The silent epidemic: tobacco and the evolution of lung cancer and its treatment.

Considered a rare disease during the 19th century, lung cancer became the most virulent and lethal cause of cancer mortality by the end of the 20th century. In this paper, lung cancer and its treatment are addressed within the social, cultural, economic, and political context of the last century. Because lung cancer is related to the consumption of cigarettes, the battles over tobacco control are highlighted. Four time periods are addressed: the early years (1900-1930), beginning of the epidemic (1930-1960), defining the problem (1960-1980), and expanding options (1980-1990s). Although improvements have been made in science and technology, attempts at finding curative treatments have met with little success. Smoking cessation and efforts to control tobacco (especially among children and adolescents) remain the most important factors if the incidence of lung cancer is to be curtailed in the future. Providing care to individuals with the illness is a current challenge. Research examining the efficacy of treatments and their effect on survival, health-related quality of life, and cost outcomes is essential and can be best achieved through the efforts of multidisciplinary teams.

Pain assessment and management.

Assessment and management of pain is crucial to the success of any program of care for dying patients and their families. With appropriate assessment and management, often using home health or hospice teams, pain can be controlled in more than 90% of patients. This article focuses on the symptomatic care of patients who are dying. The legal and regulatory issues that may inhibit delivery of adequate opioid therapy are also reviewed.

Patients with cancer referred to hospice versus a bridge program: patient characteristics, needs for care, and survival.

PURPOSE: The purpose of this study was to compare the characteristics and needs of patients with advanced cancer who were referred to hospice with those referred to a prehospice "bridge" program that is staffed by hospice nurses. PATIENTS AND METHODS: Data were gathered through retrospective review of computerized clinical records using precoded data fields of 284 patients with cancer enrolled in a bridge program and 1,000 who enrolled in a hospice program. Patient characteristics, needs for supportive care at the time of enrollment, and survival were assessed. RESULTS: Bridge patients were less likely to have Medicare or Medicaid (43% v 72%; odds ratio, 0.30; P <.001) and were younger (69 v 73 years, rank sum test; P <.001), more likely to be married (59% v 43%; odds ratio, 1.90; P <.001), and more likely to be in the highest income category (14% v 10%; odds ratio, 1.77; P =.009). Bridge patients had at least as many needs for care as did patients in hospice. Bridge patients lived significantly longer (median, 46 v 19 days; log-rank test of survivor functions, P <.001). CONCLUSION: Patients referred to this bridge program had prognoses that are significantly better than those of patients who enter hospice, but they have needs for supportive care that are at least as great. These findings underscore the importance of initiatives to extend some of the benefits of hospice care to a wider population of patients and should encourage the analysis of similar programs' ability to meet these needs.

Advances in pain management for older adult patients.

Management of pain is crucial to the success of any program of care and support for dying patients and their families. Pain can be controlled in more than 90% of older adults. Components of an effective program include comprehensive, repeated pain assessment; detection and treatment of complicating medical and psychological disorders (e.g., delirium); spiritual concerns; and the judicious use of nonpharmacologic and pharmacologic therapies, radiation, and radiopharmaceuticals. Strategies that enable clinicians to prevent and treat the expected complications of nonsteroidal anti-inflammatory and opioid therapies are reviewed. Strategies to change opioid agents or routes to minimize opioid-induced side effects and to provide effective pain relief as death nears are presented.

Development of a teaching module for quality-of-life assessment of terminal patients. The AACE Multi-Institutional Palliative Cancer Education Section. American Association for Cancer Education.

To enhance the teaching of students to assess quality of life of patients with serious disease, the AACE Palliative Cancer Education Section has developed a teaching module. The module, which focuses on four desired learning objectives, is to be used in an hour-long small-group session. The authors describe the development of the module, as well as its objectives, teaching method, evaluation, and future challenges.

Management of pain and spinal cord compression in patients with advanced cancer. ACP-ASIM End-of-life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine.

General internists often care for patients with advanced cancer. These patients have substantial morbidity caused by moderate to severe pain and by spinal cord compression. With appropriate multidisciplinary care, pain can be controlled in 90% of patients who have advanced malignant conditions, and 90% of ambulatory patients with spinal cord compression can remain ambulatory. Guidelines have been developed for assessing and managing patients with these problems, but implementing the guidelines can be problematic for physicians who infrequently need to use them. This paper traces the last year of life of Mr. Simmons, a hypothetical patient who is dying of refractory prostate cancer. Mr. Simmons and his family interact with professionals from various disciplines during this year. Advance care planning is completed and activated. Practical suggestions are offered for assessment and treatment of all aspects of his pain, including its physical, psychological, social, and spiritual dimensions. The methods of pain relief used or discussed include nonpharmacologic techniques, nonopioid analgesics, opioids, adjuvant medications, radiation therapy, and radiopharmaceutical agents. Overcoming resistance to taking opioids; initiating, titrating, and changing opioid routes and agents; and preventing or relieving the side effects they induce are also covered. Data on assessment and treatment of spinal cord compression are reviewed. Physicians can use the techniques described to more readily implement existing guidelines and provide comfort and optimize quality of life for patients with advanced cancer.

The oncologist's expanding role.

Advances in the assessment and management of pain have made it possible for over 90% of oncology patients to have a pain free death at home. Oncologists have a unique opportunity, as clinical role models, teachers, and participants in research, to insure proper management of patients' symptoms at diagnosis, during treatment, and as death approaches.

Promoting symptom control in palliative care.

OBJECTIVES: To describe management of common physical problems that occur in patients with advanced cancer. DATA SOURCES: Research and review articles, book chapters, and published guidelines. CONCLUSIONS: Effective symptom control for patients with advanced cancer requires the coordinated efforts of a multidisciplinary team. Excellent palliation can be achieved in patients suffering from pain, as well as from gastrointestinal, respiratory, or dermatologic disorders. IMPLICATIONS FOR NURSING PRACTICE: Nursing is the cornerstone of effective palliative care. Through accurate assessments and expertise in delivering pharmacologic and nonpharmacologic treatments, nurses ensure optimal palliation of physical symptoms.