Symptom prevalence and severity in palliative cancer medicine.

OBJECTIVES: To establish symptom prevalence and associated distress in a large cohort of UK patients with cancer referred to a palliative care team. METHODS: This is a secondary analysis of two large data sets of patients with advanced cancer. Each patient had completed the Memorial Symptom Assessment Scale-Short Form to assess 32 symptoms and related distress. Data frequencies were conducted in Excel. RESULTS: 1507 patients were recruited. The most common symptoms were lack of energy (89%), pain (83%), feeling drowsy (77%) and dry mouth (70%). 67% of patients had psychological symptoms, with 31% of all patients having significant psychological distress. CONCLUSIONS: Symptom burden is significant in palliative patients with cancer. Structured symptom assessment with access to relevant supportive services is recommended.

Opioid-induced constipation: a stepwise treatment algorithm feasibility study.

BACKGROUND: Opioid-induced constipation (OIC) is frequently undertreated in patients with advanced cancer. Our hypothesis is that the use of a stepwise treatment algorithm, supported by regular patient-reported outcome measures, should improve the management of OIC. The aim of this feasibility study was to determine whether a definitive study could be successfully completed. METHODS: Patients with OIC (Rome Foundation diagnostic criteria positive), and a Bowel Function Index (BFI) score of ≥30, were recruited to the study. The study involved weekly assessments, and decisions about management were based on the current BFI score (and the tolerability of the current treatment). Management was based on a four-step treatment algorithm, developed from recent international guidelines. RESULTS: One hundred patients entered the study, and 79 patients completed the study. Fifty-seven (72%) participants responded to treatment, with 34 (43%) participants having a 'complete' response (ie, final BFI<30) and 23 (29%) participants having a 'partial' response (ie, change in BFI≥12). In participants with a complete response, 73.5% were prescribed conventional laxatives, 12% were prescribed a peripherally acting mu-opioid receptor antagonist (PAMORA) and 14.5% were prescribed a PAMORA and conventional laxative. DISCUSSION: The feasibility study suggests that a definitive study can be successfully completed. However, we will amend the methodology to try to improve participant recruitment, participant retention and adherence to the treatment algorithm. The feasibility study also suggests that the use of the BFI to monitor OIC, and the use of a treatment algorithm to manage OIC, can result in clinically important improvements in OIC.Trial registration number NCT04404933.

Opioid-induced constipation in patients with cancer: a "real-world," multicentre, observational study of diagnostic criteria and clinical features.

The aim of this study was to investigate opioid-induced constipation (OIC) in a large cohort of "real-world" patients with cancer; the objectives were to determine the prevalence of OIC, the utility of a simple screening question, the accuracy of the Rome IV diagnostic criteria, the clinical features of OIC (physical and psychological), and the impact of OIC (quality of life). One thousand patients with cancer were enrolled in the study, which involved completion of the Rome IV diagnostic criteria for OIC, the Bowel Function Index, the Patient Assessment of Constipation Quality of Life questionnaire, and the Memorial Symptom Assessment Scale-Short Form. Participants also underwent a thorough clinical assessment by an experienced clinician (ie, "gold-standard" assessment of OIC). Fifty-nine percent of patients were clinically assessed as having OIC, 2.5% as having another cause of constipation, and 19% as not having constipation but were taking regular laxatives. The simple screening question produced a number of false-negative results (19% of patients), whereas the Rome IV diagnostic criteria had an accuracy of 81.9%. Patients with OIC had more symptoms overall, higher Memorial Symptom Assessment Scale-Short Form subscale scores (and total score), and higher Patient Assessment of Constipation Quality of Life questionnaire subscale scores (and the overall score). Opioid-induced constipation was not associated with demographic factors, cancer diagnosis, performance status, or opioid equivalent dosage: OIC was associated with opioid analgesic, with patients receiving tramadol and transdermal buprenorphine having less constipation. The study confirms that OIC is common among patients with cancer pain and is associated with a spectrum of physical symptoms, a range of psychological symptoms, and an overall deterioration in the quality of life.

Alcohol and drug use disorders in patients with cancer and caregivers: effects on caregiver burden.

BACKGROUND: The estimated prevalence of alcohol use disorders in patients with advanced cancer is reported as 4%-38%. There are limited data regarding alcohol and drug use disorders in caregivers of patients with cancer and the effects on other issues. AIM: To establish the prevalence of alcohol and drug use disorders in a large cohort of patients with advanced cancer and their caregivers.To evaluate the relationship between alcohol and drug use disorders and patient symptoms and caregiver burden. DESIGN: The patient with cancer and caregiver completed the Alcohol Use Disorders Identification Tool, CAGE questionnaire and Drug Abuse Screening Test. The patient completed the Memorial Symptom Assessment Scale-Short Form, and the caregiver completed the Zarit Burden Questionnaire.Statistical analysis compared cases and non-cases of alcohol and drug use disorders with symptom and burden score. SETTING/PARTICIPANTS: Patients with cancer, and their caregivers, were recruited from 11 UK sites, 6 hospices and 5 hospitals. RESULTS: Five hundred and seven patients and their caregivers were recruited. Twenty-seven patients (5%) and 44 caregivers (9%) screened positively for alcohol use disorders on the Alcohol Use Disorders Identification Tool. Thirty patients (6%), and 16 caregivers (3%), screened positively for drug abuse problems on the Drug Abuse Screening Test.There was a significantly higher carer burden score in caregivers screening positively for alcohol and drug abuse problems. CONCLUSIONS: The prevalence of alcohol use disorders in patients with cancer and caregivers was lower than reported in previous studies. Caregiver burden scores were significantly higher in carers screening positively for alcohol and drug use disorders. TRIAL REGISTRATION NUMBER: Trial registered National Institute for Health Research Clinical Research Network Portfolio (CPMS ID 30723) IRAS ID 198753.

MASCC recommendations on the management of constipation in patients with advanced cancer.

PURPOSE: The Palliative Care Study Group of the Multinational Association for Supportive Care in Cancer formed a subgroup to develop evidence-based recommendations on the management of constipation in patients with advanced cancer. METHODS: These recommendations were developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The recommendations were categorised by the level of evidence and a "category of guideline" based on the level of evidence (i.e. "recommendation", "suggestion", or "no guideline possible"). RESULTS: The group produced 15 recommendations, with varying levels of evidence and so varying categories of guideline. The recommendations relate to the assessment, the treatment, and the re-assessment of constipation. CONCLUSIONS: These recommendations provide a framework for the management of constipation in advanced cancer, although every patient needs individualised management.

Nausea and vomiting in palliative care.

Nausea and vomiting in palliative care are commonly experienced symptoms, and the aetiology is often multifactorial. The most common causes are impaired gastric emptying, chemical causes (eg medication) and visceral causes (eg constipation). Close attention should be paid to the clinical features which may suggest the likely cause. Antiemetic therapy should be guided by the likely aetiology, although in practice, the clinical picture is often complex, and so regular reassessment is essential for adequate symptom control.

Naloxegol for opioid-induced sphincter of Oddi spasm/dysfunction.

The paper describes a case report of a patient with a significant history of opioid-induced dysfunction of the sphincter of Oddi, who required morphine sulfate to manage oral mucositis pain, and who was successfully treated with concomitant oral naloxegol (Moventig: Kyowa Kirin, Galashiels, UK).