Publications by authors named "Eduardo Bruera"

751 Publications

Acupuncture for Cancer-Related Anorexia: a Review of the Current Evidence.

Curr Oncol Rep 2021 May 5;23(7):82. Epub 2021 May 5.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.

Purpose Of Review: Loss of appetite/anorexia is extremely common among cancer patients, affecting as many as half of newly diagnosed patients and 70% of patients with advanced disease. Effective management of this disabling symptom of cancer remains a major challenge in the field of oncology. We conducted a systematic review of the current evidence on acupuncture and/or moxibustion as an intervention for cancer-related anorexia.

Recent Findings: Acupuncture, as a part of traditional Chinese medicine practice, has demonstrated effectiveness in managing many cancer- and treatment-related symptoms, especially chemotherapy-induced or postoperative nausea. However, the efficacy of acupuncture in treating cancer-related anorexia/loss of appetite is not clear. The current level of evidence is insufficient to make a definitive conclusion on the benefit of acupuncture/moxibustion for treating chronic cancer-related anorexia/appetite problems. Future large randomized controlled trials of high methodological quality are needed.
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http://dx.doi.org/10.1007/s11912-021-01067-1DOI Listing
May 2021

A Comparison of Caregiver Burden of Patients with Advanced Cancer in Different Palliative Cancer Care Settings.

J Palliat Med 2021 Apr 28. Epub 2021 Apr 28.

Department of Palliative, Rehabilitation, and Integrative Medicine and The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Informal caregivers may experience a significant burden while caring for cancer patients. Little is known about how caregiver burden varies across different palliative cancer care settings and the factors influencing it. We compared the severity of caregiver subjective stress burden (emotional impact) among caregivers of patients seen in the outpatient supportive care center (SCC) with those being cared for in the acute palliative care unit (PCU). Secondary aims were to compare other caregiver burden dimensions, quality of life, and any association of caregiver subjective stress burden to various patient and caregiver factors. Eligible patients and their informal caregivers in the SCC or PCU at a comprehensive cancer center in the USA were approached and enrolled. The Montgomery-Borgatta Caregiver Burden Scale and the Short-form 36 were used to measure burden and quality of life. Multivariate general linear regression was employed to evaluate the effect of covariates on subjective stress burden. Ninety-eight dyads in the SCC and 74 dyads in the PCU were enrolled. PCU caregivers reported worse subjective stress burden ( = 0.0029) and mental health ( = 0.0299). Multivariate analysis showed correlations between subjective stress burden and caregivers' objective burden ( = 0.0136), subjective demand burden ( ≤ 0.0001), mental health ( = 0.0074), duration of caregiving ( = 0.0680), education ( = 0.0192) and with patients' anxiety ( = 0.0003) and current/recent cancer treatment ( = 0.0579). PCU caregivers demonstrated worse emotional burden and mental health than those in the SCC. More research is needed to tailor interventions for various caregiver burden dimensions. NCI Clinical Trial Registration Number ID: NCI-2019-01197.
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http://dx.doi.org/10.1089/jpm.2021.0026DOI Listing
April 2021

Repeated filling of elastomeric infuser pumps for home-based subcutaneous medications: a case series.

Int J Palliat Nurs 2021 Apr;27(2):107-115

Department Chair Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: Several medical devices have been developed for continuous subcutaneous drug infusion for home palliative care (HPC), such as elastomeric infuser pumps (EIP). There is no evidence on the repeated filling of EIP for continuous subcutaneous delivery for HPC.

Aim: A clinical case series report of terminally-ill patients cared for in HPC, with repeated filling of EIPs for home-based subcutaneous medications.

Methods: A retrospective analysis of each patient's EIP-related entries in an anonymised database regarding: 1) EIP general functioning aspects; 2) clinical aspects: symptom control and local skin complications. Overall and per-patient cost-saving was also calculated.

Findings: A total of 10 cases were analysed (four 50-hour EIP and six 30-hour EIP). All EIPs had a mean number of refillings (standard deviation (SD), mode) of 1.6 ((0.5), 2); with 3.2 drugs on average used in each EIP ((1.4), 4). Approximate total mean (SD) usage time for both types of EIP was 87 (29) hours; and all EIP were used, on average (SD), 49 (23) hours more than its labelled duration. All EIPs showed a complete reservoir deflation between refilling. Only one patient had a minor skin complication and no symptom aggravation was observed, except for two cases with mild anxiety and agitation. Cost-saving analysis for the complete case series showed that EIP refillings saved, on average, €24 per-patient and a total of nearly €240, for both types of infuser pumps.

Conclusion: This preliminary study suggests that refilling is safe and reduces cost. Future research on EIP refilling using controlled and systematic methodologies are warranted.
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http://dx.doi.org/10.12968/ijpn.2021.27.2.107DOI Listing
April 2021

Functional impairments and rehabilitation outcomes of patients with immunotherapy-induced Acute Inflammatory Demyelinating Polyradiculoneuropathy, Myasthenia Gravis and Myositis.

Am J Phys Med Rehabil 2021 Apr 8. Epub 2021 Apr 8.

The University of Texas MD Anderson Cancer Center, Department of Palliative, Rehabilitation and Integrative Medicine, Houston, Texas.

Abstract: Immunotherapy has led to a higher survival rate among different oncological disease groups but also associated with adverse related events in multiple organ systems. Immunotherapy related musculoskeletal weakness often results in a loss of cancer survivors' physical function, ultimately impacting their independence and quality of life. This is a retrospective study of 24 cancer patients who were treated with immunotherapy either alone or in conjunction with other oncological treatments. Twelve (50%) subjects were found to have acute inflammatory demyelinating polyradiculopathy (AIDP)/Guillain-Barré syndrome (GBS), 6 (25%) myositis, 2 (8%) Myasthenia Gravis (MG) and 2 (8%) diagnosis of myositis/MG and 1 (4%) GBS/MG combination. Physical Therapy (PT) was provided in 91.7% of the cases and Physiatrist was involved in 54% of the cases. Almost half (45%) were discharged home, 6 (25%) to acute inpatient rehabilitation, 2(8%) to subacute rehabilitation, 3 (12.5%) to hospice and 2 (8%) patients died. The average length of hospital stay was 30 days and eight (33%) patients re-admitted within 3 months. Our findings highlight the severity of functional impairments and the need for early rehabilitation interventions.
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http://dx.doi.org/10.1097/PHM.0000000000001764DOI Listing
April 2021

Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia-Moving From Evidence to Practice.

JAMA Oncol 2021 Apr 22. Epub 2021 Apr 22.

Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston.

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http://dx.doi.org/10.1001/jamaoncol.2021.0706DOI Listing
April 2021

First-line methadone for cancer pain: titration time analysis.

Support Care Cancer 2021 Apr 21. Epub 2021 Apr 21.

Programa de Bioética, Facultad Latinoamericana de Ciencias Sociales (FLACSO), Buenos Aires, Argentina.

Background: Methadone is a low-cost, strong opioid that is increasingly used as a first-line treatment for pain in palliative care (PC). Its long and unpredictable half-life and slow elimination phase can make titration challenging. Evidence for titration modalities is scarce.

Objective: To describe the titration phase of the treatment with low-dose first-line methadone and the use of methadone for breakthrough pain.

Methods: Prospective study with strong opioid-naïve patients with moderate to severe cancer pain followed at a tertiary PC unit in Argentina. Starting methadone dose was 2.5-5 mg/day every 8, 12, or 24 h. Titration allowed daily dose increases from day 1, and prescription of oral methadone 2.5 mg every 2 h with a maximum of 3 rescue doses/day for breakthrough pain. Pain control, methadone stabilization dose, and adverse effects, among other variables, were daily assessed over the first 7 days (T0-T7).

Results: Sixty-two patients were included. Initial median (IQR) methadone dose was 5 (2.5) mg/day. Pain intensity decreased from a median (IQR) of 8 (2.3) at T0 to 4 (2.3) at T1 and remained ≤ 4 until T7 (all p < 0.0001 compared to T0). Similar results were obtained through the categorical and tolerability scales for pain. Fifty patients (81%) reached pain control, 66% in the first 48 h. Methadone daily doses at T2 and T7 were higher than that at T0: 7.5 (3) and 6.7 (5.5) versus 5 (2.5), respectively (all p < 0.05). The opioid escalation index at T7 was 1.7%. The median (IQR) number of rescues, stabilization dose, and time for stabilization was 0 (1), 5(4.5) mg, and 3(2) days, respectively. Two patients were discontinued due to delirium. All other side effects were mild.

Conclusions: First-line, low-dose methadone using rescue methadone resulted in a pronounced and rapid decrease in pain, with minimal need for titration and for breakthrough doses, and no evidence of accumulation or sedation by the end of the week.
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http://dx.doi.org/10.1007/s00520-021-06211-yDOI Listing
April 2021

Questionable Conceptualizations of Nonmedical Use Can Contribute to Needless Distress-Reply.

JAMA Oncol 2021 Apr 15. Epub 2021 Apr 15.

Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston.

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http://dx.doi.org/10.1001/jamaoncol.2021.0572DOI Listing
April 2021

Genetic Factors associated with Pain Severity, Daily Opioid Dose Requirement, and Pain Response among Advanced Cancer Patients receiving Supportive Care.

J Pain Symptom Manage 2021 Apr 10. Epub 2021 Apr 10.

Department of Palliative care, Rehabilitation Medicine, and Integrative Medicine UT MD Anderson Cancer Center, Houston, United States.

Background: Current understanding of genetic factors associated with pain severity, and improvement of pain with opioids in advanced cancer patients (AC) is inadequate for delivery of personalized pain therapy(PPT). Therefore, the aim of this study was to determine the genetic factors associated with pain severity, daily opioid dose, and pain response in AC patients receiving supportive care.

Methods: In this prospective study, AC patients were eligible if they had cancer pain ≥4/10 on Edmonton Symptom Assessment Scale (ESAS) - Pain Item and needed opioid rotation for pain control by specialist at the outpatient supportive care center. Pain phenotype was assessed using logistic regression models and SKATO (Gene-block) analysis.

Results: 174/178 (98%) patient samples were analyzed. After adjustment for demographic and clinical variables, pain severity was negatively associated with intron variant alleles in OPRM1 rs9322446, P = 0.02; rs2270459, P=0.038; rs62052210, P= 0.038. Opioid daily dose was positively associated NFKBIA rs2233419 P=0.008, rs2233417 P=0.007, rs3138054 P=0.008, rs1050851, P= 0.015;ORPM1 rs9479759, P= 0.046, rs2003185, P= 0.047, rs636433, P= 0.044; COMT (rs9306234, P= 0.014, rs165728, P= 0.014, rs2020917, P= 0.036, rs165728, P= 0.034); ARRB2 (rs1045280, P= 0.045); and pain response to opioids was negatively associated OPRM1 rs1319339 p=0.024, rs34427887 P=0.048, and COMT rs4646316 P=0.03, rs35478083 P=0.028 respectively. SKATO analysis showed association between pain severity and CXCL8 (P=0.0056), and STAT6 (P=0.0297) genes respectively, and pain response with IL-6 (P=0.00499).

Conclusions: This study identified that SNPs of OPRM1, COMT, NFKBIA, CXCL8, IL-6, STAT6,and ARRB2 genes were associated with pain severity, opioid daily dose, and pain response in AC receiving supportive care. Additional studies are needed to validate our findings for PPT.

Key Message: This study shows unique SNPs of OPRM1, COMT, NFKBIA, CXCL8, IL-6, STAT6, and ARRB2 genes were associated with cancer pain severity, and pain response after supportive care consultation in advanced cancer patients. Additional studies are needed to validate our findings for personalized pain therapy.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.03.024DOI Listing
April 2021

Palliative medicine integration in the USA: cancer centre executives' attitudes.

BMJ Support Palliat Care 2021 Apr 12. Epub 2021 Apr 12.

Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

Objectives: To compare cancer centre (CC) executives' attitudes towards palliative care between National Cancer Institute-designated CCs (NCI-CCs) and non-NCI-designated CCs (non-NCI-CCs) in 2018 and to examine the changes in attitudes and beliefs between 2009 and 2018.

Methods: CC chief executives at all NCI-CCs and a random sample of non-NCI-CCs were surveyed from April to August 2018. Twelve questions examined the executives' attitudes towards palliative care integration, perceived barriers and self-assessments. The primary outcome was agreement on the statement 'a stronger integration of palliative care services into oncology practice will benefit patients at my institution.' Survey findings from 2018 were compared with data from 2009 to examine changes in attitudes.

Results: 52 of 77 (68%) NCI-CCs and 88 of 126 (70%) non-NCI-CCs responded to the survey. A vast majority of executives at NCI-CCs and non-NCI-CCs endorsed palliative care integration (89.7% vs 90.0%; p>0.999). NCI-CCs were more likely to endorse increasing funding for palliative care (52.5% vs 23.1%; p=0.01) and hiring physician specialists (70.0% vs 37.5%; p=0.004) than non-NCI-CCs. The top three perceived barriers among NCI-CCs and non-NCI-CCs were limited institutional budgets (57.9% vs 59.0%; p=0.92), poor reimbursements (55.3% vs 43.6%; p=0.31), and lack of adequately trained palliative care physicians and nurses (52.6% vs 43.6%; p=0.43). Both NCI-CCs and non-NCI-CCs favourably rated their palliative care services (89.7% vs 71.8%; p=0.04) with no major changes since 2009.

Conclusion: CC executives endorse integration of palliative care, with greater willingness to invest in palliative care among NCI-CCs. Resource limitation continues to be a major barrier.
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http://dx.doi.org/10.1136/bmjspcare-2020-002835DOI Listing
April 2021

Association between Spirituality, Religiosity, Spiritual Pain, Symptom Distress, and Quality of Life among Latin American Patients with Advanced Cancer: A Multicenter Study.

J Palliat Med 2021 Apr 12. Epub 2021 Apr 12.

Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

The purpose of this multicenter study was to characterize the association between spirituality, religiosity, spiritual pain, symptom distress, coping, and quality of life (QOL) among Latin American advanced cancer patients. Three hundred twenty-five advanced cancer patients from palliative care clinics in Chile, Guatemala, and the United States completed validated assessments: Faith, Importance and Influence, Community, and Address (FICA) (spirituality/religiosity), Edmonton Symptom Assessment Scale-Financial/Spiritual (ESAS-FS), including spiritual pain, Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Center for Epidemiologic Studies Depression Scale (CES-D), Brief-coping strategies (COPE) and Brief religious coping (RCOPE) and RCOPE, respectively, and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, Expanded version (FACIT-Sp-Ex). Median age: 58 years (range: 19-85); 60% female; and 62% Catholic and 30% Christian, but not Catholic. Three hundred fifteen patients (97%) considered themselves spiritual and 89% religious, with median intensities of 7 (interquartile range [IQR]: 5-10) and 7 (5-9), respectively (0-10 scale, 10 = "very much"). Median importance of spirituality/religiosity was 10 (IQR: 8-10). The frequency and associations between spirituality/religiosity and various items were as follows: helps to cope with illness (98%;  = 0.66303;  < 0.0001), positive effect on physical symptoms (81%;  = 0.42067;  < 0.0001), and emotional symptoms (84%;  = 0.16577;  < 0.0001). One hundred ninety-five patients (60%) reported that their spiritual/religious needs had not been supported by the medical team. Spiritual pain was reported in 162/311 patients (52%), with median intensity of 6 (IQR: 5-8). Spiritual pain was associated with pain ( = 0.0225), depression ( < 0.0001), anxiety ( < 0.0001), worry ( < 0.001), behavioral disengagement ( = 0.0148), FACIT-Sp-Ex score ( = 0.0002), and negative RCOPE ( < 0.0001). Spirituality and religiosity are frequent, intense, and rarely addressed among Latin American patients. Spirituality/religiosity was associated with positive COPE and higher QOL. Spiritual pain was also frequent and associated with physical and psychosocial distress. These patients need increased spiritual/religious support.
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http://dx.doi.org/10.1089/jpm.2020.0776DOI Listing
April 2021

Yoga-Based Breathing Techniques for Health Care Workers During COVID-19 Pandemic: Interests, Feasibility, and Acceptance.

J Altern Complement Med 2021 Apr 9. Epub 2021 Apr 9.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

The authors explored the feasibility of virtual yoga-based breathwork and meditation among health care workers (HCW) during the COVID-19 pandemic. Consented employees of a large cancer center accessed a video of breathwork called "Simha Kriya" to be practiced for 4 weeks. Of 217 participants who expressed interest within 2 weeks, 90 were recruited to the study in 1 month and 100 in 2 months. Of 69 participants who provided data between weeks 1 and 4, 77% perceived the intervention as useful. Yoga-based breathing practices were feasible and acceptable among HCW in the setting of a pandemic. Registered with clinicaltrials.gov: NCT04482647.
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http://dx.doi.org/10.1089/acm.2020.0536DOI Listing
April 2021

Home palliative care professionals perception of challenges during the Covid-19 outbreak: A qualitative study.

Palliat Med 2021 05 8;35(5):862-874. Epub 2021 Apr 8.

Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: Home palliative care services have played an essential role during the first wave of the SARS-CoV-2 outbreak by providing symptom control, drug procurement, and psychological support for frail patients and their families unable to leave their homes.

Aim: To understand how home palliative care professionals were affected by the outbreak, describing changes and challenges in their daily work as well as their reactions to the Covid-19 pandemic in Italy.

Design: Qualitative study conducted using telephone semi-structured interviews, with thematic analysis.

Setting/participants: Thirty home care professionals working for an Italian non-profit organization which provides home palliative care for cancer patients and their families.

Results: Three main themes were identified. The first theme showed both and challenges participants faced in their daily work, requiring the implementation of different communication methods and patient and family education on risk prevention. The second theme showed the perception of increased responsibility and being the only landmark for family played a decisive role in participants' positive attitude. The third theme highlighted the participants' perception of the critical role of a home care setting in this emergency situation.

Conclusions: The first wave of the Covid-19 pandemic brought many challenges and stressors for home palliative care professionals. On the other side, they reported a satisfaction with their critical role in carrying out their work with patients at risk.
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http://dx.doi.org/10.1177/02692163211008732DOI Listing
May 2021

Frequency of Sarcopenia, Sarcopenic Obesity, and Changes in Physical Function in Surgical Oncology Patients Referred for Prehabilitation.

Integr Cancer Ther 2021 Jan-Dec;20:15347354211000118

The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Purpose: Sarcopenia and suboptimal performance status are associated with postoperative complications and morbidity in cancer patients. Prehabilitation has emerged as an approach to improve fitness and muscle strength in patients preoperatively. We sought to describe the frequency of sarcopenia and sarcopenic obesity (SO) in a cohort of cancer patients referred for prehabilitation and the association between body composition and physical function.

Methods: In this retrospective review of 99 consecutive cancer patients referred for prehabilitation prior to intended oncologic surgery, prehabilitation included physical medicine and rehabilitation (PM&R) physician evaluation of function and physical therapy for individualized home-based exercise. Sarcopenic A was defined using sex-adjusted norms of skeletal muscle (SKM), measured using the sliceOmatic software (TomoVision, 2012) on computed tomography images at baseline. Sarcopenic B was defined by abnormal SKM and physical function. SO was defined as sarcopenia with BMI ≥ 25. Six-minute walk test (6MWT), 5 times sit-to-stand (5×STS), and grip strength were obtained at consultation (baseline) and at preoperative follow-up (if available).

Results: Forty-nine patients (49%) were Sarcopenic A, 28 (28%) SO, and 38 (38%) Sarcopenic B. Age was negatively correlated with SKM ( = .0436). There were no significant associations between Sarcopenic A/B or SO with baseline or changes in physical function. Assessed by sex, Sarcopenic A females had low 5×STS ( = .04) and Sarcopenic B females had low GS ( = .037). Sarcopenic B males had low preoperative GS ( = .026). 6MWT and grip strength at baseline were lower than age- and sex-related norms (both  < .001). Preoperatively, 6MWT distance and 5×STS time improved (both  < .001). Functional improvement in the sarcopenic and nonsarcopenic patients did not differ according to sex.

Conclusions: In this cohort of prehabilitation surgical oncology patients, frequencies of sarcopenia and SO were high, and baseline physical function was abnormal but improved significantly regardless of body composition. These findings suggest that patients have considerable prehabilitation needs and are capable of improving with comprehensive care.
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http://dx.doi.org/10.1177/15347354211000118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040607PMC
April 2021

The Impact of International Research Collaborations on the Citation Metrics and the Scientific Potential of South American Palliative Care Research: Bibliometric Analysis.

Ann Glob Health 2021 03 31;87(1):32. Epub 2021 Mar 31.

Research Group on Palliative Care and Health-Related Quality of Life (GPQual), Barretos Cancer Hospital, Barretos, São Paulo, Brazil.

Background: Progress in palliative care (PC) requires scientific advances which could potentially be catalyzed by international research collaboration (IRC). It is currently not known how often IRC occurs with PC investigators in South America.

Objectives: To evaluate the percentage of South America journal articles on PC involving IRCs and the impact of these collaborations on the scientific potential the studies and on their citations.

Methods: This was a bibliometric analysis of studies published between January 1, 1998, and December 31, 2017. A search of Pubmed, Embase, Lilacs, and Web of Science (WOS) was performed using the terms "palliative care," "hospice care," "hospices" and "terminal care," combined with the name of South America countries. The scientific potential was assessed by analyzing study design, characteristics of the journal and funding. IRCs were further subdivided in internal (within South America countries) and external (with countries outside South America).

Findings: Of the 641 articles, 117 (18.2%) involved IRCs (internal: 18, 2.8%; external: 110, 17.2%). Articles with IRCs had higher median two-year citations in WOS (2 vs. 1, p < 0.001), Scopus (3 vs. 1, p < 0.001) and Google Scholar (4.5 vs. 2, p < 0.001) compared to articles without IRC. Moreover, they were more often funded (40.7% vs. 9.7%, p < 0.001), published in Pubmed-indexed (76.1% vs. 41.6%; p < 0.001) and in WOS-indexed (70.1% vs. 29.6%; p < 0.001) journals, and with study designs most often classified as clinical trial (5.1% vs. 1.0%; p = 0.002) and cohort (10.3% vs. 2.9%; p < 0.001) compared to articles without IRC.

Conclusions: Studies with international research collaborations, both internal and external to South America, are more frequently cited and have characteristics with greater scientific potential than do studies without international collaborations.
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http://dx.doi.org/10.5334/aogh.3158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015710PMC
March 2021

Different semantic and affective meaning of the words associated to physical and social pain in cancer patients on early palliative/supportive care and in healthy, pain-free individuals.

PLoS One 2021 31;16(3):e0248755. Epub 2021 Mar 31.

Oncology and Palliative Care Units, Civil Hospital Carpi, USL, Carpi, Italy.

Early palliative/supportive care (ePSC) is a medical intervention focused on patient's needs, that integrates standard oncological treatment, shortly after a diagnosis of advanced/metastatic cancer. ePSC improves the appropriate management of cancer pain. Understanding the semantic and emotional impact of the words used by patients to describe their pain may further improve its assessment in the ePSC setting. Psycholinguistics assumes that the semantic and affective properties of words affect the ease by which they are processed and comprehended. Therefore, in this cross-sectional survey study we collected normative data about the semantic and affective properties of words associated to physical and social pain, in order to investigate how patients with cancer pain on ePSC process them compared to healthy, pain-free individuals. One hundred ninety patients and 124 matched controls rated the Familiarity, Valence, Arousal, Pain-relatedness, Intensity, and Unpleasantness of 94 words expressing physical and social pain. Descriptive and inferential statistics were performed on ratings in order to unveil patients' semantic and affective representation of pain and compare it with those from controls. Possible effects of variables associated to the illness experience were also tested. Both groups perceived the words conveying social pain as more negative and pain-related than those expressing physical pain, confirming previous evidence of social pain described as worse than physical pain. Patients rated pain words as less negative, less pain-related, and conveying a lower intense and unpleasant pain than controls, suggesting either an adaptation to the pain experience or the role played by ePSC in improving patients' ability to cope with it. This exploratory study suggests that a chronic pain experience as the one experienced by cancer patients on ePSC affects the semantic and affective representation of pain words.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248755PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011738PMC
March 2021

Exercise Barriers and Adherence to Recommendations in Patients With Cancer.

JCO Oncol Pract 2021 Mar 19:OP2000625. Epub 2021 Mar 19.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: The American College of Sports Medicine exercise guidelines for cancer survivors encourage a combination of 150 minutes of moderate-intensity aerobic activity and 2-3 weekly sessions of strength training. Cancer survivors often experience more barriers to meeting recommended guidelines because of side effects from cancer treatments. Our aim was to measure the cancer survivors' adherence and barriers with these recommendations.

Methods: Two hundred adult cancer survivors completed surveys (Stanford Patient Education Research Center Exercise Behaviors Survey and an exercise barrier scale) reporting their physical activity, barriers to physical activity, and symptom assessment.

Results: A total of 68/200 participants (34%) reported adhering to the recommended physical activity guidelines of 150 minutes or more per week. Those who adhered to the guidelines reported fewer barriers to exercise (mean of 2.44 compared with 4.15 barriers, < .0001). Female participants ( = .01), higher number of barriers, and feeling of poor well-being were less likely to report at least 60 or 150 minutes of exercise time. Lack of interest ( = .003) and self-discipline ( = .001) were reported as barriers. These participants were more likely to report high symptom burden of pain ( = .007) and fatigue ( = .005). Participants who reported < 60 minutes of exercise reported lack of enjoyment ( = .03), lack of equipment ( = .01), and symptoms of poor appetite, poor well-being, and increased dyspnea.

Conclusion: Although recommendations are given for exercise, adherence to recommendations is low. Issues of motivation, including lack of interest and self-discipline, and symptoms of pain and fatigue were some of the main reported barriers to adhering to the recommended exercise guidelines. Therefore, interventions aimed at increasing motivation and treating symptoms could improve cancer survivor adherence to recommended exercise guidelines.
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http://dx.doi.org/10.1200/OP.20.00625DOI Listing
March 2021

Models of supportive care in oncology.

Curr Opin Oncol 2021 Mar 11. Epub 2021 Mar 11.

Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.

Purpose Of Review: Supportive care services have evolved overtime to meet the growing supportive care need of patients with cancer and their families. In this review, we summarize existing definitions of supportive care, highlight empiric studies on supportive care delivery, and propose an integrated conceptual framework on supportive cancer care.

Recent Findings: Supportive care aims at addressing the patients' physical, emotional, social, spiritual, and informational needs throughout the disease trajectory. Interdisciplinary teams are needed to deliver multidimensional care. Oncology teams have an important role providing supportive care in the front lines and referring patients to supportive care services such as palliative care, social work, rehabilitation, psycho-oncology, and integrative medicine. However, the current model of as needed referral and siloed departments can lead to heterogeneous access and fragmented care. To overcome these challenges, we propose a conceptual model in which supportive care services are organized under one department with a unified approach to patient care, program development, and research. Key features of this model include universal referral, systematic screening, tailored specialist involvement, streamlined care, collaborative teamwork, and enhanced outcomes.

Summary: Further research is needed to develop and test innovative supportive care models that can improve patient outcomes.
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http://dx.doi.org/10.1097/CCO.0000000000000733DOI Listing
March 2021

Medical Complications and Prognostic Factors for Medically Unstable Conditions During Acute Inpatient Cancer Rehabilitation.

JCO Oncol Pract 2021 Mar 8:OP2000919. Epub 2021 Mar 8.

Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: Acute inpatient rehabilitation provides concurrent medical care and intensive rehabilitation. We sought to describe the nature of types of medical complications and to identify the more frequent types of medical complications management in patients with cancer undergoing acute inpatient rehabilitation.

Methods: We reviewed the records of all consecutive patients admitted to acute inpatient rehabilitation from September 1, 2017, through February 28, 2018. Presenting problem noted to be a significant change in medical status using the Centers for Medicare & Medicaid Services' Evaluation and Management Service Guide was defined as a medical complication. We recorded demographic and clinical characteristics. Multivariable logistic regression analysis was performed to assess prognostic factors for returning to acute care.

Results: Among 165 evaluable patients, 158 (96%) had at least one medical complication, and 31 (19%) had an unplanned return to acute care. After excluding three patients who had planned return to acute care, there was a cohort of 162 patients and the most common medical complication categories were electrolyte abnormalities 81 (50%), musculoskeletal 70 (43%), genitourinary or renal 61 (38%), hematologic 58 (36%), and cardiovascular problems 46 (28%). Multivariable analysis showed that tachycardia (odds ratio [OR], 7.83; 95% CI, 2.23 to 27.54; = .001) and weekly or more frequent RBC transfusions (OR, 5.23; 95% CI, 1.39 to 19.64; = .014) were independently associated with unplanned return to acute care.

Conclusion: A high frequency and wide range of medical complications and interventions occur in patients with cancer undergoing acute inpatient rehabilitation. Close monitoring and expertise are needed for this patient population.
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http://dx.doi.org/10.1200/OP.20.00919DOI Listing
March 2021

Palliative care education and research at US cancer centers: A national survey.

Cancer 2021 Mar 4. Epub 2021 Mar 4.

Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: Palliative care (PC) education and research are essential to developing a skilled workforce and evidence base to support the delivery of quality cancer care. The current state of PC education and research at US cancer centers is unclear. In this national survey, the education and research programs of the National Cancer Institute (NCI)-designated and nondesignated cancer centers and the changes between 2009 and 2018 are compared.

Methods: Between April and August 2018, PC program leaders at all NCI-designated cancer centers and a random sample of nondesignated centers were sent a survey to examine the structure, processes, and outcomes of their programs on the basis of questions from a 2009 national survey. This preplanned analysis focused on education and research.

Results: There were 52 of 61 (85%) NCI-designated and 27 of 38 (71%) nondesignated cancer centers that responded. NCI-designated centers were more likely than nondesignated centers to have a PC fellowship program (87% vs 30%; P < .001), training for advanced practice providers (71% vs 44%; P = .03), PC research program (58% vs 15%; P < .001), peer-reviewed funding (43% vs 11%; P = .005), and philanthropic grants (41% vs 7%; P = .002). There were few significant improvements in PC education or research between 2009 and 2018 for both groups, notable exceptions include an increase in PC fellowships (38% vs 87%; P < .001) and mandatory PC rotations for medical oncology fellows (29% vs 55%; P = .02) at NCI-designated cancer centers.

Conclusions: PC education and research are more developed at NCI-designated cancer centers. Despite some progress over the past decade, it is relatively slow and suboptimal.
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http://dx.doi.org/10.1002/cncr.33474DOI Listing
March 2021

Integrative Oncology Consultations Delivered via Telehealth in 2020 and In-Person in 2019: Paradigm Shift During the COVID-19 World Pandemic.

Integr Cancer Ther 2021 Jan-Dec;20:1534735421999101

The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: The COVID-19 pandemic has catalyzed the use of mobile technologies to deliver health care. This new medical model has benefited integrative oncology (IO) consultations, where cancer patients are counseled about healthy lifestyle, non-pharmacological approaches for symptom management, and addressing questions around natural products and other integrative modalities. Here we report the feasibility of conducting IO physician consultations via telehealth in 2020 and compare patient characteristics to prior in-person consultations conducted in 2019.

Methods: An integrated EHR-telemedicine platform was used for IO physician consultations. As in the prior in-person visits, patients completed pre-visit patient-reported outcome (PRO) assessments about common cancer symptoms [modified Edmonton Symptom Assessment Scale, (ESAS)], Measure Yourself Concerns and Wellbeing (MYCaW), and the PROMIS-10 to assess quality of life (QOL). Patient demographics, clinical characteristics, and PROs for new telehealth consultation in 2020 were compared to new in-person consultations in 2019 using -tests, chi-squared tests, and -Wilcoxon rank-sum test.

Results: We provided telehealth IO consultations to 509 new patients from April 21, 2020, to October 21, 2020, versus 842 new patients in-person during the same period in 2019. Most were female (77 % vs 73%); median age (56 vs 58), and the most frequent cancer type was breast (48% vs 39%). More patients were seeking counseling on herbs and supplements (12.9 vs 6.8%) and lifestyle (diet 22.7 vs 16.9% and exercise 5.2 vs 1.8%) in the 2020 cohort than 2019, respectively. The 2020 telehealth cohort had lower symptom management concerns compared to the 2019 in-person cohort (19.5 vs 33.1%).

Conclusions: Delivering IO consultations using telehealth is feasible and meets patients' needs. Compared to patients seen in-person during 2019, patients having telehealth IO consultations in 2020 reported lower symptom burden and more concerns about lifestyle and herbs and supplements. Additional research is warranted to explore the satisfaction and challenges among patients receiving telehealth IO care.
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http://dx.doi.org/10.1177/1534735421999101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934055PMC
March 2021

A retrospective review of the use of oxymorphone immediate release for long term pain control in cancer patients with gastrostomy tubes.

Ann Palliat Med 2021 Mar 27;10(3):2662-2667. Epub 2021 Jan 27.

Department of Palliative, Rehabilitation, and Integrative Medicine, UT MD Anderson Cancer Center, Houston, TX, USA.

Background: Cancer patients often require feeding or venting gastrostomy-tubes (G-tubes) for enteral nutrition or symptom palliation. The administration of most extended-release (ER) opioids via the G-tube or orally followed by clamping of the venting G-tube is contraindicated. Oxymorphone immediate release (IR) may be useful because of its longer half-life compared to other IR opioids. We examined the use of oxymorphone IR administered every 8 hours in patients with G-tubes.

Methods: This was a retrospective chart review of 40 consecutive cancer patients with G-tubes who underwent opioid rotation (OR) to oxymorphone. Demographics, symptoms, morphine equivalent daily dose (MEDD), and oxymorphone dose were collected. Successful OR was defined as a 2-point or 30% reduction in pain score and continued use of oxymorphone at follow-up in outpatient setting, or discharge in inpatient setting. Opioid rotation ration (ORR) between MEDD and oxymorphone in patients with successful OR was calculated as MEDD before the OR divided by total oxymorphone dose/day at follow-up or discharge.

Results: The median age was 56 years, 57.5% were white, 68% male, 47.5% (n=19) had head and neck cancer, 90% had advanced disease, 67.5% (n=27) were inpatient, and 15% (n=6) had venting G-tubes. 25/40 (62.5%) patients had successful OR to oxymorphone. The median ORR from MEDD to oxymorphone was 3.5 (IQR, 3.1-4). There were no independent predictors for successful OR, and ORR did not significantly differ among various groups.

Conclusions: Oxymorphone IR can be used successfully in cancer patients with G-tubes using an ORR of 3.5 to calculate dose from MEDD.
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http://dx.doi.org/10.21037/apm-20-969DOI Listing
March 2021

Rapid Transition to Virtual Care during the COVID-19 Epidemic: Experience of a Supportive Care Clinic at a Tertiary Care Cancer Center.

J Palliat Med 2021 Feb 2. Epub 2021 Feb 2.

Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

COVID-19 pandemic necessitated rapid adoption of telemedicine at our supportive care center (SCC) to ensure continuity of care while maintaining social distancing. To document the process of transition from in-person to virtual care. The charts of 1744 consecutive patients in our SCC located in the United States were retrospectively reviewed during the four weeks before transition (February 14-March 12), four weeks after transition (March 20-April 16), and transition week (March 13-March 19). Patient demographics, vital aspects of a supportive care visit such as assessments (Edmonton Symptom Assessment Scale-Financial and Spiritual [ESAS-FS], Cut-down, Annoyed, Guilty, Eye-opener Screen-Adapted to Include Drugs [CAGE-AID], and Memorial Delirium Assessment Scale [MDAS]), interdisciplinary team involvement, and visit type were recorded. In total 763 patients were seen before transition, 168 during the transition week, and 813 after transitioning to virtual care. Patient characteristics, ESAS-FS, CAGE-AID, and nurse assessment did not significantly differ among the three groups. The after-transition group had a small reduction in counseling intervention compared with before (20.2% vs. 26.2%;  = 0.0068). MDAS completion was higher after transition (99.6% vs. 98%;  = 0.007). In-person visits decreased from 100% before to 12.7% after transition ( < 0.0001) and virtual visits increased to 49.3% (video) and 38% (telephone). In-person visits decreased to 49% in the week one, 3% in week two, and <2% in week four after transition ( < 0.0001). Our supportive care team transitioned from in-person care to virtual visits within weeks while maintaining a high patient volume, continuity of care, and adherence to social distancing. Our transition can serve as a model for other centers.
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http://dx.doi.org/10.1089/jpm.2020.0737DOI Listing
February 2021

Rehabilitation Utilization by Cancer Patients with Pathology-Confirmed Leptomeningeal Disease Receiving Intrathecal Chemotherapy.

Am J Phys Med Rehabil 2021 01;100(1):100-104

From the Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas (JBF, AHN, EB); Department of Physical Medicine & Rehabilitation, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, Florida (DMM); College of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Joplin, Missouri (EAP); Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan (SM); and Department of Physical Medicine & Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Boston, Massachusetts (JKS).

Abstract: The incidence of leptomeningeal disease (LMD) is believed to be increasing in part because of more effective chemotherapy treatments allowing cancer progression behind the blood-brain barrier. However, little has been published about the rehabilitation of this growing patient population. In this study, impairments and rehabilitation utilization by cytology-proven LMD patients receiving intrathecal chemotherapy at a cancer center are described. A total of 109 consecutive patients with pathology-confirmed LMD who received an intrathecal chemotherapy infusion from January 1, 2017, through October 31, 2017, were retrospectively reviewed. Of the 109 patients, 103 (95%) had impairments described in their medical record that could impact physical function, including 74 of 109 (68%) who had deconditioning or fatigue. Kaplan-Meier median survival from initial LMD diagnosis was 13.1 mos. The median number of hospital admissions and intrathecal chemotherapy administrations was both 8. Of the 109 patients, 43 (39%) had magnetic resonance imaging radiology interpreted LMD. Most LMD patients used rehabilitation services (95/109, 87%) and most were able to forego post-acute inpatient rehabilitation facilities (96/109, 88%). Additional research and education for rehabilitation professionals about this increasingly common syndrome are needed.
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http://dx.doi.org/10.1097/PHM.0000000000001565DOI Listing
January 2021

Managing Nonmedical Opioid Use Among Patients With Cancer Pain During the COVID-19 Pandemic Using the CHAT Model and Telehealth.

J Pain Symptom Manage 2021 Jan 27. Epub 2021 Jan 27.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA.

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http://dx.doi.org/10.1016/j.jpainsymman.2021.01.005DOI Listing
January 2021

Cancer Rehabilitation Providers and Oncology Patient Expectations for Functional Outcomes after Inpatient Rehabilitation.

PM R 2020 Aug 17. Epub 2020 Aug 17.

Section of Palliative Medicine, Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: Cancer rehabilitation is a valued resource for patients and oncologists. Cancer rehabilitation providers are seeing increasing numbers of referrals for inpatient rehabilitation as the number of cancer survivors grows. However, cancer rehabilitation providers, oncologists, therapists, patients, and caregivers may not always clearly communicate the goals of care, which can lead to different expectations for inpatient rehabilitation.

Objective: To determine the difference in expectations of function after an acute inpatient rehabilitation stay between cancer patients and cancer rehabilitation providers and how they align with achieved goals after treatment.

Design: Prospective survey study.

Setting: Quaternary academic medical center inpatient rehabilitation unit.

Participants: Out of 194 eligible patients, 132 were enrolled and completed admission surveys, and 110 completed the discharge survey. Twelve cancer rehabilitation providers completed the surveys.

Interventions: Not applicable.

Main Outcome Measures: Barthel Index.

Results: Patients estimated their expected functional status as a median (interquartile range) score of 19 points (18, 20) using the Barthel Index, compared to cancer rehabilitation providers, who estimated a median score of 17 points (15, 19) (P < .001). Actual functional status upon discharge was a median score of 16 points (13, 18) using the Barthel Index, which was three points lower than expected by patients (P < .001).

Conclusions: Oncology patients and cancer rehabilitation providers significantly overestimate functional goals for acute inpatient rehabilitation. This overestimation was clinically significant for oncology patients and statistically but not clinically significant for cancer rehabilitation providers. Increased communication may allow for a more realistic expectation of functional status upon discharge.
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http://dx.doi.org/10.1002/pmrj.12473DOI Listing
August 2020

Frequency of and Factors Associated With Nonmedical Opioid Use Behavior Among Patients With Cancer Receiving Opioids for Cancer Pain.

JAMA Oncol 2021 Mar;7(3):404-411

Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston.

Importance: One of the main aims of research on nonmedical opioid use (NMOU) is to reduce the frequency of NMOU behaviors through interventions such as universal screening, reduced opioid exposure, and more intense follow-up of patients with elevated risk. The absence of data on the frequency of NMOU behavior is the major barrier to conducting research on NMOU.

Objective: To determine the overall frequency of and the independent predictors for NMOU behavior.

Design, Setting, And Participants: In this prognostic study, 3615 patients with cancer were referred to the supportive care center at MD Anderson Cancer Center from March 18, 2016, to June 6, 2018. Patients were eligible for inclusion if they had cancer and were taking opioids for cancer pain for at least 1 week. Patients were excluded if they had no follow-up within 3 months of initial consultation, did not complete the appropriate questionnaire, or did not have scheduled opioid treatments. After exclusion, a total of 1554 consecutive patients were assessed for NMOU behavior using established diagnostic criteria. All patients were assessed using the Edmonton Symptom Assessment Scale, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Cut Down, Annoyed, Guilty, Eye Opener-Adapted to Include Drugs (CAGE-AID) survey. Data were analyzed from January 6 to September 25, 2020.

Results: A total of 1554 patients (median [interquartile range (IQR)] age, 61 [IQR, 52-69] years; 816 women [52.5%]; 1124 White patients [72.3%]) were evaluable for the study, and 299 patients (19.2%) had 1 or more NMOU behaviors. The median (IQR) number of NMOU behaviors per patient was 1 (IQR, 1-3). A total of 576 of 745 NMOU behaviors (77%) occurred by the first 2 follow-up visits. The most frequent NMOU behavior was unscheduled clinic visits for inappropriate refills (218 of 745 [29%]). Eighty-eight of 299 patients (29.4%) scored 7 or higher on SOAPP, and 48 (16.6%) scored at least 2 out of 4 points on the CAGE-AID survey. Results from the multivariate model suggest that marital status (single, hazard ratio [HR], 1.58; 95% CI, 1.15-2.18; P = .005; divorced, HR, 1.43; 95% CI, 1.01-2.03; P = .04), SOAPP score (positive vs negative, HR, 1.35; 95% CI, 1.04-1.74; P = .02), morphine equivalent daily dose (MEDD) (HR, 1.003; 95% CI, 1.002-1.004; P < .001), and Edmonton Symptom Assessment Scale pain level (HR, 1.11; 95% CI, 1.06-1.16; P < .001) were independently associated with the presence of NMOU behavior. In recursive partition analysis, single marital status, MEDD greater than 50 mg, and SOAPP scores greater than 7 were associated with a higher risk (56%) for the presence of NMOU behavior.

Conclusions And Relevance: This prognostic study of patients with cancer taking opioids for cancer pain found that 19% of patients developed NMOU behavior within a median duration of 8 weeks after initial supportive care clinic consultation. Marital status (single or divorced), SOAPP score greater than 7, higher levels of pain severity, and MEDD level were independently associated with NMOU behavior. This information will assist clinicians and investigators designing clinical and research programs in this important field.
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http://dx.doi.org/10.1001/jamaoncol.2020.6789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7791402PMC
March 2021

Methylene Blue for the Treatment of Intractable Pain From Oral Mucositis Related to Cancer Treatment: An Uncontrolled Cohort.

J Natl Compr Canc Netw 2021 Jan 4:1-7. Epub 2021 Jan 4.

4Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: Oral mucositis is a complication of cancer therapy, causing severe pain that affects oral functioning, nutrition, and quality of life, as well as therapy nonadherence or dose-limiting toxicity. Anecdotal experience has suggested that methylene blue (MB) oral rinse may be an effective and safe treatment of this oral pain.

Methods: To evaluate the efficacy and safety of MB oral rinse for the treatment of oral pain due to mucositis in patients with cancer, we retrospectively evaluated patients who experienced refractory pain despite conventional therapy.

Results: We identified 281 patients who received MB oral rinse. Most were receiving treatment for leukemia (n=85; 30.3%) and head and neck squamous cell carcinoma (n=84; 29.9%). The most common treatments were radiation therapy alone (n=108; 38.4%) and chemoradiation (n=86; 30.6%). Median duration of symptoms was 14 days. Mean (SD) numeric rating scale pain scores were 7.7 (1.83; median, 8) before MB oral rinse and 2.51 (2.76; median, 2) after MB oral rinse (P<.0001). Most patients achieved pain control within the first 3 doses. The effectiveness of MB oral rinse was independent of patient age, sex, cancer type, cancer stage, MB dilution, and pain duration or baseline pain scores. The lowest response to treatment was reported in individuals with esophageal mucositis. Few patients experienced adverse effects of MB oral rinse (n=13; 4.6%); 10 had a transient burning sensation, 2 had transient blue discoloration of the teeth and mouth, and 1 had increased pain.

Conclusions: MB oral rinse is an effective and safe treatment for refractory pain from oral mucositis related to cancer treatment.
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http://dx.doi.org/10.6004/jnccn.2020.7651DOI Listing
January 2021

Fixed-Dose Netupitant and Palonosetron for Chronic Nausea in Cancer Patients: A Double-Blind, Placebo Run-in Pilot Randomized Clinical Trial.

J Pain Symptom Manage 2021 Jan 1. Epub 2021 Jan 1.

Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.

Context: No clinical trials have examined the effect of netupitant/palonosetron (NEPA) on chronic nausea in patients with cancer.

Objectives: In this pilot randomized trial, we assessed the efficacy of NEPA and placebo on chronic nausea.

Methods: This double-blind, parallel, randomized trial enrolled patients with cancer and chronic nausea for at least 1 month, intensity ≥4/10 and not on moderately or highly emetogenic systemic therapies. Patients started with a placebo run-in period from days 1 to 5; those without a placebo response proceeded to the double-blinded phase between days 6 to 15 (NEPA: placebo 2:1 ratio). The primary outcome was within-group change in average nausea over the 24 hours on a 0-10 numeric rating scale between day 5 and 15.

Results: Among the 53 enrolled patients, 46 proceeded to placebo run-in and 33 had blinded treatment (22 NEPA and 11 placebo). We observed a statistically significant within-group improvement in nausea numeric rating scale between day 5 and 15 in the NEPA group (mean change, -2.0; 95% CI, -3.1 to -0.8) and the placebo group (mean change, -2.3; 95% CI, -3.9 to -0.7). A complete response was achieved in 8 (38%) patients in the NEPA group and 2 (20%) in the placebo group by day 15. No grade 3-4 toxicities were attributed to NEPA. There were no statistically significant between-group differences for the primary/secondary outcomes.

Conclusions: NEPA and placebo were associated with similar magnitude of within-group improvement in chronic nausea without significant between-group differences (Clinicaltrials.gov NCT03040726).
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http://dx.doi.org/10.1016/j.jpainsymman.2020.12.023DOI Listing
January 2021

Duration of palliative care involvement and cancer care aggressiveness near the end of life.

BMJ Support Palliat Care 2020 Dec 21. Epub 2020 Dec 21.

Department of Supportive and Palliative Care, Centre Hospitalo-Universitaire de Grenoble, Grenoble, France

Objectives: Previous studies have found an association between aggressive cancer care and lower quality end of life. Despite international recommendations, late or very late referral to palliative care seems frequent. This study aimed to evaluate the association between the duration of involvement of a palliative care team (PCT), and aggressive cancer care, and to identify factors associated with aggressive cancer care.

Methods: We performed an observational retrospective study in a single academic teaching hospital. In total, 561 inpatients with solid tumours or haematological malignancies were included. Patients followed by a PCT for at least 1 month before death were classified in the palliative care group. Aggressive cancer care was defined as: hospitalisations and/or a new line of chemotherapy within the last month of life, location of death, the use of chemotherapy in the last 2 weeks and hospice admissions within the last 3 days of life.

Results: Among the 561 patients, 241 (43%) were referred to the PCT; 89 (16%) were followed by the PCT for a month or more before death. In the last 2 weeks of life, 124 (22%) patients received chemotherapy, 110 (20%) died in an acute care unit. At least one criterion of aggressive cancer care was found in 395 patients overall (71%). Aggressive cancer care was significantly less frequent when the PCT referral occurred >1 month before death (p<0.0001).

Conclusion: More studies are needed to understand reasons for late referrals despite international recommendations encouraging integrative palliative care.

Ethics Approval: The study was approved by the Grenoble Teaching Hospital ethics committee, and by the CNIL (French national commission for data privacy; Commission Nationale de l'Informatique et des Libertés) under the number 1987785 v 0. Due to ethical and legal restrictions, data are only available on request.
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http://dx.doi.org/10.1136/bmjspcare-2020-002641DOI Listing
December 2020

Deficiencies with the Use of Prescription Drug Monitoring Program in Cancer Pain Management: A Report of Two Cases.

J Palliat Med 2021 May 22;24(5):751-754. Epub 2020 Dec 22.

Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Prescription drug monitoring programs (PDMPs) help maintain electronic records of controlled substances and are a resource to help direct patient care. As the use of these electronic programs expands, limitations of their use are becoming more apparent. We present two cases that illustrate the effects and the need to interpret the PDMPs with caution. Case 1: A male in his 60s presented with metastatic lung cancer who was being managed by our team for pain management along with oncology for cancer directed care. The PDMP erroneously reported that he had filled methadone, thereby impacting the provider-patient relationship. The second case was a female patient in her 40s who had metastatic lung cancer currently receiving cancer directed therapy and also followed with the Supportive Care Clinic for the management of cancer associated pain. The patient had demonstrated nonmedical opioid use behaviors in past visits so a careful monitoring approach had been implemented by the clinic to help safely prescribe opioids. The patient was wearing a fentanyl patch that was found only on physical examination during a clinic visit, because it was not noted in the PDMP. The PDMP has been found to assist physicians in decision making but there are limitations with its use. Enhanced real-time reporting of opioid prescribing information, increased integration into electronic health systems, and universal interstate sharing of prescribing data are some of the ways to improve their effectiveness. More research is needed to further examine the deficiencies and improve on its utility in routine chronic opioid therapy.
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http://dx.doi.org/10.1089/jpm.2020.0537DOI Listing
May 2021