Impact of individualized management of breakthrough cancer pain on quality of life in advanced cancer patients: CAVIDIOPAL study.

PURPOSE: The main aim of the study was to assess the impact of individualized management of breakthrough cancer pain (BTcP) on quality of life (QoL) of patients with advanced cancer in clinical practice. METHODS: A prospective, observational, multicenter study was conducted in patients with advanced cancer that were assisted by palliative care units. QoL was assessed with the EORTC QLQ-C30 questionnaire at baseline (V0) and after 28 days (V28) of individualized BTcP therapy. Data on background pain, BTcP, comorbidities, and frailty were also recorded. RESULTS: Ninety-three patients completed the study. Intensity, duration, and number of BTcP episodes were reduced (p < 0.001) at V28 with individualized therapy. Transmucosal fentanyl was used in 93.8% of patients, mainly by sublingual route. Fentanyl titration was initiated at low doses (78.3% of patients received doses of 67 µg, 100 µg, or 133 µg) according to physician evaluation. At V28, mean perception of global health status had increased from 31.1 to 53.1 (p < 0.001). All scales of EORTC QLQ-C30 significantly improved (p < 0.001) except physical functioning, diarrhea, and financial difficulties. Pain scale improved from 73.6 ± 22.6 to 35.7 ± 22.3 (p < 0.001). Moreover, 85.9% of patients reported pain improvement. Probability of no ≥ 25% improvement in QoL was significantly higher in patients ≥ 65 years old (OR 1.39; 95% CI 1.001-1.079) and patients hospitalized at baseline (OR 4.126; 95% CI 1.227-13.873). CONCLUSION: Individualized BTcP therapy improved QoL of patients with advanced cancer. Transmucosal fentanyl at low doses was the most used drug. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov database (NCT02840500) on July 19, 2016.

Complejidad asistencial en la atención al final de la vida: criterios y niveles de intervención en atención comunitaria de salud / Complexity of end-of-life care: criteria and levels of intervention in community health care

OBJETIVO: Definir la complejidad en la atención al final de la vida y los criterios relacionados y proponer, en función de su agrupación por niveles de complejidad, un modelo marco de intervención de los profesionales de la atención primaria de salud y de los recursos paliativos específicos. MATERIAL Y MÉTODOS: Estructura: grupo técnico interdisciplinario de consenso formado por 10 profesionales expertos en la atención al final de la vida (áreas contempladas: atención primaria de salud, paliativa específica, geriátrica, oncológica, trabajo social, bioética y espiritualidad) y la colaboración externa de 2 profesionales expertos en psicooncología y medicina interna. METODOLOGÍA: consenso de los profesionales mediante un procedimiento cualitativo tipo Delphi. Las etapas de consenso corresponden a los apartados de los RESULTADOS: El trabajo se realiza bajo la coordinación de la Sociedad Catalano-Balear de Cuidados Paliativos, la colaboración de la Sociedad Catalana de Medicina Familiar y Comunitaria (CAMFIC) y la dirección del Plan Director Sociosanitario del Departamento de Salud de la Generalitat de Catalunya. RESULTADOS: Definición: la complejidad resulta de la emergencia de procesos que interactúan cumpliendo las propiedades de los sistemas complejos. Modelo de referencia: se parte del modelo de necesidades de pacientes y familias, obteniendo 6 áreas de complejidad: necesidades físicas, psicoemocionales, sociofamiliares, espirituales, relacionadas con la muerte (situación de últimos días y duelo) y aspectos éticos. Áreas y criterios de complejidad: en cada área se describen: conceptos, situaciones habitualmente complejas y criterios de complejidad agrupados en 3 niveles de complejidad (baja, media y alta). Modelo de intervención: la propuesta es baja complejidad, intervención del equipo de referencia y puntualmente del equipo paliativo específico; complejidad media: atención compartida de intensidad pactada; alta complejidad: intervención prioritaria del equipo específico. Ingreso hospitalario. CONCLUSIONES: Resulta necesario diferenciar entre situaciones habitualmente complejas y criterios de complejidad. Aquellas se comportan frecuentemente como proceso emergente, mientras que los criterios corresponderían a la propia emergencia o su resultado. El modelo de intervención propuesto puede resultar útil para facilitar la colaboración asistencial entre los equipos referentes y paliativos específicos, ya que se trata de un modelo corresponsable y dinámico que no parcela la intervención

OBJECTIVE: To define the complexity in end-of-life care and the criteria of complexity, and depending on their grouping within these levels of complexity, to propose a model of intervention that will allow different levels of care to be established, and the framework within which the professionals of primary health care and the palliative team should work. MATERIAL AND METHODS: Structure: a technical and interdisciplinary group of consensus formed by ten professional experts in end of life care in the areas of: community health care, palliative care, geriatric care, oncology, social work, bioethics and spirituality; with external collaboration from two professionals of psycho-oncology and internal medicine. METHODOLOGY: we established a Delphi type qualitative method to obtain a consensus of all the professionals. The different stages of consensus correspond to the points described in the results. The work took place under the coordination of the Catalan-Balearic Society of Palliative Care, with the collaboration of the Catalan Society of Family and Community Medicine (CAMFIC), and the Directorate of the Social-Health Master Plan of the Health Department of the Generalitat of Catalonia. RESULTS: Definition: the complexity is caused by the emerging of processes that, when they interact, fulfil the criteria to be defined complex systems. Reference model: our base model is modelled on the needs of patients and families, thus obtaining six areas of complexity: physical needs, psycho-emotional, socio-family, spiritual, an area related directly with death (situation in the last days, grief), and an area of ethical aspects. Areas and criteria of complexity: in each area the following are obtained: base definitions, situations usually creating complexity, and criteria of complexity grouped in three levels: low medium and high. Model of intervention: the proposal is: low complexity: intervention of the community health care team with occasional intervention by the palliative care team. Medium complexity: shared caring decided between the community health care team and the palliative team. High complexity: main intervention by the palliative team. Hospital admission. CONCLUSIONS: It is necessary to differentiate between situations that are usually complex and the criteria of complexity. The first are those situations that often behave as an emerging process, whereas the criteria of complexity correspond to the actual emergence or its results. The intervention model proposed should improve the collaboration between community care and the palliative care team, as this is a co-responsibility and dynamic model that does not divide the intervention

Structure, organisation and clinical outcomes in cancer patients of hospital support teams in Spain.

OBJECTIVES: To describe the structure, characteristics of patients and basic clinical outcomes in cancer patients receiving care from palliative care hospital support teams (HSTs) in Spain. METHOD: A multi-centre observational two phase study. Phase I: A descriptive survey of all HSTs in Spain. Phase II: A quasi-experimental prospective cohort study to describe the clinical outcomes, symptom severity and survival. RESULTS: 60 HSTs in Spain met the inclusion criteria. All HSTs were multidisciplinary with wide experience (mean 6.8 years). HSTs coverage was 21.5% of all cancer deaths in Spain. A total number of 364 advanced cancer patients were included in the cohort study; 76% were classified as moderate or high complexity. Overall, 64% were male subjects and the most frequent primary cancer site was lung (26%). Half of the patients had no detailed information about cancer staging and only 19% knew their short-term prognosis. The mean length of intervention was 6.5 days (mean three visits per patient). Outcomes were: 34% deaths during the admission process; 38% were discharged home; and 28% were transferred to another medium-term-stay specialist unit. The main symptoms were pain (68%), dyspnoea (43%), vomiting (24%), anorexia (72%), asthenia (78%), insomnia (50%), anxiety (45%) and depression (35%). After the HSTs intervention, the symptom severity was significantly reduced (p<0.001) for all symptoms, except for weakness and anorexia. The mean survival from inclusion was 111 days. CONCLUSIONS: Palliative intervention of HSTs is characterised by being adjusted to patient needs and short duration. Their care was focused on the preterminal phase of cancer patients of moderate-high complexity.

Rotación de opioides: una alternativa en el tratamiento del dolor refractario en pacientes con cáncer / Opioid rotation: A therapeutic choice in the management of refractory cancer pain

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Patient appointment process, symptom control and prediction of follow-up compliance in a palliative care outpatient clinic.

Activities and outcomes in an outpatient palliative care clinic (PCC) have attracted little attention in the literature. We describe the results of our patient appointment scheduling process, our efficacy in relieving cancer-associated symptoms and an analysis of risk factors for patient non-compliance with the appointment schedule. Over a one-year study period, 730 first-time appointments were scheduled and 73.1% of them were kept. Only patients who had kept 3 consecutive visits (n=203) were included in the symptom control analysis. All symptoms except constipation, physical weakness, and anxiety improved significantly with palliative care. History of alcohol abuse was not associated with poorer pain control. A low Karnofsky index and high anxiety levels were identified as risk factors for early withdrawal from the PCC scheduled appointment. These data indicate that the PCC is an effective place for symptom management, but specific organizational strategies are needed to encourage patients to comply with scheduled appointments.