Outpatient Palliative Radiotherapy Clinic Research Articles

Evolution of antiemetic studies for radiation-induced nausea and vomiting within an outpatient palliative radiotherapy clinic.

Radiation-induced nausea and vomiting (RINV) is a common side effect of radiotherapy and can affect up to 50-80% of patients, potentially causing detrimental effects to physical health, clinical efficacy, and patient quality of life. Antiemetic drugs act on receptors involved in the emesis pathway to block the uptake of neurotransmitters and inhibit stimulation of vomiting centers in the brain to prevent and treat RINV. The most commonly prescribed antiemetics for RINV are 5-hydroxytryptamine receptor antagonists (5-HT3 RA). Guidelines describing the optimal management of RINV are produced by the Multinational Association for Supportive Care in Cancer, the European Society of Medical Oncology, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. This review will present findings from research on antiemetic management for RINV conducted at our center. A selective review of research conducted in a palliative outpatient radiotherapy clinic relating to antiemetic management for RINV was performed. Several studies investigating the efficacy of different routes of administration, new antiemetic drug types, and novel combinations of antiemetics have been tested at our clinic to elucidate which approach provides the best response. These include studies on the use of ondansetron rapidly dissolving film, palonosetron, and the addition of a neurokinin-1 receptor antagonist to traditional 5-HT3 RA regimens. These studies provide a framework for future research and could potentially inform changes to future guidelines to include the use of these novel regimens and techniques.

Inadequate pain management in cancer patients attending an outpatient palliative radiotherapy clinic.

The aim of this study is to assess the prevalence of undertreated cancer pain in an outpatient palliative radiotherapy clinic using the Pain Management Index (PMI). A retrospective analysis of a prospective database to assess pain management was done on patients with cancer pain enrolled from January 2009 to March 2015 using recorded pain intensity (0-10) and baseline pain medications. The pain intensities were categorized into no pain (0), mild pain (1), moderate pain (2), and severe pain (3), and an analgesic score was assigned to the most potent pain medication the patient was taking during the time of data collection. "0" was assigned to no analgesics, "1" to non-opioids, "2" to weak opioids, and "3" for strong opioids based on the WHO guidelines. The PMI was calculated for each patient by subtracting the pain score from the analgesic score. A negative value indicated undertreatment, and a value of 0 or greater corresponded to adequate pain management. Three hundred fifty-four patients were included in the study. The incidence of inadequate pain management was 33.3 %, similar to that reported in our previous studies. Additionally, 106 patients were taking strong opioids and reporting severe pain despite being the PMI reporting adequately treated. The rate of undertreatment is similar to that reported in past studies; however, the rates have shown a slight increase in our palliative radiotherapy clinic since the last assessment. Inadequate management of cancer pain continues to be a problem.

Projected referral to other healthcare services in an outpatient palliative radiotherapy clinic

Aims: To investigate the projected referral to other healthcare services in an outpatient palliative radiotherapy clinic. Methods: Patients referred for palliative radiotherapy from 1999 to 2002 inclusive and 2007 to 2009 inclusive were evaluated. The Edmonton Symptom Assessment System, which assesses nine symptoms, was completed by 1439 patients prior to radiotherapy consultation. The numeric scale was converted into a categorical scale of none, mild, moderate and severe. Patients with moderate-to-severe symptoms were identified as potential referrals to other healthcare services. Results: Tiredness (66%), poor sense of wellbeing (64%), pain (57%) and poor appetite (52%) had the most patients scoring in the moderate-to-severe range. Moderate-to-severe anxiety and depression occurred in 39 and 30% of patients, respectively, reflecting the percentage of projected referrals for symptom and/or psychosocial management. Conclusion: Cancer symptoms are complex, and a multidisciplinary and collaborative approach should be taken to provide timely management and maintain patients’ quality of life.

What QLQ-C15-PAL Symptoms Matter Most for Overall Quality of Life in Patients With Advanced Cancer?

BackgroundFew studies have evaluated the QLQ-C15-PAL health-related quality of life (QOL) questionnaire, an abbreviated version of the QLQ-C30 questionnaire that was designed specifically for patients with advanced cancer. The present study assessed whether certain symptoms or functional domains from the QLQ-C15-PAL predicted overall QOL when rated prior to palliative radiation treatment (RT).Patients and MethodsPatients attending an outpatient palliative radiotherapy clinic completed QLQ-C15-PAL questionnaires prior to palliative RT for bone, brain or lung disease. Pearson correlations were computed between the QLQ-C15-PAL functional/symptom scores and overall QOL scores. Multiple linear regressions were used to evaluate the relative importance of functional/symptom scales in association with overall QOL.ResultsData from 369 patients were analyzed. The QLQ-C15-PAL domains of physical and emotional functioning, pain, and appetite loss were significant predictors of overall QOL in these patients with advanced cancer. Appetite loss was the only significant independent predictor of overall QOL in the subgroup of patients with advanced lung cancer (n = 29). Both appetite loss and emotional functioning were independently predictive of overall QOL in patients with bone metastases (n = 190). In patients with brain metastases (n = 150), independent predictors of overall QOL included physical and emotional functioning as well as fatigue.ConclusionThe QLQ-C15-PAL domains of physical and emotional functioning, pain and appetite loss were significant predictors of overall QOL in this cohort of patients with advanced cancer. Different functional and symptom scales predicted overall QOL in patients with bone metastases, brain metastases or advanced lung cancer.

Fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic as screened by the Edmonton Symptom Assessment System

Advanced cancer patients present with a variety of physical and psychological symptoms. Fatigue is one such symptom which reduces overall quality of life and is difficult to manage. The purpose of this study was to report the presence, severity, and correlating factors of fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic. Patients referred to the Rapid Response Radiotherapy Program between January 1999 and October 2009 completed the Edmonton Symptom Assessment System (ESAS) prior to consultation. Demographic information including age, Karnofsky Performance Status (KPS), gender, and primary cancer sites were collected. Ordinal logistic regression analysis was conducted to determine relationships between demographic information, other ESAS items, and levels of fatigue. Multivariate ordinal logistic regression analysis was used to determine the most significant predictors of fatigue. A p value of <0.05 was considered statistically significant. A total of 1,397 patients completed the ESAS prior to consultation. Median age was 68 years (range, 21-95), median KPS was 60 (range, 10-100), and slightly more males completed the ESAS (53.0%). Common primary cancers were of the lung (35.8%), breast (20.7%), and prostate (17.7%). Only 179 (12.8%) patients reported no fatigue; the majority of patients reported moderate (31.8%) or severe (34.4%) fatigue. A low KPS (p < 0.0001), being female (p = 0.0056), or being referred for bone metastases (p = 0.0185) significantly correlated with higher levels of fatigue. Patients with a genitourinary primary cancer (p = 0.0078) and/or referred for malignant spinal cord compression (p = 0.0004) reported less fatigue. All other ESAS items were significantly related to fatigue. The most significant predictors of fatigue were pain (p < 0.0001, odds ratio (OR) = 1.07), nausea (p = 0.0010, OR = 1.10), depression (p < 0.0001, OR = 1.10), drowsiness (p < 0.0001, OR = 1.33), dyspnea (p = 0.0003, OR = 1.08), and overall well-being (p < 0.0001, OR = 1.19). Moderate fatigue was reported in over 66% of our advanced cancer patients prior to radiotherapy. Since radiotherapy inherently causes fatigue, proactive and multidisciplinary management is required for these patients. Similar rates of fatigue severity, in lengthier, fatigue-specific tools, suggest that the ESAS may be a good tool for screening the advanced cancer population.

EORTC QLQ-C15-PAL quality of life scores in patients with advanced cancer referred for palliative radiotherapy

Symptom control and improved quality of life (QOL) are primary goals of treatment in palliative oncology. The present study assessed and compared patient demographics, baseline Karnofsky Performance Status (KPS) and QOL using the QLQ-C15-PAL questionnaire prior to palliative radiotherapy (RT) for bone, brain, or lung disease. Few studies have used this questionnaire, an abbreviated version that was developed by the European Organization for Research and Treatment of Cancer specifically for patients with advanced cancer to decrease the burden of completing the longer, more time-consuming QLQ-C30. Patients referred to an outpatient palliative RT clinic completed QLQ-C15-PAL questionnaires prior to palliative RT for bone, brain, or lung cancer sites. The associations between baseline QLQ-C15-PAL functional/symptom scales, patient demographics, and clinical variables including KPS were explored. When data from all 369 patients were analyzed, higher KPS scores correlated significantly with better overall QOL and higher physical and emotional functioning. The QLQ-C15-PAL provided more detailed information regarding how symptom burden varied depending on disease site. Patients with bone metastases had worse QLQ-C15-PAL scores for pain, while those with brain and lung disease had worse scores for fatigue. Other health-related QOL scores measured by the QLQ-C15-PAL varied as a function of age and gender. As the QLQ-C15-PAL provides detailed and often critical information regarding symptom burden, it may eventually be recognized as a universal core questionnaire to assess QOL in this patient population with advanced cancer while relieving the survey burden.

Optimizing pain relief in a specialized outpatient palliative radiotherapy clinic: Contributions of a clinical pharmacist

Bone metastases are the most common cause of cancer pain, with palliative radiotherapy (RT) the mainstay of treatment. However, relief from RT may be delayed, incomplete, or short-lived and therefore optimized pharmacologic therapy is essential. Our objective was to describe the contribution of the clinical pharmacist (CP) to an outpatient palliative RT clinic. The Edmonton Symptom Assessment System, an 11-point scale for measuring nine symptoms, and other validated screening tools were administered, and a medication history performed by the CP. Baseline CP assessment also included opioid toxicity, need for supportive medications, and drug interactions. Anonymized clinical information was collected prospectively and descriptive statistics were compiled including themes of counselling performed by the CP. The CP reviewed 114 patients over 140 clinic visits (01/2007-12/2008). Median age was 68.3 years, 68.4% were male and 36.8% had prostate cancer. All symptoms improved or stabilized in ≥ 80% by 4 weeks. Median pain score was 6/10 (SD 2.6) at baseline, and 2.1/10 (SD 2.4) by week 4. Average morphine equivalent daily dose was 76.8 mg at baseline and 44.5 mg at week 4. CP assessment included screening for opioid toxicity (87.9%), recommending a change in analgesic (28.9%), and liaison with the community pharmacy (17.1%). Medication counselling took place in 84.3% of visits, on bowel routine (85.6% of the time), opioids (82.2%), and hydration (40.7%). The CP plays a key role in holistic patient assessment and optimization of pharmacologic therapy, contributing to improved symptom control of patients receiving palliative RT.

Comparing baseline symptom severity and demographics over two time periods in an outpatient palliative radiotherapy clinic

The primary objective of this study was to compare the symptom severity in two different patient populations assessed in an outpatient palliative radiotherapy clinic over two time periods spanning 10 years. The secondary objective was to assess any changes in the baseline demographics of these patients. Data were collected from 1999 to 2009. Upon initial presentation to the clinic, the Edmonton Symptom Assessment Scale (ESAS) was administered to patients to capture symptom severity. This validated assessment tool asks patients to score their level of pain, tiredness, nausea, depression, anxiety, drowsiness, loss of appetite, well-being, and dyspnea on an 11-point Likert scale. Differences between the two patient groups were assessed using chi-squared analysis and Wilcoxon rank-sum tests. A p value of <0.05 was considered significant. A total of 1,439 patients completed the ESAS from 1999 to 2009. Patients were divided into two time periods 1999-2002 (n = 689) and 2006-2009 (n = 750). Pain, depression, nausea, fatigue, anxiety, drowsiness, and dyspnea were significantly better in 2006-2009 (p < 0.0001). Loss of appetite was not statistically different between the two time periods (p = 0.236). Significantly more patients with genitourinary cancers (p = 0.03) or a referral for a mass (p < 0.0001) were seen in 2006-2009. More patients with breast cancer (p = 0.04) and bone pain (p = 0.0002) were seen in 1999-2002. The median age was significantly higher (70 years vs. 68 years, p = 0.03) for patients seen in 2006-2009. No significant differences were seen in performance status or gender between the two groups. There have been statistically significant lower scores in the severity of the majority of symptoms as scored by the latter patient cohort; however, whether this difference in magnitude is clinically significant is debatable. The reason for referral and demographics in patients sent for palliative radiotherapy has changed over a 10-year period. This may be a reflection of the changes in systemic therapies and improvements in supportive care for patients with advanced cancer.

Correlation of Computed Tomography Imaging Features With Pain Response in Patients With Spine Metastases After Radiation Therapy

To correlate computed tomography (CT) imaging features of spinal metastases with pain relief after radiotherapy (RT). Thirty-three patients receiving computed tomography (CT)-simulated RT for spinal metastases in an outpatient palliative RT clinic from January 2007 to October 2008 were retrospectively reviewed. Forty spinal metastases were evaluated. Pain response was rated using the International Bone Metastases Consensus Working Party endpoints. Three musculoskeletal radiologists and two orthopaedic surgeons evaluated CT features, including osseous and soft tissue tumor extent, presence of a pathologic fracture, severity of vertebral height loss, and presence of kyphosis. The mean patient age was 69 years; 24 were men and 9 were women. The mean worst pain score was 7/10, and the mean total daily oral morphine equivalent was 77.3 mg. Treatment doses included 8 Gy in one fraction (22/33), 20 Gy in five fractions (10/33), and 20 Gy in eight fractions (1/33). The CT imaging appearance of spinal metastases included vertebral body involvement (40/40), pedicle involvement (23/40), and lamina involvement (18/40). Soft tissue component (10/40) and nerve root compression (9/40) were less common. Pathologic fractures existed in 11/40 lesions, with resultant vertebral body height loss in 10/40 and kyphosis in 2/40 lesions. At months 1, 2, and 3 after RT, 18%, 69%, and 70% of patients experienced pain relief. Pain response was observed with various CT imaging features. Pain response after RT did not differ in patients with and without pathologic fracture, kyphosis, or any other CT features related to extent of tumor involvement. All patients with painful spinal metastases may benefit from palliative RT.

Retrospective Assessment of Cancer Pain Management in an Outpatient Palliative Radiotherapy Clinic Using the Pain Management Index

The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization's "analgesic ladder" approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain. The aim of this study was to assess prevalence of inadequate pain management in an outpatient palliative radiotherapy clinic using the PMI. All patients with bone metastases referred for palliative radiotherapy from 1999 to 2006 were retrospectively analyzed for patient-rated pain scores (0-10 scale) and analgesic consumption. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients were prescribed no pain medication, nonopioids, "weak" opioids, and "strong" opioids, respectively. The PMI score was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain management by the prescriber. Descriptive statistics, Pearson's r correlation, and univariate and multivariate logistic regression analysis were used to determine the relationship of PMI over time, and the relationship with predictive factors. One thousand patients were included from January 1999 to December 2006. A negative PMI was calculated for 25.8% of patients at initial consultation. Prevalence of negative PMI significantly increased over years (P<0.0001). Higher Karnofsky Performance Status (P<0.0001) and breast primary cancer site (P<0.0001) were significantly associated with negative PMI after adjusting for year variable. Despite publication of numerous cancer pain management guidelines, undermedication appears to be a persistent problem for patients with painful bone metastases referred for radiotherapy.

Multidisciplinary Team Contributions Within a Dedicated Outpatient Palliative Radiotherapy Clinic: A Prospective Descriptive Study

Patients with bone metastases may experience pain, fatigue, and decreased mobility. Multiple medications for analgesia are often required, each with attendant side effects. Although palliative-intent radiotherapy (RT) is effective in decreasing pain, additional supportive care interventions may be overlooked. Our objective was to describe the feasibility of multidisciplinary assessment of patients with symptomatic bone metastases attending a dedicated outpatient palliative RT clinic. Consecutive patients referred for RT for painful bone metastases were screened for symptoms and needs relevant to their medications, nutritional intake, activities of daily living, and psychosocial and spiritual concerns from January 1 to December 31, 2007. Consultations by appropriate team members and resulting recommendations were collected prospectively. Patients who received RT were contacted by telephone 4 weeks later to assess symptom outcomes. A total of 106 clinic visits by 82 individual patients occurred. As determined by screening form responses, the clinical Pharmacist, Occupational Therapist, Registered Dietician and Social Worker were consulted to provide assessments and recommendations within the time constraints presented by 1-day palliative RT delivery. In addition to pain relief, significant improvements in tiredness, depression, anxiety, drowsiness and overall well-being were reported at 4 weeks. Systematic screening of this population revealed previously unmet needs, addressed in the form of custom verbal and written recommendations. Multidisciplinary assessment is associated with a high number of recommendations and decreased symptom distress. Our findings lend strong support to the routine assessment by multiple supportive care professionals for patients with advanced cancer being considered for palliative RT.

Validation of a Predictive Model for Survival in Metastatic Cancer Patients Attending an Outpatient Palliative Radiotherapy Clinic

To validate a predictive model for survival of patients attending a palliative radiotherapy clinic. We described previously a model that had good predictive value for survival of patients referred during 1999 (1). The six prognostic factors (primary cancer site, site of metastases, Karnofsky performance score, and the fatigue, appetite and shortness-of-breath items from the Edmonton Symptom Assessment Scale) identified in this training set were extracted from the prospective database for the year 2000. We generated a partial score whereby each prognostic factor was assigned a value proportional to its prognostic weight. The sum of the partial scores for each patient was used to construct a survival prediction score (SPS). Patients were also grouped according to the number of these risk factors (NRF) that they possessed. The probability of survival at 3, 6, and 12 months was generated. The models were evaluated for their ability to predict survival in this validation set with appropriate statistical tests. The median survival and survival probabilities of the training and validation sets were similar when separated into three groups using both SPS and NRF methods. There was no statistical difference in the performance of the SPS and NRF methods in survival prediction. Both the SPS and NRF models for predicting survival in patients referred for palliative radiotherapy have been validated. The NRF model is preferred because it is simpler and avoids the need to remember the weightings among the prognostic factors.

Has Pain Management in Cancer Patients with Bone Metastases Improved? A Seven-Year Review at An Outpatient Palliative Radiotherapy Clinic

The primary objective of this study was to determine the prevalence of underdosage of analgesics for pain associated with bone metastases in outpatients referred to the Rapid Response Radiotherapy Program at the Odette Cancer Centre from 1999 to 2006. A prospective database containing data for all patients with bone metastases who were referred to the Rapid Response Radiotherapy Program for palliative radiotherapy from 1999 to 2006 was analyzed. The database included patient demographic information, including age at referral for radiation to the bone, gender, primary cancer site, and Karnofsky Performance Status; information on treatment-related factors, such as worst pain ratings and analgesic consumption in the past 24 hours (recorded as oral morphine equivalent doses); pain intensity ratings (none [rating = 0], mild [rating = 1–4], moderate [rating = 5–6] or severe [rating = 7–10]; and analgesic consumption (rated as none, nonopioids, weak opioids [e.g., codeine] and strong opioids [e.g., morphine and hydromorphone]). Patients who experienced moderate or severe pain and were prescribed no pain medication, nonopioids, or weak opioids were considered to be undermedicated. Between January 1999 and December 2006, 1,038 patients were included in the study database. Approximately 56% of patients were male and 44% were female. The median age was 68 years (range 28–95) and the median Karnofsky Performance Status was 70 (range 10–100). The percentages of undermedicated patients were 40% in 1999, 34% in 2000, 29% in 2001, 37% in 2003, 39% in 2004, 36% in 2005, and 48% in 2006. No appreciable decline was noted in the proportion of patients with moderate-to-severe pain who received no pain medication, nonopioids, or weak opioids during the study period. Despite the publication of pain management guidelines and the dissemination of data regarding the proportion of patients with bone metastases who are being prescribed inadequate analgesics, our findings suggest that a significant proportion of patients continue to be undermedicated.

Symptom Clusters in Cancer Patients with Brain Metastases

Aim To explore the presence of symptom clusters in patients with brain metastases. Materials and methods Patients with brain metastases referred to an outpatient palliative radiotherapy clinic were asked to rate their symptom distress using the Edmonton Symptom Assessment Scale (ESAS). Baseline demographic data were obtained. To determine interrelationships between symptoms, a principal component analysis with ‘varimax rotation’ was carried out on the nine ESAS items. Follow-up was carried out by telephone 1, 2, 4, 8 and 12 weeks after radiation. Results Between January 1999 and January 2002, 170 patients with brain metastases provided complete baseline data on the ESAS. The most common primary cancer sites were lung, breast and gastrointestinal. Fatigue was the highest scored symptom, followed by a poor sense of well-being, anxiety, drowsiness and poor appetite. The four most prevalent symptoms were fatigue (91.7%), a poor sense of well-being (88.1%), drowsiness (82.2%) and anxiety (82.1%). Three symptom clusters were found at baseline. Cluster 1 included fatigue, drowsiness, shortness of breath and pain. Cluster 2 included anxiety and depression. Cluster 3 included poor appetite, nausea and a poor sense of well-being. Fatigue, nausea, drowsiness and poor appetite showed an overall increase in symptom severity over time; whereas fatigue, drowsiness and poor appetite were experienced to some extent by a greater proportion of patients at week 12 compared with baseline. Symptom clusters emerged in all weeks of follow-up, but consisted of different symptoms in each week. Conclusion Symptom clusters seemed to exist in patients with brain metastases before and after whole brain radiotherapy. However, different symptoms clustered at various time points. The effectiveness of whole brain radiotherapy in providing palliative relief to patients with brain metastases needs to be explored with regards to symptom clusters.

Mild, Moderate, or Severe Pain Categorized by Patients with Cancer with Bone Metastases

To examine how patients categorize their pain with the two commonly employed scales. Patients with bone metastases referred to an outpatient palliative radiotherapy clinic were asked to rate their current pain on a numerical scale of 0-10 (0 = no pain, 10 = worst pain possible) and a categorized scale: none, mild, moderate and severe. Two hundred and seventeen patients were enrolled in the study. The median age was 66 years and median Karnofsky Performance Score was 70. The most common primary cancer sites were lung, prostate and breast. Based on patient-evaluated symptoms, 60% of patients who categorized pain as mild assigned it a 3 (24%) or 4 (36%), 63% who categorized pain as moderate assigned it a 5 (16.9%), 6 (19.1%) or 7 (27%) and 80% who categorized pain as severe assigned it an 8 (28.2%), 9 (12.6%) or 10 (39.8%). Our patients scored pain as mild if pain was < or =4, moderate if pain was 5-7 and severe if pain was > or =8.

Successful validation of a survival prediction model in patients with metastases in the spinal column

The Dutch Bone Metastases Study Group developed a survival prediction model in patients with symptomatic spinal bone metastases to guide the treating physician. The objective of this study was to validate the Dutch model and compare with our previously developed survival model at the Rapid Response Radiotherapy Program (RRRP model). The following prognostic factors were extracted from a prospective database in an outpatient palliative radiotherapy clinic: Karnofsky Performance Scores (KPS), primary cancer site, and visceral involvement for the Dutch model; primary cancer site, site of metastases, KPS, fatigue, appetite, and shortness of breath scores in the Edmonton Symptom Assessment Scale for the RRRP model. Patients were assigned scores according to each model. The survival probabilities were generated and calibration was performed for each model. A total of 231 patients with spinal bone metastases from 1999 and 2002 were included in the analysis. The survival probabilities were similar to those in the original models. The calibration comparing actual survival with predicted survival from the Dutch and RRRP models gave R2 values of 0.90 and 0.86, respectively. The two models were successfully validated. The Dutch model using three clinical prognostic factors was easier to administer.

Symptom Distress in Patients Attending an Outpatient Palliative Radiotherapy Clinic

Patients with advanced cancer are often polysymptomatic. Different symptoms occur with varying frequency, intensity, and impact. Despite the high prevalence of symptoms in this population, reports of symptomatology in palliative outpatients have been limited. We report the symptom distress in metastatic cancer patients attending an outpatient palliative radiotherapy clinic. Patients referred for palliative radiotherapy for symptom control to the Rapid Response Radiotherapy Program (RRRP) were asked to rate symptom distress using the Edmonton Symptom Assessment Scale (ESAS) at the time of initial consultation. Patient demographics, cancer history, disease status, and analgesic consumption during the previous 24 hours were recorded. Between January 1999 and January 2002, 1,296 patients were seen at the RRRP and consented to participate in the study. Mean symptom distress rates ranged from 1.41 to 5.04. Fatigue, poor sense of well-being, pain, and poor appetite were the highest scored symptoms consecutively. Patients with poorer performance status (KPS ≤ 60) had significantly higher symptom distress scores for all nine symptoms (P < 0.001). We conclude that the symptoms of metastatic cancer, including pain, fatigue, depression, anxiety, drowsiness, poor appetite, and sense of well-being, are common among patients attending outpatient palliative clinics. Symptom assessment tools, such as the ESAS, allow for the identification of symptoms and their severity. The appropriate regimen for management of pain and symptoms in metastatic cancer patients can then be planned.

A predictive model for survival in metastatic cancer patients attending an outpatient palliative radiotherapy clinic

Purpose : To develop a predictive model for survival from the time of presentation in an outpatient palliative radiotherapy clinic. Methods and Materials : Sixteen factors were analyzed prospectively in 395 patients seen in a dedicated palliative radiotherapy clinic in a large tertiary cancer center using Cox’s proportional hazards regression model. Results : Six prognostic factors had a statistically significant impact on survival, as follows: primary cancer site, site of metastases, Karnofsky performance score (KPS), and fatigue, appetite, and shortness of breath scores from the modified Edmonton Symptom Assessment Scale. Risk group stratification was performed ( 1) by assigning weights to the prognostic factors based on their levels of significance, and ( 2) by the number of risk factors present. The weighting method provided a Survival Prediction Score (SPS), ranging from 0 to 32. The survival probability at 3, 6, and 12 months was 83%, 70%, and 51%, respectively, for patients with SPS ≤13 ( n = 133); 67%, 41%, and 20% for patients with SPS 14–19 ( n = 129); and 36%, 18%, and 4% for patients with SPS ≥20 ( n = 133) ( p < 0.0001). Corresponding survival probabilities based on number of risk factors were as follows: 85%, 72%, and 52% (≤3 risk factors)( n = 98); 68%, 47%, and 24% (4 risk factors)( n = 117); and 46%, 24%, and 11% (≥5 factors)( n = 180)( p < 0.0001). Conclusion : Clinical prognostic factors can be used to predict prognosis among patients attending a palliative radiotherapy clinic. If validated in an independent series of patients, the model can be used to guide clinical decisions, plan supportive services, and allocate resource use.

Use of the CAGE Questionnaire for Screening Problem Drinking in an Out-Patient Palliative Radiotherapy Clinic

To determine the positive rate of the CAGE questionnaire in an outpatient palliative radiotherapy clinic and to examine the association between problem drinking, pain control, and analgesic consumption, patients referred for palliative radiotherapy were screened with the CAGE questionnaire and asked to rate their symptom distress using the modified Edmonton Symptom Assessment System (ESAS). The latter instrument uses 11-point numeric scales (0 = best, 10 = worst). Their daily analgesic consumption in oral morphine equivalent was recorded. A total of 128 patients participated in the study. Only 9 patients answered one of the four CAGE questions affirmatively (positive group). All the rest answered negatively (negative group). The mean pain intensity at index site/overall pain was 4.97 ± 3.31/3.27 ± 2.76 for the negative group and 6.29 ± 4.42/2.89 ± 3.37 for the positive group. The mean total daily oral morphine equivalent for the negative and positive group were 112.35 ± 233.58 mg and 36.82 ± 58.85 mg, respectively. There was no significant difference found in other symptoms in the modified ESAS between these two groups. The positive rate of the CAGE in patients with advanced cancer attending an out-patient radiotherapy clinic was only 7%, and analyses were limited by the small sample size of those with a positive CAGE. Whether our observed low positive rate of CAGE represents the true prevalence of problem drinking or the CAGE questionnaire is an insensitive tool for screening problem drinking in an outpatient palliative radiotherapy clinic requires further investigation. We did not find a statistically significant worse pain intensity nor higher analgesic consumption in patients who screened positive for CAGE questionnaire.