -2.09; 95% CI, -3.81 to -0.37; I2 = 94.3%; P for heterogeneity = .02; moderate SOE) and bilevel ventilation (estimated slope difference, -0.58; 95% CI, -0.92 to -0.23; low SOE), lasting for a few minutes to hours, in the inpatient setting. In the outpatient setting, nonpharmacological interventions associated with improved breathlessness were acupressure and reflexology (integrative medicine) (low SOE) and multicomponent interventions (combined activity and rehabilitation, behavioral and psychoeducational, and integrative medicine) (low SOE) lasting for a few weeks to months. Five of the 29 RCTs (17%) reported adverse events, although adverse events and study dropouts were uncommon.

Conclusions and Relevance

Findings of this review include the safety and association with improved breathlessness of several nonpharmacological interventions for adults with advanced cancer. Guidelines and clinical practice should evolve to incorporate nonpharmacological interventions as first-line treatment for adults with advanced cancer and breathlessness.

High-Flow Nasal Cannula Therapy for Exertional Dyspnea in Patients with Cancer: A Pilot Randomized Clinical Trial

BACKGROUND

Exertional dyspnea is common in patients with cancer and limits their function. The impact of high-flow nasal cannula on exertional dyspnea in nonhypoxemic patients is unclear. In this double-blind, parallel-group, randomized trial, we assessed the effect of flow rate (high vs. low) and gas (oxygen vs. air) on exertional dyspnea in nonhypoxemic patients with cancer.

PATIENTS AND METHODS

Patients with cancer with oxygen saturation >90% at rest and exertion completed incremental and constant work (80% maximal) cycle ergometry while breathing low-flow air at 2 L/minute. They were then randomized to receive high-flow oxygen, high-flow air, low-flow oxygen, or low-flow air while performing symptom-limited endurance cycle ergometry at 80% maximal. The primary outcome was modified 0-10 Borg dyspnea intensity scale at isotime. Secondary outcomes included dyspnea unpleasantness, exercise time, and adverse events.

RESULTS

Seventy-four patients were enrolled, and 44 completed the study (mean age 63; 41% female). Compared with low-flow air at baseline, dyspnea intensity was significantly lower at isotime with high-flow oxygen (mean change, -1.1; 95% confidence interval [CI], -2.1, -0.12) and low-flow oxygen (-1.83; 95% CI, -2.7, -0.9), but not high-flow air (-0.2; 95% CI, -0.97, 0.6) or low-flow air (-0.5; 95% CI, -1.3, 0.4). Compared with low-flow air, high-flow oxygen also resulted in significantly longer exercise time (difference + 2.5 minutes, p = .009), but not low-flow oxygen (+0.39 minutes, p = .65) or high-flow air (+0.63 minutes, p = .48). The interventions were well tolerated without significant adverse effects.

CONCLUSION

Our preliminary findings support that high-flow oxygen improved both exertional dyspnea and exercise duration in nonhypoxemic patients with cancer. (ClinicalTrials.gov ID: NCT02357134).

IMPLICATIONS FOR PRACTICE

In this four-arm, double-blind, randomized clinical trial examining the role of high-flow nasal cannula on exertional dyspnea in patients with cancer without hypoxemia, high-flow oxygen, but not high-flow air, resulted in significantly lower dyspnea scores and longer exercise time. High-flow oxygen delivered by high-flow nasal cannula devices may improve clinically relevant outcomes even in patients without hypoxemia.

Use of short-acting opioids in the management of breathlessness: an evidence-based review

PURPOSE OF REVIEW

To provide an evidence-based review on the use of short-acting opioids for management of breathlessness in patients with advanced diseases.

RECENT FINDINGS

We identified 28 randomized controlled trials that examined the effect of short-acting opioids on breathlessness under three study settings: as a prophylactic dose given prior to exertion; as a rescue dose for treatment of breathlessness at rest or episodic breathlessness; or as a scheduled medication for overall reduction of breathlessness. These trials varied widely in regard to patient population (opioid naive or tolerant), opioid (formulation, dose, timing of administration, and scheduling) and control intervention. Taken together, there is good evidence to support that short-acting opioids can reduce breathlessness and improve activity level when given before exertion. There is some evidence that parenteral opioids are efficacious for the as needed treatment of episodic breathlessness or breathlessness at rest. However, there is only limited evidence to support scheduled short-acting opioids for overall relief of breathlessness.

SUMMARY

There is evidence to support that short-acting opioids have a pharmacologic effect on breathlessness. More research is needed to clarify how opioids can be prescribed to optimize breathlessness relief, function, and quality of life.

Episodic Breathlessness with and without Background Dyspnea in Advanced Cancer Patients Admitted to an Acute Supportive Care Unit

Aim: To characterize episodic breathlessness (EB) in patients with advanced cancer, and to determine factors influencing its clinical appearance. Methods: A consecutive sample of advanced cancer patients admitted to an acute palliative care unit was surveyed. Continuous dyspnea and EB were measured by a numerical scale. The use of drugs used for continuous dyspnea and EB was recorded. Patients were asked about the characteristics of EB (frequency, intensity, duration and triggers). The Multidimensional dyspnea profile (MDP), the Brief dyspnea inventory (BDI), the Athens sleep scale (AIS) and the Hospital Anxiety and Depression Scale (HADS) were also administered. Results: From 439 advanced cancer patients surveyed, 34 and 27 patients had EB, without and with background dyspnea, respectively. The mean intensity and the number of episodes were higher in patients with background dyspnea (p < 0.0005 and p = 0.05, respectively). No differences in duration were observed. Most episodes lasted <10 min. A recognizable cause triggering EB was often found. The presence of both background dyspnea and EB was associated with higher values of MDP and BDI. EB was independently associated with frequency and intensity of background dyspnea (OR = 20.9, 95% CI (Confidence interval) 9.1–48.0; p < 0.0005 and OR = 1.97, 95% CI 1.09–3.58; p = 0.025, respectively) and a lower Karnofsky level (OR = 0.96, 95%CI 0.92–0.98, p = 0.05). Discussion: EB may occur in patients with and without continuous dyspnea, and is often induced by physical and psychological factors. EB intensity is higher in patients with continuous dyspnea. The duration was often so short that the use of drugs, as needed, may be too late, unless administered pre-emptively when the trigger was predictable.

Acceptability and accuracy of patient-reported outcome measures (PROMs) for surveillance of breathlessness in routine lung cancer care: A mixed-method study

BACKGROUND

Breathlessness in lung cancer negatively impacts on quality of life but often goes undetected and undertreated in clinical practice. There is a need for routine surveillance for early identification and proactive management of breathlessness using patient reported outcome measures (PROMs) in clinical care but it is unclear what PROMs should be used or are accurate for use in routine care.

METHODS

We used mixed-methods (quantitative surveys and qualitative interviews) to examine the predictors of breathlessness in 339 lung cancer participants and acceptability of PROMs. In addition to multivariate analysis to examine predictors of dyspnea, participants completed an acceptability survey and themes were derived for the qualitative data (n = 26) to explore patient experience of PROMs. We also tested the accuracy of PROMs using a Receiver Operating Characteristic and Area Under the Curve analysis.

RESULTS

A total of 339 patients completed the breathlessness PROMs and acceptability survey and 26 patients participated in an in-depth interview to investigate their experiences of breathlessness and its PROMs. Prevalence of breathlessness was 51.9 % (n = 176) and 70.5 % of patients preferred the Medical Research Council (MRC) scale followed by the Breathlessness Intensity (BI) scale (63.7 %) among the five measures for breathlessness- Modified Borg Scale (MBS), Cancer Dyspnea Scale (CDS), MRC, BI, and Breathlessness Distress (BD). The finding showed wide variation in the MRC grades across the BI rating even among patients with the same BI score. AUC scores for the Borg scale was 0.71 (using MRC cut-off score of < 2), for CDS, 0.72, for BD, 0.70, and for BI 0.79. For an MRC score of 2, the Borg score cut-off was 0.8 (optimal sensitivity, 50 %; specificity, 93.3 %); the cut-off score of CDS, BD, BI score was 1.4 (optimal sensitivity, 67.1 %; specificity, 70 %), 1.5 (optimal sensitivity, 57.5 %; specificity, 73.3 %), and 1.5 (optimal sensitivity, 72.6 %; specificity, 83.3 %) respectively. AUC by ROC analysis for breathlessness and modest concordance among five PROMs showed important gaps between the individuals' experience and PROMs data. Three main themes from qualitative data included 1) Making sense of symptom reporting, 2) Valuing the reported data, 3) Managing the symptom of breathlessness.

CONCLUSION

This study examined measurement of breathlessness using PROMs for routine clinical care and showed that severity measures alone do not accurately detect this symptomnor the experiential dimensions of breathlessness that are critical to guide appropriate intervention.

Characteristics and health related quality of life in a population with advanced chronic obstructive pulmonary disease, a cross-sectional study

Background

It is important to understand the total burden of COPD and thereby be able to identify patients who need more intensive palliative care to avoid deteriorated quality of life. The aim of this study was to describe the psychosocial and demographic characteristics of a population with advanced COPD in a stable phase of the disease.

Methods

This study was cross-sectional based on a prospective observational cohort. The following questionnaires were administered: Chronic Respiratory Disease Questionnaire (CRQ), The COPD Assessment Test (CAT), The Hospital and Anxiety and Depression Scale (HADS), The Medical Research Council dyspnoea scale (MRC), and self-rate general health.

Results

We included 242 patients with advanced COPD from a Danish pulmonary outpatient clinic. Their mean FEV₁ was 38% (±12.7) and 19% were treated with long term oxygen. The mean CRQ domain score was CRQ-dyspnea 4.21 (±1.4), CRQ-Mastery 4.88 (±1.3), CRQ-Emotional 4.81 (±1.2), CRQ-Fatigue 3.93 (±1.3). The mean CAT-score was 18.4 (± 6.7), and 44% had a CAT score > 20. The mean score on the subscale for anxiety (HADS-A) and depression (HADS-D) was 5.07 (±3.9) and 5.77 (±3.9), respectively. Thirty percent self-rated their health as bad or very bad and 19.8% were current smokers.

Conclusions

This study describes the characteristics of a population with advanced COPD in a stable phase of their disease. Our results illustrate how the population although treated in an outpatient structure already focusing on palliative needs, still live with unmet palliative needs and impaired quality of life.

Oral morphine drops for prompt relief of breathlessness in patients with advanced cancer-a randomized, double blinded, crossover trial of morphine sulfate oral drops vs. morphine hydrochloride drops with ethanol (red morphine drops)

PURPOSE

Episodic breathlessness is frequent in palliative cancer patients. Opioids are the only pharmacological agents with sufficient evidence in treatment. In Denmark, the main recommendation is red morphine drops (RMD), an off-label solution of morphine, ethanol, and red color (cochenille) described since 1893 (Pharmacopoea Danica). In 2015, the Danish Medicines Agency increased focus on off-label medicines and recommended registered morphine drops without ethanol instead. However, our palliative patients told us that RMD was better. For that reason, we conducted a clinical trial to clarify any perceived difference between the two types of drops.

METHODS

We conducted a randomized, double blinded, crossover trial. Patients were asked to perform standardized activity (2-min walk) aiming to provoke breathlessness. Primary endpoint (breathlessness NRS) and secondary endpoints (saturation, pulse, respiratory frequency) were measured before (t = 0) and after test medicine at t = 1, t = 3, t = 5, t = 10, and t = 20 min. After 2-4 days (washout period), the patients repeated the test, receiving the alternative drops in a blinded setup (crossover).

RESULTS

In the first 3 min, the relative drop in breathlessness for morphine drops with ethanol (RMD) was significant more than for morphine drops without ethanol. We found no significant difference in secondary endpoints.

CONCLUSIONS

A conclusion could be that ethanol might facilitate morphine absorption in the mouth. Our results needs further research of opioid absorption in the mouth as well as trials, testing morphine vs. more lipophilic opioids. The RMD drops are cheap, easy to use, and noninvasive and keep the patient independent of health care professionals.

Impact of pain, fatigue and dyspnoea on occupational performance in people with advanced cancer: A longitudinal study

Background: Pain, fatigue and dyspnoea are symptoms commonly experienced by people with advanced cancer, which may impact on their occupational performance. It is not known whether these symptoms impact their occupational performance over time.Objective: To examine correlation between pain, fatigue and dyspnoea and occupational performance and the impact of such symptoms on occupational performance over time in people with advanced cancer.Material and Methods: A longitudinal study was conducted including 242 participants assessed at baseline and after six and 12 weeks. Spearman's rank-order test and mixed linear models were performed.Results: The correlation between pain, fatigue and dyspnoea and occupational performance at baseline spanned from trivial to moderate (Spearman's rho: -0.004 to 0.34). Only pain had a statistically significant impact on activities of daily living (ADL) motor ability over time (p = 0.01). Participants with no pain problems had the largest decrease in ADL motor ability (-0.24 logits (95%-CI: -0.37 to -0.12)), but the observed decrease was not clinically relevant (≥-0.30).Conclusion: Pain, fatigue and dyspnoea did not seem to highly correlate with occupational performance or impact occupational performance over time of people with advanced cancer.

Prophylactic Fentanyl Sublingual Spray for Episodic Exertional Dyspnea in Cancer Patients: A Pilot Double-Blind Randomized Controlled Trial

CONTEXT

The optimal dose of fentanyl sublingual spray (FSS) for exertional dyspnea has not been determined.

OBJECTIVES

We examined the effect of two doses of prophylactic FSS on exertional dyspnea.

METHODS

In this parallel, dose-finding, double-blind randomized clinical trial, opioid-tolerant cancer patients completed a shuttle walk test at baseline. Patients completed a second shuttle walk test 10 minutes after a single dose of FSS equivalent to either 35%-45% (high dose) or 15%-25% (low dose) of the total daily opioid dose. The primary outcome was change in modified dyspnea Borg scale (0-10) between the first and second shuttle walk tests. Secondary outcomes included adverse events as well as changes in walk distance, vital signs, and neurocognitive function.

RESULTS

Thirty of the 50 enrolled patients completed the study. High-dose FSS (n = 13) resulted in significantly lower dyspnea (mean change -1.42; 95% CI -2.37, -0.48; P = 0.007) and greater walk distance (mean change 44 m; P = 0.001) compared to baseline. Low-dose FSS (n = 17) resulted in a nonsignificant reduction in dyspnea (mean change -0.47; 95% CI -1.26, 0.32; P = 0.24) and significant increase in walk distance (mean change 24 m; P = 0.01) compared to baseline. Global evaluation showed high-dose group was more likely to report at least somewhat better improvement (64% vs. 24%; P = 0.06). No significant adverse events or detriment to vital signs or neurocognitive function was detected.

CONCLUSION

Prophylactic FSS was well tolerated and demonstrated a dose-response relationship in improving both dyspnea and walk distance. High-dose FSS should be tested in confirmatory trials.

A Practical Guide to Geriatric Syndromes in Older Adults With Cancer: A Focus on Falls, Cognition, Polypharmacy, and Depression

Geriatric syndromes are multifactorial conditions that are prevalent in older adults. Geriatric syndromes are believed to develop when an individual experiences accumulated impairments in multiple systems that compromise their compensatory ability. In older adults with cancer, the presence of a geriatric syndrome is common and may increase the complexity of cancer treatment. In addition, the physiologic stress of cancer and cancer treatment may precipitate or exacerbate geriatric syndromes. Common geriatric syndromes include falls, cognitive syndromes and delirium, depression, and polypharmacy. In the oncology setting, the presence of geriatric syndromes is relevant; falls and cognitive problems have been shown to be predictive of chemotherapy toxicity and overall survival. Polypharmacy and depression are more common in older adults with cancer compared with the general geriatric population. Multiple screening tools exist to identify falls, cognitive problems, polypharmacy, and depression in older adults and can be applied to the oncology setting to identify patients at risk. When recognized, several interventions exist that could be considered for this vulnerable population. We review the available evidence of four geriatric syndromes in the oncology setting, including clinical implications, validated screening tools, potential supportive care, and therapeutic interventions.

Definition of Episodic Dyspnea in Cancer Patients: A Delphi-Based Consensus among Spanish Experts: The INSPIRA Study

BACKGROUND

Episodic dyspnea is an increasingly recognized phenomenon that occurs frequently in patients with cancer. Although numerous definitions have been proposed to describe episodic dyspnea, to date, no common widely accepted definition in Spanish has yet emerged. Without a clear well-accepted definition, it is difficult to design rigorous clinical trials to evaluate candidate treatments for this emerging entity and to compare outcomes among studies.

OBJECTIVE

The aim of the study was to reach a consensus definition of episodic dyspnea in the Spanish language based on professional criteria in cancer patients.

DESIGN

A two-round Delphi study.

SETTING/SUBJECTS

Sixty-one Spanish specialists in medical oncology, radiation oncology, pneumology, palliative care, and pain management participated in the study.

MEASUREMENTS

Sixteen different questions on dyspnea-related terminology, including the definition of episodic dyspnea, were assessed.

RESULTS

The panel of experts reached a consensus on 75% of the 16 assessments proposed: 56.25% in agreement and 18.75% in disagreement. The term that most panelists considered most appropriate to define dyspnea exacerbation was dyspnea crisis. The panelists disagreed that dyspnea exacerbation is equivalent to dyspnea at effort and that the presence of dyspnea at rest is required for exacerbation to occur. However, there was wide agreement that exacerbation may or may not be predictable and can be triggered by comorbidities as well as emotional, environmental, or effort factors.

CONCLUSIONS

The broad consensus reached in this study is a necessary first step to design high-quality methodological studies to better understand episodic dyspnea and improve treatment.

Managing chronic breathlessness in the community

Breathlessness or dyspnoea is a subjective experience that can be described as an unpleasant or uncomfortable awareness of breathing. It is a subjective experience for patients and often they learn to adapt to the limitations caused by their condition, which makes their breathlessness less apparent to others. Breathlessness can be subdivided in the context of chronic refractory breathlessness, such as acute breathlessness, which is either an episodic breathlessness or breathlessness crisis. Chronic refractory breathlessness is defined as breathlessness at rest or on minimal exertion that will persist chronically despite optimal treatment of the underlying causative factors. The role of the community nurse in managing the breathless patient should involve differentiating between different types of breathlessness and knowing how to effectively manage it in a holistic manner.

Symptom burden in heart failure: assessment, impact on outcomes, and management

Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.

Utility of the revised Edmonton Symptom Assessment System (ESAS-r) and the Patient-Reported Functional Status (PRFS) in lung cancer patients

BACKGROUND

Symptom palliation is an important objective of treatment in advanced/metastatic lung cancer (LC). Significant psychological, minor physical symptoms and several social/emotional issues often go unnoticed. This prospective study aimed to evaluate utility of patients' perspectives [self-reported symptom assessment by revised Edmonton Symptom Assessment System (ESAS-r) and self-reported functional status by Patient-Reported Functional Status (PRFS)] amongst LC patients undergoing chemotherapy.

METHODS

Consecutive newly diagnosed treatment-naïve LC patients attending a tertiary referral center in North India from January 2014 to March 2015 were included. All patients received standard histology-guided platinum-doublet chemotherapy. ESAS-r and PRFS questionnaires were administered under guidance, once at the time of initial assessment/diagnosis, repeated at start of chemotherapy, before C4, and after completion of chemotherapy (end of chemotherapy (EOCTx)). Functional Assessment of Cancer Therapy-Lung (FACT-L) questionnaire was also administered. Baseline and post-treatment scores were compared.

RESULTS

Majority of 133 patients enrolled were males (86.5%,n = 115), were current/ex-smokers (81.2%, n = 108), had advanced stage [IIIB = 30.1% (n = 40), IV = 52.6% (n = 70)], and were of non-small-cell type (NSCLC;84.2%,n = 112). On baseline ESAS-r, the highest mean symptom scores were observed for tiredness followed by anorexia. Mean ESAS-r scores before C4 as well as at EOCTX were significantly better than baseline ESAS-r scores in all its components except nausea. Similarly, PRFS before C4 and EOCTx was significantly improved compared to baseline. However, Karnofsky Performance Scale (KPS) and Eastern Cooperative Oncology Group Performance Status assessed at baseline did not show significant improvement at treatment completion. FACT-L score at EOCTx showed significant improvement from baseline in physical and functional well-being domains but not for social/family and emotional well-being domains.

CONCLUSION

This study validated utility of ESAS-r and PRFS in Indian LC patients. These instruments should be used in routine clinical practice besides physicians' assessment of PS (KPS/ECOG).

Effect of Prophylactic Fentanyl Buccal Tablet on Episodic Exertional Dyspnea: A Pilot Double-Blind Randomized Controlled Trial

CONTEXT

Episodic dyspnea is one of the most common, debilitating, and difficult-to-treat symptoms.

OBJECTIVE

We conducted a pilot study to examine the effect of prophylactic fentanyl buccal tablet (FBT) on exercise-induced dyspnea.

METHODS

In this parallel, double-blind randomized placebo-controlled trial, opioid-tolerant patients were asked to complete a six-minute walk test (6MWT) at baseline and then a second 6MWT 30 minutes after a single dose of FBT (equivalent to 20-50% of their total opioid dose) or matching placebo. We compared dyspnea Numeric Rating Scale (NRS, 0-10, primary outcome), walk distance, vital signs, neurocognitive function, and adverse events between the two 6MWTs.

RESULTS

Among 22 patients enrolled, 20 (91%) completed the study. FBT was associated with a significant within-arm reduction in dyspnea NRS between 0 and six minutes (mean change -2.4, 95% CI -3.5, -1.3) and respiratory rate (mean change -2.6, 95% CI -4.7, -0.4). Placebo was also associated with a nonstatistically significant decrease in dyspnea (mean change -1.1). Between-arm comparison of dyspnea scores in the second 6MWT favored FBT, albeit not statistically significant (estimate -0.25, P = 0.068). Global impression revealed more patients in the FBT group than placebo group reporting their dyspnea was at least "somewhat better" in the second 6MWT (4 of 9 vs. 0 of 11, P = 0.03). The other secondary outcomes did not differ significantly between arms.

CONCLUSIONS

This study supports that prophylactic FBT was associated with a reduction of exertional dyspnea and was well tolerated. Our findings support the need for larger trials to confirm the therapeutic potential of rapid-onset opioids.

Unpredictable episodic breathlessness in patients with advanced chronic obstructive pulmonary disease and lung cancer: a qualitative study

PURPOSE

The internationally consented definition and categorization describe two categories of episodic breathlessness: predictable (with known triggers) and unpredictable. The link of known triggers only to predictable episodes can be read that unpredictable episodes have none known trigger. Our aim was to illuminate patients' experiences with episodes of unpredictable breathlessness, to collect descriptions of the episodes' impact on the patients' lives, and, in turn, the patients' individual coping strategies in this connection.

DESIGN

Qualitative study using semi-structured in-depth interviews with patients suffering from unpredictable episodes of breathlessness and chronic obstructive pulmonary disease (COPD; Global Initiative for Obstructive Lung Disease III and IV) or lung cancer (all stages). Interviews were audio-recorded, transcribed verbatim, and analyzed using Framework Analysis.

RESULTS

One hundred one patients were screened in a large university hospital; ten participants fulfilled the inclusion criteria and provided consent. The experienced episodes were evaluated as unpleasant and with higher intensity compared to predictable episodes. Non-pharmacological interventions were identified as useful coping strategies. Interestingly, although patients experienced the episodes in an unpredictable manner, a trigger could be detected retrospectively for the majority of cases (mostly emotions (especially panic) and, occasionally, physical exertion). Unpredictable episodes are less frequent than previously assumed.

CONCLUSION

The unpredictability of unpredictable breathless episodes refers to the patients' experience that these episodes occur "out-of-the-blue." However, a known trigger can be identified for the majority of unpredictable breathless episodes. These are therefore triggered as well. Further research needs to describe more possible triggers, to inquire the prevalence of unpredictable episodic breathlessness, and to develop effective management strategies.

Symptom management challenges in heart failure: pharmacotherapy considerations

Heart failure is a chronic, progressive illness that is increasing in prevalence in the USA. Patients with advanced heart failure experience a high symptom burden that is comparable to patients with advanced cancer. Palliative care, however, is underutilized in patients with heart failure, and symptoms may go untreated as the disease progresses. A combination of pharmacologic and non-pharmacologic interventions should be used to address symptoms and maintain quality of life. While there have been significant advances in evidence-based heart failure treatments in recent years, selection of appropriate palliative medications as symptoms progress is challenging due to limited clinical studies in this patient population. Medications that are commonly used for symptom management in other life-limiting illnesses may have little to no evidence in heart failure, or have undesirable cardiac effects that preclude use. Clinicians must extrapolate available clinical evidence and prescribing considerations relevant to heart failure to palliate symptoms as well as possible. The objectives of this paper are to review the most common and distressing symptoms in heart failure, analyze evidence, or lack thereof, for pharmacologic management of symptoms, and provide prescribing considerations based on side effect profiles and comorbid conditions.

Impact of dyspnea on advanced cancer patients referred to a palliative radiotherapy clinic

PURPOSE

Dyspnea is a debilitating symptom commonly experienced by advanced cancer patients that can lead to negative effects on function and quality of life (QOL). The present study aims to determine the relationship between dyspnea and other Edmonton Symptom Assessment System (ESAS) symptoms in palliative cancer patients referred to a radiotherapy clinic.

METHODS

The presence and severity of dyspnea was measured using the ESAS. All patients that visited a palliative radiotherapy clinic between 1999 to 2002 and 2006 to 2009 and completed the ESAS were included. ESAS scores and other demographic and clinical information were extracted from a prospectively collected database. Statistical tests including chi-squared tests, Spearman correlations, and multivariate analysis were conducted to explore the relationship between dyspnea, other ESAS items, and other demographic factors. Kaplan-Meier overall survival curves were generated based on dyspnea severity.

RESULTS

One thousand three hundred forty-four patients were included in the dyspnea analysis; reported moderate or severe dyspnea. Dyspnea severity was significantly associated with eight other ESAS interference severities (p < 0.001). Upon multivariate analysis, greater severity of dyspnea was significantly related to higher ESAS scores for tiredness, nausea, depression, anxious, drowsiness, and poor appetite (p < 0.05). The actuarial median survival time was 6.57 months (95% CI 5.91-7.29 months). There were highly significant differences in overall survival between those with none, mild, and moderate dyspnea (p < 0.0001).

CONCLUSION

Cancer patients often experience dyspnea along with a multitude of other symptoms. Moderate and severe dyspnea should be assessed and optimally managed to reduce functional and QOL debilitations. As presence of increased dyspnea severity is associated with worse overall survival, interventions should occur at the end of life to reduce symptom burden in palliative patients.

Assessment of Breathlessness in Lung Cancer: Psychometric Properties of the Dyspnea-12 Questionnaire

CONTEXT

The Dyspnea-12 (D-12) Questionnaire is a well-validated instrument in respiratory illnesses for breathlessness assessment, but its psychometric properties have not been tested in lung cancer.

OBJECTIVE

To demonstrate the psychometric properties of the D-12 in lung cancer patients.

METHODS

Baseline data from a lung cancer feasibility trial were adopted for this analysis. D-12 and a series of patient-reported tools, including five Numeric Rating Scales (NRS), the Hospital Anxiety and Depression Scale (HADS), and the Lung Cancer Symptom Scale (LCSS), were used for the psychometric assessment. Spearman's correlation coefficients (rs) were used to estimate the convergent validity of the D-12 with the NRS, HADS, and LCSS. Exploratory factor analysis was performed to examine construct validity. Reliability was tested by Cronbach's alpha and item-to-total correlations. D-12 score difference between patients with or without anxiety, depression, and chronic obstructive pulmonary disease (COPD) was explored to identify its discriminate performance.

RESULTS

One hundred and one lung cancer patients were included. There were significantly positive correlations between the D-12 and the HADS, LCSS, and NRS measuring breathlessness severity and its associated affective distress. Factor analysis clearly identified two components (physical and emotional) of the D-12. Cronbach's alpha for D-12 total, physical, and emotional subscales was 0.95, 0.92, and 0.94, respectively. Patients with anxiety or depression demonstrated significantly higher D-12 scores than those without it, and patients with COPD reported significantly more severe breathlessness than those without COPD.

CONCLUSION

The D-12 is a valid and reliable self-reported questionnaire for use in breathlessness assessment in lung cancer patients.

Background and episodic breathlessness in advanced cancer patients followed at home

BACKGROUND

The aim of this study was to assess the phenomenon of episodic breathlessness in advanced cancer patients followed by palliative care services at home.

METHODS

A consecutive sample of patients with advanced cancer, admitted to home care for a period of six months, was surveyed. The presence of background breathlessness and episodic breathlessness, their intensity, and drugs used for their treatment were collected. Factors inducing episodic breathlessness, and its influence on daily activities were investigated.

RESULTS

Three hundred forty-seven advanced cancer patients admitted to home palliative care were surveyed. The prevalence of breathlessness was 35.3%. The mean intensity of breathlessness was 3.8 (SD 1.96), out of a maximum score of 10 for worst imaginable. Sixty patients (49.2%) were receiving drugs for background breathlessness. In the multivariate analysis the risk of breathlessness increased with cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer while it decreased in patients with a better performance status. The prevalence of episodic breathlessness in patients with background breathlessness was 79.5% and its mean intensity was 7.1 (SD 1.5, range 2-10). The mean duration of episodic breathlessness was 28.6 minutes (SD 47.1, range 1-300 minutes). Forty-three patients (44.3%) were receiving one or more drugs as needed. The majority of episodic breathlessness events were triggered by activity. Episodic breathlessness was interfering with daily activities in 65 patients (67%). Episodic breathlessness wasn't associated with any variable taken into consideration.

CONCLUSION

This study showed that episodic breathlessness frequently occurs in advanced cancer patients admitted to home care, is severe in intensity, is triggered in most cases by activity, and is characterized by a short duration which requires rapid measures.

Identification of Symptom Clusters in Cancer Patients at Palliative Care Clinic

Objective:

Cancer patients often experience a large number of symptoms together. The aim of this study is to determine the symptom clusters in cancer patients at palliative care clinic.

Methods:

Hundred and seventy consecutive patients were enrolled in the study. Memorial Symptom Assessment Scale was used for symptom assessment of the patients.

Results:

The most experienced symptoms by the patients during the past week before hospitalization in palliative care clinic were lack of energy (95.4%), weight loss (91.2%), lack of appetite (89.4%), pain (88.2%), dry mouth (87.6%), feeling sad (87.6%), feeling nervous (82.9%), worrying (81.2%), and feeling irritable (80.6%). Five symptom clusters were defined. First cluster: pain, feeling nervous, dry mouth, worrying, feeling irritable, weight loss; second cluster: feeling drowsy, numbness/tingling in hands/feet, difficulty in sleeping, dizziness, constipation, I do not look like myself; third cluster: nausea, vomiting; fourth cluster: shortness of breath, difficulty in swallowing, cough, change in the way food tastes; and fifth cluster: feeling bloated, problems with urination, diarrhea, itching, mouth sores, hair loss, swelling of arm or legs, change in the skin.

Conclusions:

We encountered various symptom clusters in advanced cancer patients. Identification of symptom clusters and knowledge of cluster composition in oncological population may particularly contribute individualization of the treatment.

EffenDys-Fentanyl Buccal Tablet for the Relief of Episodic Breathlessness in Patients With Advanced Cancer: A Multicenter, Open-Label, Randomized, Morphine-Controlled, Crossover, Phase II Trial

CONTEXT

Episodic breathlessness is a frequent and burdensome symptom in cancer patients but pharmacological treatment is limited.

OBJECTIVES

To determine time to onset, efficacy, feasibility, and safety of transmucosal fentanyl in comparison to immediate-release morphine for the relief of episodic breathlessness.

METHODS

Phase II, investigator-initiated, multicenter, open-label, randomized, morphine-controlled, crossover trial with open-label titration of fentanyl buccal tablet (FBT) in inpatients with incurable cancer. The primary outcome was time to onset of meaningful breathlessness relief. Secondary outcomes were efficacy (breathlessness intensity difference at 10 and 30 minutes; sum of breathlessness intensity difference at 15 and 60 minutes), feasibility, and safety. Study was approved by local ethics committees.

RESULTS

Twenty-five of 1341 patients were eligible, 10 patients agreed to participate (four female, mean age 58 ± 11, mean Karnofsky score 67 ± 11). Two patients died before final visits and two patients dropped-out because of disease progression leaving six patients for analysis with 61 episodes of breathlessness. Mean time to onset was for FBT 12.7 ± 10.0 and for immediate-release morphine 23.6 ± 15.1 minutes with a mean difference of -10.9 minutes (95% CI = -24.5 to 2.7, P = 0.094). Efficacy measures were predominately in favor for FBT. Both interventions were safe. Feasibility failed because of too much study demands for a very ill patient group.

CONCLUSION

The description of a faster and greater relief of episodic breathlessness by transmucosal fentanyl versus morphine justifies further evaluation by a full-powered trial.