Russell K. Portenoy, MD

Opioid rotation is now consideredstandard practice in themanagement of cancer pain.The rationale for the approach hasbeen well summarized by Estfan andcolleagues. Rotation should be viewedas one strategy among many to dealwith patients who demonstrate relativelypoor responsiveness to an opioid.[1] Application of well acceptedclinical guidelines for opioid administration,beginning with those originallypromulgated by the WorldHealth Organization,[1] emphasizethe need to individualize the opioiddose through a process of gradualdose titration, irrespective of the specificdrug. Most cancer patients attainan adequate balance betweenanalgesia and side effects, at leastinitially. Some, however, experiencetreatment-limiting toxicity, the sinequa non of “poor responsiveness.”This response reflects an outcome thatis related to a specific drug, route ofadministration, set of patient-relatedvariables, and time.

Dyspnea is an extremely common symptom among cancer patients.[1] Like pain, it is inherently subjective and is best defined as the perception of difficulty in breathing, or an uncomfortable awareness of breathing. Although it may be associated with one or more physiologic disturbances (such as hypercapnia, hypoxia, obstructive or restrictive patterns on pulmonary function tests, or various abnormalities on chest imaging studies), it is not strongly associated with any specific abnormality and may occur in the absence of any. Patient self-report is the gold standard for assessment and may range from mild breathlessness on exertion to a terrifying sense of suffocation.

In their article, Drs. Choi and Billings address a number of strategic areas in palliative care. These topics include the definition and scope of the evolving field, the complexities involved in the use of modalities that carry burden or risk (such as artificial nutrition and bowel decompression), and the underappreciated importance of communication skills and a capacity for ethical reasoning.

Fatigue is one of the most common symptoms experienced by patients with cancer and other progressive diseases. Although reported to be a major obstacle to maintaining normal daily activities and quality of life, remarkably few studies of this syndrome have been conducted.

Neuropathic pain may be defined as pain related to abnormal somatosensory processing in either the peripheral or central nervous system. This pathophysiologic label is typically applied when the painful symptom is associated

It is a propitious time for the publication of Dr. Wein’s thoughtful paper on sedation in the imminently dying. Although this intervention has been accepted by most palliative care specialists for many years, it seems to be unfamiliar to many oncologists. The numerous surveys[1-7] and published guidelines[8] that have informed discussions of the technique have not appeared in the oncology literature and probably have been read by few of the front-line clinicians who care for dying cancer patients. Like the broader model of palliative care of which it is part, sedation in the imminently dying must be “mainstreamed”-ie, understood in all its complexity by clinicians whose patients may benefit most from its skillful application.

Michael H. Levy, MD: This 38-year-old white male first came to his physician in January of 1993 complaining of epigastric and low back pain. In March of 1993, he was diagnosed with pancreatic cancer that was metastatic to his

As a result of a burgeoning science and an intensive educational campaign that began more than a decade ago, oncologists

Dr. Peter Staats presented the case of a 15-year-old, 40-kg boy with a primitive neurectodermal tumor located in

Large surveys of populations with cancer pain indicate that as many as 90% of patients can attain adequate relief of pain using optimal, systemic, opioid-based pharmacotherapy. Skilled clinicians should be able to achieve

As indicated in this review by Patt and Ellison, the literature pertaining to the association between transitory acute pains and chronic cancer-related pain is limited and plagued by nomenclatural problems. Nonetheless, the clinical relevance of these so-called breakthrough pains is apparent to those who treat cancer patients.

The relationship between the therapeutic use of potentially abusable drugs for symptom control and the multifaceted nature of abuse and addiction is extremely complex. Research is only beginning to elucidate the

Drug abuse presents a complex set of physical and psychosocial issues that complicate cancer treatment and pain/symptom management. Most oncologists are not be well versed in either the conceptual or practical issues related to addiction.

In their article, von Gunten et al lucidly define palliative care and analyze the status of this discipline within the current American health-care delivery system. They make a series of excellent points, a few of which deserve emphasis and clarification:

Economic analysis of cancer pain management is hampered by the lack of systematic outcomes research. There is some consensus on the broad structures that should be in place to provide optimal care, but the relative costs and