Palliative and Supportive Care

Bisphosphonates have an established role in treating tumor-inducedhypercalcemia and decreasing the incidence of skeletal-related events.Recent data suggest that these agents may also prevent skeletal metastases.This review explains how cancer metastasizes to bone and howbisphosphonates may block this process, with a summary of clinicaltrials supporting the use of bisphosphonates to treat and prevent bonemetastases. For skeletal metastases in patients with breast cancer,multiple myeloma, or other solid tumors, bisphosphonates are importantadjuncts to systemic therapy. Despite promising results in metastaticprostate cancer, additional trials are needed before bisphosphonatesbecome part of standard treatment in this setting. Ongoing trials areevaluating the preventive role of the third-generation bisphosphonatesin breast cancer patients. Until the results of these trials are presented,bisphosphonates should only become a component of adjuvant treatmentin the context of a clinical trial. Bone loss, a common consequenceof cancer treatment, should be treated with the usual measures indicatedfor the management of osteoporosis, including bisphosphonates.

Approximately 70% of patientswith life-threatening diseasestreatable with allogeneic bloodstem cell transplantation do not havematched related donors. The NationalMarrow Donor Program (NMDP) wasestablished in 1986 to provide humanleukocyte antigen (HLA)-matched,volunteer unrelated donors for thesepatients. The NMDP performs thistask by maintaining a registry of morethan 4.9 million volunteer donors ofmarrow and peripheral blood stemcells (PBSC) and 12 cord blood bankscontaining more than 25,000 units ofumbilical cord blood.

DENVER, Colorado-Evidencebasedclinical practice has become a hottopic in the current nursing community.Victoria Mock, DNSc, RN, recipient ofthe 2003 Distinguished Researcher Award,related her group’s experience in helpingto develop evidence-based fatigue managementinterventions that have now becomepart of nursing practice. Director ofnursing research at the Kimmel ComprehensiveCancer Center at Johns HopkinsHospital in Baltimore, Dr. Mock has thedistinction of being the only nurse tochair a National Comprehensive CancerNetwork (NCCN) clinical guidelines panel(the committee that developed the firstNCCN guidelines on cancer-related fatigue).

DENVER, Colorado-Treatingcancer-related anemia improves qualityof life and may have other potential therapeuticbenefits for cancer patients, accordingto speakers at a cancer-relatedanemia symposium presented in conjunctionwith the 28th Annual Congress of theOncology Nursing Society. The expertpanel also discussed the need for earlierintervention with flexible dosing regimensand outlined potential future applicationsof erythropoietic agents.

With recent advances in the management of cancer, the clinicalcourse of patients with metastatic bone disease is more likely to beprolonged and accompanied by morbidity, including severe pain, hypercalcemia,pathologic fracture, and spinal cord and/or nerve root compression.The early identification of patients at higher risk for developingbone metastases enables practitioners to be proactive in their diagnosisand treatment. A multidisciplinary approach that integrates the diagnosisand treatment of the cancer, symptom management, and rehabilitationensures optimal care. Bisphosphonates can reduce the number ofskeletal-related complications, delay the onset of progressive disease inbone, and relieve metastatic bone pain caused by a variety of solidtumors with a resulting enhanced quality of life. The complexity of theclinical problem and the need to involve an array of health-careproviders present a logistical and clinical challenge. A strong argumentis made for a thematically integrated bone metastases program as partof the primary care of patients with cancer.

Published literature indicates that the selective estrogen-receptormodulators (SERMs) tamoxifen and raloxifene (Evista) have favorableeffects on bone density, lipid profiles, and the incidence of secondbreast cancers, and unfavorable effects on the incidence of venousthrombosis and hot flushes. Tamoxifen increases the risk of endometrialcancer, but raloxifene does not. The effects of SERMs on sexualfunction and cognition are unclear. Because the selective antiaromataseagents are relatively new, the long-term effects of these agentson normal tissues are less well established. It appears that the nonsteroidalagents (anastrozole [Arimidex], letrozole [Femara]) and steroidal(exemestane [Aromasin]) antiaromatase agents may have differenteffects on normal tissues. Preliminary data demonstrate that anastrozoleincreases the risk of arthralgias and produces a decrease in bonedensity. In contrast, exemestane appears to favorably affect bonedensity and lipid profile, similar to tamoxifen and raloxifene. Theincidence of contralateral breast cancer is decreased in women onadjuvant anastrozole, but data for the other antiaromatase agents arenot yet available. Hot flushes have been reported with the use ofselective aromatase inhibitors, but their incidence seems to be comparableto what is reported with SERMs. Antiaromatase agents do notappear to cause venous thrombosis. More information about the effectsof the antiaromatase agents on normal tissue will become available asdata from ongoing adjuvant and chemoprevention trials are reported.Clinically, we should be conscious of the differences between antiaromataseagents and SERMs and their impact on women’s health.

SAN ANTONIO-Once-weekly treatment with recombinant human erythropoietin (epoetin alfa, Epogen, Procrit), given concurrently with adjuvant chemotherapy for breast cancer, maintains or improves hemoglobin levels while attenuating decreases in quality of life (QOL), interim trial results show.

Two cancer-related issues-evidence-based cancer screening andpain control in advanced cancer-are among 20 priority areasthat an Institute of Medicine (IOM) committee has urged publicand private organizations to focus on as a way of transforming healthcare in the United States. Goals regarding screening, especially forcolorectal and cervical cancer, the report said, are "to increase thenumber of people who receive screenings and to provide timely followup."Regarding pain control in patients with advanced cancer, thecommittee urged efforts to "emphasize cooperation in protocols acrosscare settings, advance planning for changes in settings, as well asheightened pain, and public education regarding the merits of opioidmedications in this area."

Blood and marrow transplantation, a curative treatment for avariety of serious diseases, induces a period of sustained immunosuppressionpredisposing recipients to opportunistic infections. Both forthe protection of the individual transplant recipient and as a matter ofpublic health policy, the US Centers for Disease Control and Prevention(CDC) has developed guidelines for the use of vaccination in theprevention of infectious disease following transplantation. This reviewexamines the primary clinical research supporting vaccinationpolicies in this target population. Widely accepted recommendationsfor transplant recipients based on scientific data are sparse, as fewlarge studies have been conducted in this population. Anecdotalreports, expert advice, summaries, and limited series involving lessthan 50 patients using surrogate end points form the basis of thescientific literature, with the result being a wide variation in practice.Although based largely on inadequate scientific data, the CDC recommendationsoffer a pragmatic approach to the prevention of opportunisticdisease in hematopoietic transplant recipients and serve as auseful starting point for standardization of practice while defining thedirection of future studies in transplant recipients and other immunocompromisedhosts.

Drs. Kochhar and coauthors areto be congratulated for providingconcrete examples ofopioid dosing errors that contributeto inadequate management of cancerpain. As the authors note, controllingcancer pain is far more complicatedthan the World Health Organization’sthree-step ladder of nonsteroidal antiinflammatorydrug (NSAID)/aspirin,codeine, and morphine would suggest.

Iread with pleasure this articlefrom the staff of the Harry R.Horvitz Center for Palliative Medicine,an institution with expertiseand experience to draw upon. Allmultidisciplinary cancer centersshould have an expertise in palliativemedicine if not a formalized program,as one of the most important jobs ofoncologists is to relieve pain and sufferingfor patients and their families.When pain is effectively addressed,the patient’s aggregate quality of lifeis optimized and time spent with familyand friends is more enjoyable.

Many individuals with advanced malignancy continue to sufferfrom pain and, consequently, impaired quality of life. The clinicalscenarios in advanced cancer pain are complex, and successful managementmay require a more sophisticated and individualized approachthan suggested by the World Health Organization guidelines.In patients referred to the Harry R. Horvitz Center for PalliativeMedicine in Cleveland, numerous commonly occurring errors inopioid use have been noted. This article describes these errors andoffers strategies with which to improve outcomes for patients sufferingwith cancer pain.

Each year, 2.4 million patients in the United States develop healthcare–associated infections (HAIs), requiring treatment at an annualcost of approximately $4.5 billion. HAI is the primary cause of deathin approximately 30,000 patients and contributes to the death of 70,000annually. Oncology patients are more susceptible than other patientsto HAIs due to compromised immune systems, surgery (drains),invasive technology (catheters), and environmental factors. This paperwill review each of these risk factors and discuss preventive steps suchas a predictive index, antibiotic therapy, and infection control practices.

PHILADELPHIA-Chronic myeloid leukemia (CML) patients treated with imatinib mesylate (Gleevec) reported better quality of life (QOL) than those on interferon/cytarabine, and those who switched from interferon/cytarabine to imatinib reported improved QOL, compared with those who remained on interferon, Elizabeth A. Hahn reported. This is clinically important because about 20% of CML patients drop out of interferon treatment within 6 months due to intolerable adverse effects.

Advanced cancer is associated with symptomsthat negatively affect the quality of life of patientsand their families. One significant effect is thechange cancer evokes in the nociceptive system. Thepatient's pain threshold may change to the pointwhere stimuli not previously considered painful (eg,touching, coughing, and walking) are now perceivedas painful, and painful stimuli evoke an exaggeratedperception of pain. About 75% of patients withadvanced cancer experience moderate to severe pain.

For several decades, the nutritional deterioration ofpatients diagnosed with cancer has been recognized,and attempts have been made to prevent orreverse it. However, with all the advancements intechnology and medicine, it is somewhat surprisingto find that little has altered in the approach or themanagement of cancer patients suffering from acompromised nutritional status or altered metabolismdue to either the treatment or the disease process.

In a recent study, Wolfe and others interviewed 103parents of children who had died from cancer.[1]Approximately 80% of these children suffered anorexia,or loss of appetite. Over 35% of parents identifiedanorexia as a cause of distress for their child whena physician failed to recognize it. Wolfe and othersconcluded,"greater attention to symptomcontrol.…might ease…suffering." In adults, the syndromeof cancer anorexia/weight loss is no lesspervasive, and no less distressing. Anorexia is one ofthe most deleterious symptoms, surpassed only bypain and fatigue.[2] The majority of adults withadvanced cancer suffer from it toward the end of life.Among all cancer patients-regardless of age orcancer type-"greater attention to [the anorexia/weightloss syndrome]…might ease…suffering."

Specialty nutrition for patients with cancer is anexciting area in research. It is well known thatpatients with cancer experience many nutritionalproblems during the course of their disease-in particularanorexia and weight loss.[1,2] Specialty nutritioncan impact nutritional status directly by improvingweight and lean body mass, or indirectly by improvingcommon symptoms often associated with cancerand cancer therapies.

Paclitaxel-induced myalgias and arthralgias occur in a significantfraction of patients receiving therapy with this taxane, potentiallyimpairing physical function and quality of life. Paclitaxel-inducedmyalgias and arthralgias are related to individual doses; associationswith the cumulative dose and infusion duration are less clear. Identificationof risk factors for myalgias and arthralgias could distinguisha group of patients at greater risk, leading to minimization of myalgiasand arthralgias through the use of preventive therapies. Optimalpharmacologic treatment and possibilities for the prevention of myalgiasand arthralgias associated with paclitaxel are unclear, partially dueto the small number of patients treated with any one medication. Theeffectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs) is themost frequently documented pharmacologic intervention, although noclear choice exists for patients who fail to respond to NSAIDs. However,the increasing use of weekly paclitaxel could necessitate daily administrationof NSAIDs for myalgias and arthralgias and leave patients at riskfor adverse effects. This concern may also limit the use of corticosteroidsfor the prevention and treatment of paclitaxel-induced myalgias andarthralgias. Data from case reports suggest that gabapentin (Neurontin),glutamine, and, potentially, antihistamines (eg, fexofenadine [Allegra])could be used to treat and/or prevent myalgias and arthralgias. Giventhe safety profile of these medications, considerable enthusiasm existsfor evaluating their effectiveness in the prevention and treatment ofpaclitaxel myalgias and arthralgias, particularly in the setting ofweekly paclitaxel administration.

Approximately 30,300 people will be diagnosedwith pancreatic cancer in the UnitedStates this year. The 99% mortality rate is thehighest of any cancer, and most patients die within 1year of diagnosis.[1] There are only two drugs approvedas a first-line indication for pancreatic cancerpatients, and treatment options are very limited.These patients have poor prognoses and few options,and must make decisions in short time frames.

Nurses seeking to meet the palliative care nutritionalneeds of their patients are increasinglychallenged to work with ongoing, evolving situations,as patients live longer and longer. In the complexcase described below, which illustrates some ofthese challenges, it was useful to have in place,accessible, standardized assessment tools that allowedfor continued nutritional follow-up acrosspractice settings, targeting interventions that best fitwith the patient's goals.

Traditionally, dietitians have relied on objectiveparameters (such as anthropometric, biochemical,and immunologic measures) to assess nutritionalstatus. The usefulness of these parameters has beenquestioned in view of the many non-nutritional factorsaffecting the results. Hence, subjective assessmentof nutritional status has been used to overcomethese difficulties.

Palliative care, previously viewed by many as anend-of-life movement, is now recognized as anapproach whose principles should infuse the care ofall patients with a chronic illness throughout the fullcourse of that illness. For example, the World HealthOrganization (WHO) has redefined palliative care asfollows:

NEW YORK-The importance of pain management in the treatment of cancer is well understood now. But a corollary-that most of that pain is experienced at home-has not been as well understood, says Nessa Coyle, RN, MS, director of supportive care programs, Pain and Palliative Care Service, Memorial Sloan-Kettering Cancer Center.

BOSTON-A review of more than 1,600 patients in the Oncology Practice Pattern Study found a 50% higher risk of febrile neutropenia for elderly patients than younger patients. Most incidents occurred during the first 21 days of chemotherapy, according to a presented at the third meeting of the International Society of Geriatric Oncology (SIOG abstract P-22). Based on the analysis, Vincent Caggiano, MD, medical director, Sutter Cancer Center, Sacramento, and his colleagues urged oncologists to consider giving prophylactic colony-stimulating factors (CSFs) during the first two chemotherapy cycles-especially among older patients who are more vulnerable to the complication.

NIAGARA-ON-THE-LAKE, Ontario, Canada-Survivors of childhood cancer generally enjoy good quality of life (QOL) as adults, according to two reports presented at the 7th International Conference for Long-Term Complications of Treatment of Children and Adolescents for Cancer, hosted by Roswell Park Cancer Institute.

SAN DIEGO, California-Researchers at the Jones Group/JMI Laboratories, North Liberty, Iowa, have confirmed that Gram-positive pathogens predominate in neutropenic cancer patients with infections. The study also found that these organisms are no more likely to be resistant to available drugs in the cancer population than in the general population. They presented the results of the first year of the study in two poster presentations at the 43rd Annual Inter-science Conference on Antimicrobial Agents and Chemotherapy (ICAAC abstracts C2-290 and C2-296).

Venous thromboembolic disease is a common but likely underdiagnosedcondition in the cancer patient population. Timely and accuratediagnosis of venous thromboembolism is imperative due to the unacceptablemorbidity and mortality associated with a misdiagnosis.Because diagnosis of the condition based on clinical grounds alone isunreliable, physicians should select an appropriate objective diagnostictest to confirm or refute their clinical impressions. Compressionduplex ultrasound is the best initial imaging test for both suspectedupper- and lower-extremity deep venous thrombosis. Magnetic resonancevenography (MRV) is a valid alternative when ultrasound isinconclusive, but contrast venography remains the “gold standard.”Suspected pulmonary embolism should be initially evaluated by helical(spiral) computed tomography (CT) or ventilation/perfusion lungscintigraphy, the former being preferred in cases of obvious pulmonaryor pleural disease. Indeterminate studies should prompt performanceof contrast pulmonary angiography. Inferior vena cava thrombosis isalso best assessed by contrast venography, with MRV and CT reservedas alternative imaging modalities. Evidence to date suggests thatD-dimer assays remain unreliable in excluding venous thromboembolismin cancer patients. A newer latex agglutination D-dimer assay mayprove to be clinically useful in this setting.

Researchers at the University of Texas M. D. Anderson Cancer Center have found that cancer patients who develop heart failure as a result of chemotherapy can be treated effectively, with the condition potentially reversed, when standard medication

Plastic surgery represents a small but critical component of the comprehensive care of cancer patients. Its primary role in the treatment of cancer patients is to extend the ability of other surgeons and specialists to more