Randomized comparison of four tools measuring overall quality of life in patients with advanced cancer

PURPOSE

We report on a clinical trial developed to compare four different instruments that provide overall quality-of-life (QOL) scores, ranging from a simple, one-item instrument to more detailed instruments. Two issues addressed were (1) Will QOL tools suffer from missing data when used in a community-based cooperative group setting?, and (2) Are there additional data generated by a more detailed multiitem instrument over that provided by a single-item global QOL question?

MATERIALS AND METHODS

A four-arm randomized trial was designed to compare four instruments that provide overall QOL scores in patients with advanced colorectal cancer. Patients and physicians completed the single-item Spitzer Uniscale (UNISCALE) at baseline and monthly. Patients were randomly assigned to complete, in addition, either the 22-item Functional Living Index-Cancer (FLIC), the five-item Spitzer QOL index (QLI), a picture-face scale (PICT), or nothing else.

RESULTS

A total of 128 patients were randomized. Greater than 90% complete QOL data were obtained. There was strong correlation, concordance, and criterion-related validity among all four patient-completed tools. The UNISCALE had a greater decrease over time than did the FLIC (P=.005), which suggests a greater sensitivity; the UNISCALE was similar to the QLI and the PICT in this regard. Physicians provided lower UNISCALE scores than patients. Results supported the hypothesis that QOL is prognostic for survival.

CONCLUSION

Patients can effectively complete QOL tools in a cooperative group setting with proper education of health care providers and patients. A simple single-item tool (UNISCALE) appears to be appropriate to obtain a measure of overall QOL.

Postdural puncture headache in pediatric oncology patients

This prospective cohort study determined the incidence and risk factors for development of postdural puncture headache (PDPH) in children after lumbar puncture (LP). Eighty-six children were enrolled. LPs were performed with use of 22-gauge spinal needles with the bevel oriented parallel to the long axis of the spine. Follow-up telephone interviews and patients' diary of symptoms were collected. Headache brought on by sitting up and relieved by lying down was defined as PDPH. Of the 80 who completed the study, six (8%) developed PDPH. Two (3%) were less than 6 years old and four (5%) were 6 to 12 years of age. Children with a history of headache following a previous LP were nine times as likely to experience PDPH. PDPH occurs not infrequently in children. A prior history of headache is a predisposing factor.

Transdermal fentanyl in the management of cancer pain in ambulatory patients: an open-label pilot study

We performed an open-label pilot study to define analgesic efficacy, acceptability, and toxicity of transdermal fentanyl in an ambulatory population of patients with cancer pain. Our 7-day study included 35 patients, all of whom had failed a trial of an opioid analgesic conventionally used for moderate pain. Patients received either a 25 micrograms/hr or 50 micrograms/hr fentanyl transdermal patch depending on prior opioid dose. Pain was measured daily utilizing visual analogue (VAS) and categorical (CAT) scales. Hours of nighttime sleep, quality of life, toxicities, and use of rescue medication were also assessed. There was a 24%-29% reduction in mean VAS and CAT pain scores as compared with the baseline and a 25% increase in mean hours of nighttime sleep. Fifty-nine percent of those patients responding (46% of all study patients) were satisfied to very satisfied with the analgesia provided by transdermal fentanyl. Six percent of all study patients were not at all satisfied with the pain relief obtained. Toxicities were similar to those seen with other opioids. No patient developed severe sedation or respiratory depression. The 25-50 micrograms/hr patch appears to be a safe starting dosage in ambulatory patients previously receiving opioids conventionally used for moderate pain.

Sweet syndrome in a patient with osteosarcoma

Neutrophilic dermatosis (Sweet syndrome) is a rare condition characterized by painful indurated cutaneous plaques infiltrated with mature neutrophils and may be accompanied by fever, granulocytosis, arthritis, and conjunctivitis. It is associated with various malignant and preneoplastic states, the most common being leukemia and myeloproliferative disorders. Its association with solid tumors is infrequent. The case described here represents, to our knowledge, the first report of Sweet syndrome in a patient with osteogenic sarcoma, a primary tumor of bone arising from mesenchymal cells.

Randomized trial of dietician counseling to try to prevent weight gain associated with breast cancer adjuvant chemotherapy

This study was developed to test whether prospective dietician counseling could abrogate the unwanted weight gain seen among women receiving adjuvant chemotherapy for resected breast cancer. It was also designed to examine predictive factors for weight gain in an exploratory manner. Premenopausal women starting adjuvant chemotherapy for primary breast cancer were recruited for this trial. After appropriate stratification, they were randomized to a group which received monthly dietician counseling primarily aimed at weight maintenance versus a control group (whose attending physicians and nurses told them about possible weight gain but provided no formalized dietician counseling). One hundred and seven evaluable women were equally divided between the two protocol arms. The median weight changes 6 months after start of chemotherapy were gains of 2.0 kg in the dietician counseling group versus 3.5 kg in the control group. The median changes in average calorie consumption were reductions of 120 versus 46 cal/day on weekdays and 196 versus 20 cal/day on weekends for the counseling and control groups, respectively. Study data suggest that more weight was gained by patients with higher Quetelet's indices (p = 0.01) and patients who had been on a diet in the preceding 6 months (p = 0.02). Routine prospective dietician counseling aimed at weight maintenance appeared to produce small but statistically insignificant reductions in both calorie consumption and weight gain in this group of patients.

A randomized, crossover evaluation of methylphenidate in cancer patients receiving strong narcotics

Sedation may be a dose-limiting side-effect of opioid therapy in some cancer patients. This study was designed to evaluate further the use of the psychostimulant, methylphenidate, an agent that has been reported to counter-act opioid-induced sedation, in patients with cancer-related pain. Patients receiving a stable dose of an opioid for cancer-related pain were recruited for this randomized, double-blind, crossover clinical trial. In addition to their regular dose of narcotics, they received 5 days of methylphenidate followed by 5 days of placebo, or vice versa. Our data did not definitively demonstrate any statistically significant benefit for methylphenidate, but did suggest that this drug could mildly decrease narcotic-induced drowsiness and could increase night-time sleep. These data, in conjunction with other published data, suggest that methylphenidate can counteract narcotic-induced daytime sedation to a limited degree.

Trial of a topically administered local anesthetic (EMLA cream) for pain relief during central venous port accesses in children with cancer

Procedure-related pain is a significant problem for many children receiving cytotoxic chemotherapy. In an effort to lessen this toxicity, we studied the efficacy and safety of administering topical local anesthesia using EMLA cream in 47 evaluable children with cancer undergoing implanted central venous port injections. Children (< 21 years old) scheduled to undergo repeated venous access procedures were selected for study. A placebo-controlled, randomized, double-blind, crossover study design was utilized. Statistically significant decreases in pain intensity scores (P < 0.002) were recorded by both children and investigators during the use of EMLA cream as compared with placebo. There was a good correlation between pain scores recorded by both patients and health care providers using both visual analog scales and categorized pain measurement tools. The topical application of EMLA cream 5% provides highly effective superficial anesthesia, and promises to be extremely useful for pain relief during percutaneous access procedures in cancer patients.

Transdermal clonidine for ameliorating post-orchiectomy hot flashes

To determine the efficacy of transdermal clonidine for alleviating post-orchiectomy hot flashes, a randomized, double-blind, crossover clinical trial was designed including 70 men with a history of prostate cancer who had undergone a medical or surgical orchiectomy and were suffering from hot flashes. The results of this study demonstrated that clonidine did not significantly decrease hot flash frequency or severity. Future research is necessary to find effective means of alleviating hot flashes in post-orchiectomy patients.

Transdermal clonidine for ameliorating tamoxifen-induced hot flashes

PURPOSE

To determine the efficacy of transdermal clonidine for alleviating tamoxifen-induced hot flashes in women with a history of breast cancer.

PATIENTS AND METHODS

A randomized, double-blind, crossover design was used in this prospective study. Women with a history of breast cancer who were receiving tamoxifen and suffering from hot flashes were potentially eligible for this protocol study.

RESULTS

Clonidine did reduce hot-flash frequency to a degree that was statistically impressive (P < .0001), but clinically moderate (20% reduction from baseline). It also decreased hot-flash severity (P = .02, 10% reduction from baseline). Clonidine was related to increased mouth dryness (P < .001), constipation (P < .02), itchiness under the patch (P < .01), and drowsiness (P < .05).

CONCLUSION

Better means are needed to alleviate hot flashes among patients in whom estrogen therapy is contraindicated.

Comparative morphine pharmacokinetics following sublingual, intramuscular, and oral administration in patients with cancer

Previous literature reports have suggested that sublingually administered morphine sulfate results in an improved bioavailability of the drug when compared to orally administered morphine. To investigate this possibility further, we studied six cancer patients all of whom received 10 mg doses of morphine sulfate by intramuscular, oral and sublingual routes. Pharmacokinetic analyses failed to suggest an advantage of sublingual administration when compared with oral dosing. Bioavailability of morphine following intramuscular administration appeared superior to both oral and sublingual routes.

Epidemiologic features of pain in pediatric cancer patients: a co-operative community-based study. North Central Cancer Treatment Group and Mayo Clinic)

The prevalence, etiology, and management of pain in pediatric cancer patients seen at the Mayo Clinic and member institutions of the North Central Cancer Treatment Group were assessed. Participating centers, including both primary care and referral institutions, surveyed all patients seen during a 1-week period (Monday through Friday); procedure-related pain was excluded. Of the 160 children surveyed, 28 reported pain of which 57.8% was related to a side effect of anticancer treatment, 21.1% was unrelated to the malignancy, and 21.1% arose directly from the cancer. Pain intensity assessment was performed by both health-care professional and patient using a variety of measurement tools. Correlation between assessors was close except in young children. The predominance of treatment-related rather than cancer-related pain differs from results in series in adult cancer patients.

The treatment of cancer pain in children

In summary, expertise is currently available to successfully manage most pediatric cancer pain; it behooves the responsible physician to be sufficiently familiar with the available methodology and to appropriately deliver state-of-the-art management to the child to ensure optimal care.

The effect of adjuvant chemotherapy on relapse-free survival in patients with osteosarcoma of the extremity

We conducted a randomized controlled trial to determine whether intensive multi-agent adjuvant chemotherapy improves the chances of relapse-free survival in patients with nonmetastatic high-grade osteosarcoma of the extremity, as compared with concurrent controls. After undergoing definitive surgery, 36 patients were randomly assigned to adjuvant chemotherapy or to observation without adjuvant treatment. At two years the actuarial relapse-free survival was 17 percent in the control group, similar to that found in studies before 1970, and 66 percent in the adjuvant-chemotherapy group (P less than 0.001). Similar results were observed among 77 additional patients who declined to undergo randomization but who elected observation or chemotherapy. We conclude that the natural history of osteosarcoma of the extremity has remained stable over the past two decades, that adjuvant chemotherapy increases the chances of relapse-free survival of patients with high-grade osteosarcoma, and that it should be given to all such patients.

Narcotic withdrawal syndrome in young adults after the therapeutic use of opiates

Five young adults with malignant neoplasms developed symptoms of narcotic withdrawal six to 48 hours after the abrupt discontinuation of narcotic therapy that had been administered for six to 21 days. The symptoms, which included agitation, irritability, muscular jerks, abdominal pain, diarrhea, burning sensations, "gooseflesh," and itching, rapidly resolved when narcotic therapy was reinstituted. Four patients were then successfully weaned from opiates without recurrence of their withdrawal symptoms; the fifth patient continues to receive methadone hydrochloride treatment for continuing pain.

Variation in morphine pharmacokinetics in children with cancer

Morphine plasma concentrations were determined in 19 children with cancer. A single dose of morphine, 0.09-0.15 mg/kg, was given intravenously over 3-5 min. The plasma concentrations of morphine ranged from 23 to 472 ng/ml at 10 min and from 6.1 to 20.8 ng/ml at 60 min after morphine administration. The morphine plasma concentration exceeded the reported average analgesic concentration of about 20 ng/ml in only 1 patient at 60 min and subsequently declined further except for 4 patients in whom plasma levels exhibited a secondary peak. The pharmacokinetics of morphine was studied in 6 children. The total clearance of morphine ranged from 9.03 to 53.4 ml/min/kg. The apparent volume of the central compartment and the apparent volume of distribution at steady state ranged from 0.17 to 1.10 and from 2.06 to 7.86 l/kg, respectively. The elimination half-life ranged from 0.86 to 7.55 h. These data indicate that an interindividual variation in morphine pharmacokinetics is one factor responsible for varying dosage requirements in children with cancer.

Continuous subcutaneous infusion of morphine in children with cancer

Seventeen children with severe pain due to malignant neoplasm were successfully treated with a subcutaneous infusion of morphine sulfate using a syringe pump. Pain relief was adequate in every case without major side effects. The median dosage required was 0.06 mg/kg/hr (range, 0.025 to 1.79 mg/kg/hr). Three patients received the subcutaneous infusion at home. No patient required an intravenous line for pain control.

Septicemia in childhood malignancy. Analysis of 101 consecutive episodes

One hundred one consecutive episodes of blood-culture-positive infection were evaluated in 83 children with malignancy between 1972 and 1977. Eighty-two per cent occurred in relapse, and 75% developed when the absolute neutrophil count was less than 500 per microliters. Forty per cent were fatal. Forty-five per cent of the episodes occurring in relapse and 17% occurring in remission were fatal. Of 88 cases of single-organism infection, 46% were due to gram-positive organisms with a 13% mortality (of these, 28% were due to Staphylococcus aureus with a 4% mortality); 52% were due to gram-negative organisms with a 52% mortality; and two episodes were due to fungal organisms with no fatalities. Multiple-organism infection occurred 13 times, of which 11 episodes were fatal. The authors' data confirm observations by others that the organisms most commonly causing blood-culture-positive infection in children with malignancy are S. aureus and Escherichia coli and that infection due to gram-positive organisms, particularly S. aureus, is less than frequency fatal.

Staphylococcus aureus sepsis in childhood malignancy

Forty-five episodes of Staphylococcus aureus septicemia occurred in 44 children with malignant neoplasms over a seven-year period. The frequent findings at diagnosis were fever, neutropenia, and an active malignant process. Twenty-six (58%) of 45 episodes had a primary focus of infection. Multiple-organism sepsis occurred four times; three episodes were fatal. Only one patient with single-organism S aureus sepsis died (a mortality of 2%). Direct infectious complications occurred in nine (20%) of 45 episodes. Endocarditis and osteomyelitis were not seen as complications of S aureus sepsis.