Appropriate chemotherapy for palliating advanced cancer

To be involved or not: factors that influence nurses' involvement in providing treatment decisional support in advanced cancer

Decisional support is a multifaceted process of facilitating patients' decision making regarding treatment choices. Effective decisional support practices of nurses in relation to the use of anticancer therapies in patients with advanced disease are central to quality cancer care. A recent qualitative descriptive study (n=21) exploring the decision making practices of doctors and nurses in one tertiary cancer centre in New Zealand identified many complexities associated with nurses and their participation in decisional support. The study revealed that cancer nurses had varied opinions about the meaning and importance of their roles in treatment related decision making. This variation was significant and led the researchers to undertake a detailed secondary exploration of factors that impacted on the nurses' involvement in the provision of decisional support. Four key groups of factors were identified. These were factors relating to degree of knowledge, level of experience, beliefs and understandings about nursing roles and cancer therapies, and structural interfaces in the work setting. Understanding these factors is important because it allows modification of the conditions which impact on the ability to provide effective decisional care. It also provides some understanding of clinical drivers associated with nurses' decisional support work with patients who have advanced cancer.

[Perceptions of patients and physicians involved in clinical trials: an overview of the literature]

OBJECTIVE - METHOD: The purpose of this review is to explore the expectations of patients and physicians prior to participate to a clinical trial and their positive or negative experiences after participating. A systematic review of Medline database from 1966 to 2005 identified 79 papers reported patients and physicians perceptions of clinical trials (only 3 in French), whom 27 English surveys conducted on patients and physicians.

RESULTS

If primary patients' motivation for enrolment was altruistic, physicians wish to help their patient. After enrolment, the most perceived positive benefit for patients and physicians are, respectively, the emotional improvement and the greater opportunity for personal benefit offered to enrolled patients. Most physicians' negative experience included logistical difficulties while patients are unease with randomisation and often uncomfortable with medical procedures. Unlike patients, all physicians' expectations seem to be fulfilled.

CONCLUSION

The knowledge of patients' and physicians' perception of participation may improve recruitment in clinical trials.

Advanced Breast Cancer Patients' Perceptions of Decision Making for Palliative Chemotherapy

Purpose

To examine advanced breast cancer patients' perceptions of the key decision-making consultation for palliative chemotherapy.

Patients and Methods

One hundred two women with advanced breast cancer, who were offered palliative chemotherapy, participated in a study-specific semistructured interview examining perceptions of the information they had received and their involvement in the decision-making process. One hundred seventeen interviews included 70 in relation to first-line chemotherapy and 47 in relation to second-line chemotherapy (15 patients were interviewed in relation to both first- and second-line chemotherapy).

Results

Eighty-six percent of patient interviews (n = 101) reported patient satisfaction with the information they received, and 91% (n = 106) reported satisfaction with the decision-making process. Factors most influential in decisions to accept chemotherapy were the possibility of controlling the tumor (45%, n = 53 of patient interviews) and providing hope (33%, n = 28 of patient interviews; 19%, n = 13 being offered first-line chemotherapy v 43%, n = 20 being offered second-line chemotherapy; P = .006). Thirty-eight percent of patient interviews (n = 44) reported the patient as taking an active role in the decision-making process (33%, n = 23 at first-line chemotherapy v 43%, n = 20 at second-line chemotherapy; P = .06).

Conclusion

Women offered second-line chemotherapy were more likely to undergo chemotherapy because of the hope it offers and were more likely to take an active role in that decision compared with women who were offered first-line chemotherapy. Compassionate and honest communication about prognosis and likelihood of benefit from treatment may help to close the gap between hope and expectation and enable patients to make fully informed decisions about palliative chemotherapy.

Symptom control

Symptom control has become increasingly recognized as an important goal in patient care. In this article, advances in symptom assessment, and various definitions of symptom improvement are reviewed. Theoretical concepts underlying symptom control and clinically significant change are presented, as well as the role of symptom control as an endpoint in clinical trials. Symptom control is then surveyed in two broad categories for selected symptoms. The first area is therapy related symptoms, secondary to chemotherapy, radiation, hormonal therapy, and surgery. Symptoms reviewed include chemotherapy related mucositis, emesis, fatigue; hot flashes; and radiation related dermatitis, xerostomia, and mucositis. The second area is palliative oncologic approaches to disease-related symptoms. Results in palliative chemotherapy, palliative radiation therapy, cancer pain, and lack of appetite are summarized. Areas requiring further research are noted. Findings are presented in both a clinical and research context to help guide the reader with interpreting symptom control studies.

Why patients don't take part in cancer clinical trials: an overview of the literature

Clinical trials have been recognized extensively within the literature as a crucial component in the research, development and evaluation of treatment strategies within health care services. However, it has also been acknowledged that clinicians and researchers have historically experienced problems in terms of attaining adequate recruitment to clinical trials. The purpose of this review is to explore some of these questions and, more importantly, provide possible explanations for non-participation in clinical trials, with specific reference to the field of cancer research. In addition, approaches that have been used by researchers in order to explore the issue of non-participation, and suggestions in terms of the ways that further research into this key area may be undertaken, are also be considered.

Chemotherapy for advanced breast cancer: what influences oncologists' decision-making?

Chemotherapy is widely used in the management of patients with advanced breast cancer. However, a considerable proportion of patients experience toxic side effects without gaining benefit. This study aimed to elicit oncologists' views of the goals of chemotherapy for patients with advanced breast cancer and to elicit which factors are important in decisions to recommend chemotherapy to such patients. 30 oncologists underwent a semi-structured interview to examine their views of 5 goals of chemotherapy and of various disease, treatment and patient-related factors that might influence decisions to offer treatment. The clinicians also made decisions regarding treatment in relation to a hypothetical patient scenario under varying clinical conditions. Relief of symptoms and improvement of activity were rated as the most valuable and achievable goals of treatment. The patient's performance status, frailty and their wishes regarding treatment were the most important patient-related factors in determining decision-making. The most important disease/treatment-related factors were pace of the disease, previous poor response to chemotherapy, co-existing symptoms and concurrent medical conditions. The hypothetical scenario revealed that co-existing medical conditions, adverse previous response, increased age and depression would decrease the likelihood of recommending chemotherapy, whereas key symptoms (e.g. breathlessness) and the patient's goals would increase the likelihood. The findings suggest that British oncologists primarily aim to improve patients' physical function, although subjective factors, such as a patient's desire for anti-cancer treatment and their future goals, also influence decisions to offer treatment.

Strategies to manage the adverse effects of oral morphine: an evidence-based report

Successful pain management with opioids requires that adequate analgesia be achieved without excessive adverse effects. By these criteria, a substantial minority of patients treated with oral morphine (10% to 30%) do not have a successful outcome because of (1) excessive adverse effects, (2) inadequate analgesia, or (3) a combination of both excessive adverse effects along with inadequate analgesia. The management of excessive adverse effects remains a major clinical challenge. Multiple approaches have been described to address this problem. The clinical challenge of selecting the best option is enhanced by the lack of definitive, evidence-based comparative data. Indeed, this aspect of opioid therapeutics has become a focus of substantial controversy. This study presents evidence-based recommendations for clinical-practice formulated by an Expert Working Group of the European Association of Palliative Care (EAPC) Research NETWORK: These recommendations highlight the need for careful evaluation to distinguish between morphine adverse effects from comorbidity, dehydration, or drug interactions, and initial consideration of dose reduction (possibly by the addition of a co analgesic). If side effects persist, the clinician should consider options of symptomatic management of the adverse effect, opioid rotation, or switching route of systemic administration. The approaches are described and guidelines are provided to aid in selecting between therapeutic options.

Coping with new treatments for cancer: a feasibility study of daily diary measures

This article describes a study of the feasibility and value of using daily diary measures to assess coping, adjustment and symptoms in patients participating in phase I clinical trials of new anticancer drugs. Ten patients (six women, four men) with advanced metastatic cancer were studied during a four-week phase I trial. Measures of psychological well-being, mental adjustment and symptoms were determined prior to treatment, and participants also completed daily ratings of psychological coping responses, mood and symptoms. Completion rates for diaries were high, and the amount of missing data averaged only 3.2% per patient. Overall, the most frequently endorsed coping responses were 'acceptance' and 'positive reinterpretation and growth'. There were systematic variations in coping by seeking social support across the trial, with more frequent use during phases of hospitalisation. Idiosyncratic fluctuations in patterns of coping were also observed. Positive daily mood was greater among patients who coped by ignoring their condition, and was also correlated with fighting spirit. Daily symptoms were inversely associated with positive mood and with fighting spirit. It is concluded that the daily diary approach is feasible, and may help to increase understanding of the experience of patients taking part in experimental anticancer drug trials.

Differential effects of respiratory syncytial virus and adenovirus on mononuclear cell cytokine responses

Respiratory syncytial virus (RSV) and adenovirus (Advs) serotype 3 (Adv3) and 7h (Adv7h) are associated with mild to severe respiratory infection and are indistinguishable during the acute phases of the illnesses. However, outcome and long-term prognosis are different with both infections. RSV infection is associated with later development of asthma, and Adv, mainly Adv7h, with severe lung damage, bronchiectasis, and hyperlucent lung. We hypothesized that this difference could be partly due to different immune responses induced by these viruses. To test this hypothesis we quantified TCD4+, TCD8+, and BCD19+ expressing the interleukin-2 receptor-alpha chain (CD25) and interferon-gamma (IFN-gamma), interleukin (IL)-10, and IL-4 in the supernatant of peripheral blood mononuclear cells (PBMC) from school children infected in vitro with and without RSV, Adv7h, and Adv3 and after phytohemagglutinin (PHA) stimulation in the presence or absence of these viruses at a multiplicity of infection (MOI) of 1. PBMC from every child produced more IL-10 (p </= 0.05) when infected with RSV than with Advs and noninfected control, and Adv induced more (p </= 0.05) IFN-gamma than did RSV and control. The IL-10/IFN-gamma ratio was significantly higher (p </= 0.05) in RSV-infected and significantly lower (p </= 0.05) in Adv-infected PBMC, than in noninfected cells. PHA-stimulated BCD19+ RSV- infected cells expressed more (p </= 0.05) IL-2R than did Adv-infected cells. These results suggest that Advs induce a Th-1-type immune response that is not seen with RSV. These patterns persist despite intersubject variation in the absolute quantity of cytokine produced.

Do patients with advanced breast cancer benefit from chemotherapy?

This study aimed to assess the proportion of patients with advanced breast cancer who report benefit from first-line palliative chemotherapy using a simple global measure of wellbeing and to identify factors predicting benefit. A consecutive series of women with advanced breast cancer undergoing first-line palliative chemotherapy was evaluated. The main outcome measure was patient report of overall wellbeing assessed at post-treatment interview. Physical, psychological and functional status were assessed using the Rotterdam Symptom Checklist (RSCL) on three occasions (pretreatment, at the start of the third cycle and post treatment). It was planned that treatment would be discontinued after six cycles (i.e. 18-24 weeks). One hundred and sixty patients started treatment, of whom 155 were assessable for quality of life. After treatment, 41 (26%) patients reported they felt better, 29 (19%) felt the same and 34 (22%) felt worse than they did before treatment. The other 51 (33%) patients either died or stopped attending the hospital before the post-treatment interview and were assigned as treatment 'failures'. Patients who reported feeling better after treatment had improvements in psychological distress (P < 0.0001), pain (P = 0.01), lack of energy (P = 0.02) and tiredness (P = 0.02), as well as improvement in functional status (P = 0.07). Feeling better was also correlated with disease response (P = 0.03). Feeling worse after treatment or treatment 'failure' was predicted by the pretreatment presence of a dry mouth (P = 0.003) and high levels of psychological distress (P = 0.03). Pretreatment lack of energy (P = 0.01), dry mouth (P = 0.02), presence of liver metastases (P = 0.03) and breathlessness (P = 0.03) predicted treatment 'failures'. The results of this study suggest that first-line palliative chemotherapy for advanced breast cancer confers benefit on a substantial proportion of patients, with about one-quarter feeling better after treatment and nearly a half feeling better or the same some 4-6 months after the start of treatment. Factors identified in this study may assist clinicians in deciding which patients should not be offered treatment, because of high risk of feeling worse or treatment 'failure'. This work now needs to be validated on a further cohort of women receiving chemotherapy for advanced breast cancer.

Symptom duration and delay in referral for palliative radiotherapy in cancer patients: a pilot study

OBJECTIVE

To estimate the frequency of delay in referral for palliative radiotherapy (PRT), and to identify factors associated with delay.

DESIGN

Prospective survey over three months in 1997.

SETTING

Radiotherapy department of a cancer centre in Melbourne, Victoria.

PARTICIPANTS

158 consecutive patients prescribed PRT in the lung, breast, urology and haematology units.

MAIN OUTCOME MEASURES

Duration of symptoms; incidence of "unreasonable" delay in referral; and incidence of negative clinical outcome associated with referral delay.

RESULTS

The median duration of symptoms before prescription of radiotherapy was four weeks. Thirty-eight patients (24%) were considered to have had an unreasonable delay in referral, with median symptom duration of 15 weeks, and median delay in referral of 12 weeks. Causes of delay were classified as "diagnostic uncertainty" (29%), "other treatment given" (18%), "patient related" (18%), "language difficulty" (3%), and "unexplained" (32%). Twenty-seven of these 38 patients (71%) had negative outcomes, including persistent pain, neurological deterioration and persistent respiratory symptoms.

CONCLUSIONS

These data suggest that delay in referral for PRT is not uncommon, has a variety of causes and can result in negative clinical outcomes. There appears to be a need for greater awareness of patients' symptoms and of the role of PRT among clinicians caring for patients with cancer.

Treatment of patients with advanced gastric carcinoma with a 5-fluorouracil-based or a cisplatin-based regimen: two parallel randomized phase II studies

BACKGROUND

Although many drug combination therapies have been proposed, there is no standard therapy for patients with advanced gastric carcinoma. The superiority of combination therapy over monochemotherapy has not been demonstrated convincingly. To explore the role of monochemotherapy, the authors evaluated 5-fluorouracil (5-FU), modulated by 6S-leucovorin (6S-LV) and a cisplatin-containing regimen, which was comprised of epirubicin, etoposide, and cisplatin with the addition of the reversal agent lonidamine (EEP-L).

METHODS

After stratification according to performance status (PS) and resection of the primary tumor, 72 patients with advanced gastric carcinoma were randomized to 2 parallel Phase II trials with 5-FU/6S-LV and EEP-L, respectively. Thirty-six patients in Study A received bolus 6S-LV, 100 mg/m2, followed by bolus 5-FU, 370 mg/m2, on Days 1-5 and 36 others in Study B received epirubicin, 30 mg/m2, on Days 1 and 5; etoposide, 100 mg/m2, on Days 1, 3, and 5; cisplatin, 30 mg/m2, on Days 2 and 4; and lonidamine, 150 mg/day.

RESULTS

There were 6 partial responses (18.2%) (95% confidence interval [CI] +/- 13.2) in Study A and 7 partial responses (21.9%) (95% CI +/- 14.3) in Study B. Partial responses were more frequent in patients with resected tumors or with an Eastern Cooperative Oncology Group PS of 0-1. The median duration of response was 8.8 and 8.3 months, respectively, in Study A and Study B. The median survival reached 8 months in Study A and 9 months in Study B. In the whole population of patients survival was significantly higher in patients with a PS of 0-1 (P < 0.05). Patients with a PS of 0-1 and a resected tumor had the significantly longest survival both in EEP-L treated patients and in all evaluable patients in the two studies. The most frequent World Health Organization Grade 3-4 toxic effects were gastrointestinal in Study A and hematologic in Study B. No treatment-related death was observed.

CONCLUSIONS

The efficacy of 5-FU, modulated with 6S-LV, is moderate in patients with advanced gastric carcinoma, similar to cisplatin-containing regimens. PS and other prognostic factors could influence the response rate, which does not appear to be a reliable parameter for evaluating the outcome of chemotherapy trials.

Chemotherapy improves survival and quality of life in advanced pancreatic and biliary cancer

BACKGROUND

In certain patients with pancreatic and biliary cancer, chemotherapy may relieve tumour-related symptoms, improve quality of life and possibly prolong survival. The extent of these improvements is not completely known in spite of the extensive use of this treatment modality. The aim of this study was to estimate any gain in the quantity and quality of life produced by chemotherapy in patients with pancreatic and biliary cancer.

PATIENTS AND METHODS

Between January 1991 and February 1995, 90 eligible patients with pancreatic or biliary cancer were randomized to either chemotherapy in addition to best supportive care or to best supportive care. Chemotherapy was allowed in the latter group if the supportive measures did not lead to palliation. Chemotherapy was either sequential 5-fluorouracil/leucovorin combined with etoposide (FELv) or, in elderly and poor performance patients, the same regimen without etoposide (FLv). Quality of life was evaluated with the EORTC-QLQ-C30 instrument.

RESULTS

Mean scale scores in the QLQ-C30 improved more often/deteriorated less frequently in the chemotherapy group than in the best supportive care group. More patients in the chemotherapy group (36%, 17/49) had an improved or prolonged high quality of life for a minimum period of 4 months compared to those in the best supportive care group (10%, 4/41, P < 0.01). Overall survival was significantly longer in the chemotherapy group (median 6 vs. 2.5 months, P < 0.01). Also, the quality-adjusted survival time was longer for patients randomized to chemotherapy (median 4 vs. 1 months, P < 0.01). The effects were seen both in pancreatic and biliary cancer.

CONCLUSIONS

The results show that chemotherapy can add to both quantity and quality of life in advanced pancreatic and biliary cancer. The number of patients who benefit from treatment is, however, still limited; for this reason careful selection before, and close monitoring during, treatment are necessary.

Ethical and practical problems of early anti-cancer drug trials: a review of the literature

Early clinical trials for new anti-cancer drug treatments typically use patients with cancer as research subjects. This paper identifies some of the ethical and practical concerns that arise from the recruitment of a vulnerable group of patients and their exposure to a drug of unknown risk or benefit. This review discusses the ethical principles related to recruitment and informed consent in cancer trials, and indicates that there is a lack of consensus concerning the requirements, process and practice of informed consent. It is suggested that, as yet, little is known about patients' decision making framework in this situation, and the need for further work that concentrates on the patient's point of view is highlighted. The paper concludes by discussing some of the difficulties associated with obtaining patients' opinions, and suggests that the use of a qualitative approach may overcome some of these problems.

The last 3 months of life of cancer patients: medical aspects and role of home-care services in southern Switzerland

The clinical data on terminal cancer patients who have died since the establishment of a program of collaboration between community services and the cancer center of Canton of Ticino, southern Switzerland, were retrospectively analyzed to describe the characteristics of patients seen and the effect on them of a home-care program coordinated by the cancer center. The home-care program is based on five geographically grouped community-based domiciliary services, with the addition of one nurse responsible for coordination and one physician from the oncology center. Selection criteria for participation in the home-care program are defined. The main outcome measures were: number of hospitalizations and median hospital stay during the last 3 months of life; reasons for and median length of last hospitalization; place of death of patients who had home care and those who did not. In the group of 993 patients analyzed, the median contact time with the cancer center was 9.5 months (10th percentile: 1 month, 90th percentile: 71 months); the most frequent neoplasm was lung cancer (22%) with the briefest contact time (7.5 months; 10th percentile: 1 month; 90th percentile: 21 months); 13.5% of patients were never hospitalized; half of the patients had a total hospital stay of 24 days or longer and 23% died at home. The sociodemographic and medical characteristics of home-care users were similar to those of the home-care non-users and to those of the overall group. In the group of home-care users (32% of the total) 22% were never hospitalized, half of the patients had a total hospital stay of 17 days or longer, and 43.5% of them died at home. These values were significantly different (P > 0.001) from those reported in the group of home-care non-users. Palliative care, provided at home through community-based domiciliary services, is associated with less frequent and shorter hospitalizations in the last 3 months of life. Medical oncology and palliative treatments should be mutually complementary to improve patients care. Cancer centers should be involved in the planning and coordination of supportive-care domiciliary services.

Key issues in the treatment of advanced breast cancer. Expectations and outcomes

Advanced breast cancer is common and can cause extensive morbidity, often over long periods of time. A variety of treatments, including symptomatic measures, surgery, radiotherapy, endocrine treatment and cytotoxic drugs, may be applicable for individual patients. Cytotoxic chemotherapy is the most contentious therapy because of its potentially severe adverse effects. While clinical trials give information concerning objective response rates, they are of relatively little value in ascertaining the true value of treatment in routine practice. In recent years, increasing importance has been attached to the evaluation of symptom relief and quality of life. A scoring method for outcome analysis has been developed, in which the resultant of beneficial and adverse effects of treatments is estimated. Sensitivity analysis demonstrated the robustness of this method, which indicated that only about 20% of all patients with advanced breast cancer given first-line chemotherapy gain net benefit. This result was corroborated in a prospective study in which patient reports of benefit were systematically recorded. Most of the expenditure incurred when treating patients with advanced breast cancer is derived from treatment of serious illness rather than from specific antitumour treatment; cytotoxic drug therapy accounts for less than 10% of total expenditure.

Cost-effectiveness of palliative chemotherapy in advanced gastrointestinal cancer

BACKGROUND

Chemotherapy may relieve tumor-related symptoms, may improve quality of life and prolong survival in advanced gastrointestinal cancer. The extent of such improvements is unclear despite the extensive use of this treatment modality, and there are no studies concerning the economic cost of any gain achieved in the quantity and quality of life by chemotherapy.

PATIENTS AND METHODS

Between January 1991 and May 1992, 61 patients with inoperable cancer (18 gastric, 22 pancreatic or biliary, and 21 colorectal) were randomized to either primary chemotherapy in addition to best supportive care or to best supportive care. Chemotherapy was allowed in the latter group if the supportive measures did not achieve palliation. All economic costs for medical care were prospectively recorded, and marginal cost-effectiveness analyses were performed.

RESULTS

More patients in the primary chemotherapy group (19/33, 58%) had improved/prolonged high quality of life (QoL-patient, minimum duration 4 months) than in the best supportive care group (8/28, 29%, p < 0.05). Overall survival and quality-adjusted survival were significantly longer in the primary chemotherapy group (median 9 vs. 4 months, p < 0.05), and median 7 vs. 2 months, p < 0.05, respectively). When analysed by cancer site, survival was significantly prolonged in gastric cancer patients (median 10 vs. 4 months, p < 0.02), but not in colorectal (median 12 vs. 6 months, p = 0.1) and pancreatic-biliary cancer patients (median 8 vs. 5 months, p = 0.8). The average cost for all medical care was approximately 50% higher in the primary chemotherapy group, but the average cost per day was the same in the two groups. Hospitalization accounted for most of the costs in both groups. The incremental costs per gained year of life was SEK 166,400 ($21,300), per gained quality-adjusted year of life SEK 157,200 ($20,200), and per QoL-patient SEK 160,300 ($20,600). These costs were lower for gastric and colorectal cancer patients, and much higher for pancreatic-biliary cancer patients.

CONCLUSIONS

The results of this study suggest that palliative chemotherapy is cost-effective in patients with advanced gastric and colorectal cancer. Knowledge about survival and quality of life benefits is still limited in patients suffering from gastric and pancreatic-biliary cancer.

Hospice management of patients receiving cytotoxic chemotherapy: problems and opportunities

In Britain, the specialty of palliative medicine continues to develop, encouraging the referral of patients early in the palliative phase of their illness. This had led to an increased number of patients receiving palliative chemotherapy and hospice care concurrently, posing special problems to the professionals involved. In this retrospective study, 52 patients were identified who received chemotherapy and hospice care simultaneously. Case notes were reviewed to reveal problems arising from sharing the duty of care. The poor quality of communication between professionals, perhaps reflecting a limited understanding of the various roles in patient care, we found to cause significant difficulties. The duration and discontinuation of cytotoxic therapy seems to be a particularly difficult matter. Hospice admission often signalled the end of this treatment. In a third of the patients, no decision was taken to stop chemotherapy despite the last dose being an average of just 1 week before death. The value of chemotherapy for patients who are too ill to return home is questioned. Seven patients were diagnosed as suffering from chemotherapy-induced sepsis and neutropenia either by hospice inpatient or home care teams, and were admitted to their acute centres accordingly. Most patients who died during the study period received terminal care in the hospice. Suggestions are made on improving professional education and communication, including the use of a 'chemotherapy card'.

Cost effectiveness in the treatment of advanced solid tumours

When the treatment of advanced cancer is palliative in intent, evaluation of quality of life is of paramount importance in judging the effectiveness of treatment. The balance between adverse effects (costs) and benefits has been particularly difficult to determine with cytotoxic drugs. An approach to this problem using medical audit is described. It has been found to be a reliable method which has demonstrate a highly significant correlation between achievement of objective regression and acquisition of benefit. The method is now undergoing corroboration by a prospective study.