Top Ten Tips for Palliative Care Clinicians Caring for Cancer Patients Receiving Immunotherapies.

Patients with cancer face an ever-changing landscape of tumor-directed therapies available to improve quality of life and potentially increase survival. The most recent advances, immunotherapeutics, offer a novel way to target cancer cells by engaging the body's own immune system. Using an expert panel of oncologists, palliative medicine physicians, and dual-trained specialists, we discuss current immunotherapies and their clinical uses, potential side effects and management strategies, and the implications of these newer treatments on goals of care conversations and care coordination. We aim to further engage palliative care specialists in the active care of cancer patients receiving immunotherapeutics and use a "Top 10" tips format to concisely present practical learning points to busy clinicians.

Information Framing Reduces Initial Negative Attitudes in Cancer Patients' Decisions About Hospice Care.

BACKGROUND: Negative attitudes toward hospice care might prevent patients with cancer from discussing and choosing hospice as they approach end of life. When making a decision, people often naturally focus on either expected benefits or the avoidance of harm. Behavioral research has demonstrated that framing information in an incongruent manner with patients' underlying motivational focus reduces their negative attitudes toward a disliked option. OBJECTIVE: Our study tests this communication technique with cancer patients, aiming to reduce negative attitudes toward a potentially beneficial but often-disliked option, that is, hospice care. METHODS: Patients (n = 42) with active cancer of different types and/or stages completed a paper survey. Participants read a vignette about a patient with advanced cancer and a limited prognosis. In the vignette, the physician's advice to enroll in a hospice program was randomized, creating a congruent message or an incongruent message with patients' underlying motivational focus (e.g., a congruent message for someone most interested in benefits focuses on the benefits of hospice, whereas an incongruent message for this patient focuses on avoiding harm). Patients' attitudes toward hospice were measured before and after receiving the physician's advice. RESULTS: Regression analyses indicated that information framing significantly influenced patients with strong initial negative attitudes. Patients were more likely to reduce intensity of their initial negative attitude about hospice when receiving an incongruent message (b = -0.23; P < 0.01) than a congruent one (b = -0.13; P = 0.08). CONCLUSION: This finding suggests a new theory-driven approach to conversations with cancer patients who may harbor negative reactions toward hospice care.

Patient-Reported Outcomes and Opioid Use by Outpatient Cancer Patients.

The Memorial Sloan Kettering Pain Registry contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,534 chronic pain cancer patients who were seen at outpatient pain service clinics. Average pain intensity (Brief Pain Inventory) was reported as mild by 24.6% of patients, moderate by 41.5%, and severe by 33.9%. The patient's report of average percent pain relief and health state (EuroQOL 5 dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Eighty-six percent of patients received an opioid at 1 or more clinic encounters. Regression analysis revealed that male sex or being younger (65 years of age or younger) was associated with a greater likelihood of an opioid ordered. Male sex nearly doubled the likelihood of a higher dose being ordered than female sex. Bivariate analysis found that patients receiving opioids reported significantly more pain relief than no-opioid patients. However, patients receiving opioids had higher pain interference scores, lower index of health state, and more physical distress than no-opioid patients Our results identify the need to consider opioid use and dosage when attempting to understand patient-reported outcomes (PROs) and factors affecting pain management. PERSPECTIVE: This report describes the results of the analyses of PROs and patient-related electronic health record data collected under standard of care from cancer patients at outpatient pain management clinics of Anesthesiology and Palliative Care at the Memorial Sloan Kettering Cancer Center. Consideration of sex and age as predictors of opioid use is critical in attempting to understand PROs and their relationship to pain management.

Impact of Palliative Medicine Involvement on End-of-Life Services for Patients With Cancer With In-Hospital Deaths.

PURPOSE: Palliative care (PC) has been shown to improve the quality of care and resource utilization for inpatients. We examined the relationship between PC consultation before and during final admission and patterns of care for dying patients at our tertiary cancer center. METHODS: We retrospectively reviewed adult patients with solid tumor cancer with a length of stay ≥ 3 days who died in hospital between December 2012 and November 2014. We recorded services, including laboratory testing, imaging, blood products, medications, diet orders, do not resuscitate orders, and consultations, delivered within 3 days of death. We assessed the differences among services delivered to patients with outpatient PC, inpatient PC only, and no PC involvement. RESULTS: Of 695 patients, 21% received outpatient PC, 46% received inpatient PC only, and 33% received no PC. During their final admission, 11.2% of patients received radiation therapy, and 12.5% received tumor-directed therapy, with no differences on the basis PC involvement ( P = .09 to .17). In the last 3 days of life, imaging tests occurred in 50.1%; patients with outpatient or inpatient-only PC underwent fewer studies (43.5% and 47.3%) than did those with no PC involvement (58.1%; P = .048). Do not resuscitate orders were in place within the 6 months before final admission at a greater rate for patients with outpatient PC (22%) than for patients with inpatient-only PC (8%) or those with no PC involvement (12%; P = .002). CONCLUSION: In this retrospective cohort of patients with solid tumor dying in hospital, few patients received cancer-directed therapies at the end of life. Involvement of PC was associated with a decrease in diagnostic testing and other services not clearly promoting comfort as patients approached death.

Methadone Use and the Risk of Hypoglycemia for Inpatients With Cancer Pain.

CONTEXT: Methadone is an important drug in the management of both cancer-related and non-cancer-related pain and is the main pharmacologic agent used in the treatment of opioid addiction. Unexpected hypoglycemia has been observed in patients receiving methadone, prompting a more detailed investigation. OBJECTIVES: To evaluate the incidence of hypoglycemia in a cohort of inpatients receiving methadone versus other opioids including fentanyl, hydromorphone, and morphine. METHODS: Retrospective observational cohort of inpatients in a tertiary cancer center admitted for more than 48 hours from November 1, 2011 to October 30, 2013. The main outcomes were lowest measured daily blood glucose (in mg/dL) and incidence of hypoglycemia (defined as blood glucose < 70 mg/dL, equivalent to 3.9 mmol/L) with variable methadone doses compared with other non-methadone opioids. RESULTS: Of the 641 eligible patients admitted during the study period who received at least one dose of methadone during admission, multivariable logistic regression showed significant associations between methadone and hypoglycemia at doses greater than 40 mg oral equivalents per day or with patient-controlled analgesia use. A dose-response relationship was observed, with an odds ratio of 3.1 (95% confidence interval 2.5, 3.6) when doses greater than 80 mg/day were used. No evidence of increased risk of hypoglycemia or of a dose-response curve was seen for the other opioids. CONCLUSION: The risk of hypoglycemia is increased for patients taking more than 40 mg oral methadone equivalents per day. When starting methadone at or more than 40 mg/day, we recommend blood glucose monitoring.

Capecitabine-induced systemic lupus erythematosus and palmoplantar erythrodysesthesia.

Capecitabine is emerging as an important drug in the treatment of metastatic breast and colorectal cancers. Marketed as Xeloda ®, this prodrug is taken orally and readily absorbed. It is novel in its increased convenience for patients, similar efficacy to the intravenous form of its active metabolite and its increased tolerability.1 We present a woman with metastatic breast cancer who presented with cutaneous abnormalities two months after starting treatment with capecitabine. Various dermatologic side effects have been attributed to capecitabine, often requiring cessation of the offending drug. We describe an unreported dermatological side effect of capecitabine therapy, systemic lupus erythematosus concurrent with palmoplantar erythrodysesthesia. As the use of this chemotherapeutic agent becomes more prevalent, it is important to recognize the range of its cutaneous side effects.

Nanoparticles: small and mighty.

The properties of engineered nanomaterials and nanoparticles such as zinc oxide and titanium dioxide may differ substantially from naturally occurring materials and particles. Nanoparticles have unique physical properties making them ideal for use in various skin care products currently on the market. Nano-preparations are currently under investigation as novel treatments of acne vulgaris, recurrent condyloma accuminata, atopic dermatitis, hyperpigmented skin lesions, and other non-dermatologic diseases. Because of their increased surface area, nanoparticles have increased reactivity and a small size allowing for enhanced mobility through the human body and environment. As their use becomes more prevalent, nanoparticles are being scrutinized for their safety and long-term effects. This review discusses the benefits of nanoparticles in dermatological therapies and skin care products as well as potential disadvantages and possible mechanisms of toxicity.

A firm plaque on the back of a newborn.

We report a case of subcutaneous fat necrosis of the newborn (SCFN), a rare disorder in term or post-term neonates. Although it is often associated with hematological abnormalities such as anemia and hypercalcemia, SCFN in this patient presented with hyperbilirubinemia. The course of SCFN is generally benign and self-limiting, though may be associated with complications secondary to hypercalcemia.