Symptoms in advanced pancreatic cancer are of importance for energy intake

Purpose Cancer cachexia and low energy intake (EI) probably contribute to weight loss in advanced pancreatic cancer (PC). However, little is known about the actual EI in this disease. Aims were to assess EI, weight loss and symptoms during the disease course and investigate associations between symptoms and EI. Methods Thirty-nine patients (21 males) with advanced PC were consecutively included and followed every 4 weeks until the end of life. A 24-h dietary recall was used to assess EI. The Edmonton Symptom Assessment System (ESAS) and the PC-specific health-related quality of life questionnaire (QLQ-PAN26) were used for symptom assessment. Results Median age was 62 years (48–88), WHO performance status 1 (0–2) and survival 5 months (1–25). Seventeen (44 %) patients had unresectable cancer, 16 (41 %) metastatic and six (15 %) recurrent disease. Upon inclusion, 37 (95 %) reported weight loss (median 4.0 kg per month). During follow-up, median weight loss per month was <1.0 kg. Forty to 65 % had EI <29 kcal/kg/day (cut-off value for weight maintenance) during the observation period but they did not lose more weight than patients with EI ≥ 29 kcal. Strong negative correlations (r range) were found between EI and pain (0.51–0.61), fatigue (0.54–0.67), oral dryness (0.61–0.64) and loss of appetite (0.53–0.71). Conclusion In this study, several symptoms influenced EI negatively. Low EI did not completely explain weight loss in this patient group, but careful monitoring and early follow-up of symptoms may be important interventions to reduce weight loss in advanced PC

Place of death : hospital-based advanced home care versus conventional care - A prospective study in palliative cancer care

The purpose of this prospective nonrandomized study was to evaluate time spent at home, place of death and differences in sociodemographic and medical characteristics of patients, with cancer in palliative stage, receiving either hospital-based advanced home care (AHC), including 24-hour service by a multidisciplinary palliative care team or conventional hospital care (CC). Recruitment to the AHC group and to the study was a two-step procedure. The patients were assigned to either hospital-based AHC or CC according to their preferences. Following this, the patients were asked to participate in the study. Patients were eligible for the study if they had malignant disease, were older than 18 years and had a survival expectancy of 2-12 months. A total of 297 patients entered the study and 280 died during the study period of two and a half years, 117 in the AHC group and 163 in the CC group. Significantly more patients died at home in the AHC group (45%) compared with the CC group (10%). Preference for and referral to hospital-based AHC were not related to sociodemographic or medical characteristics. However, death at home was associated with living together with someone. Advanced hospital-based home care targeting seriously ill cancer patients with a wish to remain at home enable a substantial number of patients to die in the place they desire

Lack of concealment may lead to selection bias in cluster randomized trials of palliative care

Comprehensive palliative care programs are often implemented on a community level, and to evaluate such interventions, randomization by cluster (community) may be the only feasible method. In trials randomizing individual subjects, the importance of proper concealment has been stressed. In cluster randomized trials, however, concealment of individual patient allocation is often impossible. The following risk of selection bias has been given little attention. In the present study, comparing palliative care to conventional care, community health care districts were defined as clusters and randomized. The patients' treatment assignment was determined by the allocation of the cluster in which they resided, and hence predictable by their address. A biased selection based on practical considerations related to patients' diagnoses and hospital departments was suspected. To explore this, cancer diagnoses were grouped according to local tradition for sharing of treatment responsibility among hospital departments. A significant difference between trial arms in distribution of these groups was revealed and strongly supported our suspicion. The finding carries an important message to future researchers: when using cluster randomization, any evidence of selection bias should be carefully checked and reported

Health-related quality of life during the last three months

Goals of work The aim of the study was to explore the development of functioning impairments and symptom occurrence during the last months of life of advanced cancer patients. Materials and methods Self-reported data from 116 patients who all completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire—Core 30 (EORTC QLQ-C30) at 3, 2 and 1 month before death were analysed. Main results All functioning aspects deteriorated. For physical, cognitive and social function, the most marked changes occurred between 2 and 1 month before death. The proportion reporting serious difficulties with self-care activities increased from 14% to 43%. The most seriously affected activity could not be distinguished from the EORTC QLQ-C30 scores. Levels of fatigue, dyspnoea and appetite loss increased significantly. More than 50% of the patients had severe pain at all assessments, and only a minor number (8%) reported any improvement. Conclusions The findings have implications for the planning of care and indicate that further research is required to improve assessment, treatment and follow-up procedures. Adequate pain treatment seems still to be a challenge. Anorexia, fatigue as well as dyspnoea are all symptoms that need further focus

Quality of life in palliative cancer care : results from a cluster randomized trial

PURPOSE: To assess the impact of comprehensive palliative care on patients' quality of life. The intervention was based on cooperation between a palliative medicine unit and the community service and was compared with conventional care. PATIENTS AND METHODS: A cluster randomized trial was carried out, with community health care districts defined as the clusters. Patients from these districts who had malignant disease and survival expectancy between 2 to 9 months were entered onto the trial. The main quality-of-life end points were physical and emotional functioning, pain, and psychologic distress assessed monthly by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) questionnaire and Impact of Event scale (IES). In total, 235 intervention patients and 199 controls were included. RESULTS: During the initial 4 months of follow-up, the compliance was good (72%) and comparable among treatment groups. No significant differences on any of the quality-of-life scores were found. At later assessments and for scores that were made within 3 months before death, there was also no consistent tendency in favor of any treatment group on the main outcomes or other EORTC QLQ-C30 scales/items. CONCLUSION: A general program of palliative care may be important to ensure flexibility and to meet the needs of terminally ill patients. However, to achieve improvements on a group level of the various dimensions of quality of life, specific interventions directed toward specific symptoms or problems may have to be defined, evaluated, and included in the program

Characteristics and Quality of Life of Patients Who Choose Home Care at the End of Life.

Cancer patients with advanced disease and short-survival expectancy were given hospital-based advanced home care (AHC) or conventional care (CC), according to their preference. The two groups were compared at baseline to investigate whether there were differences between the AHC and the CC patients that may help explain their choice of care. The patients were consecutively recruited over 2(1/2) years. Sociodemographic and medical data, and the health-related quality of life (HRQL) of the two groups were compared. HRQL was assessed using a self-reporting questionnaire, including the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), the Impact of Event Scale (IES), five questions about social support, and two items concerning general well-being. The AHC group showed significantly poorer functioning on all the EORTC QLQ-C30 scales and an overall higher symptom burden than the CC patients. Fewer of the AHC patients were receiving cancer treatment. The AHC patients had lived longer with their cancer diagnosis, had a significantly shorter survival after study enrollment, and a significantly poorer performance status. The major differences between the two groups seemed to be related to being at different stages in their disease. The results indicate that patients are reluctant to accept home care until absolutely necessary due to severity of functioning impairments and symptom burden. These findings should be taken into consideration in planning palliative care services

Use of item response theory to develop a shortened version of the EORTC QLQ-C30 emotional functioning scale

BACKGROUND: As part of a larger study whose objective is to develop an abbreviated version of the EORTC QLQ-C30 suitable for research in palliative care, analyses were conducted to determine the feasibility of generating a shorter version of the 4-item emotional functioning (EF) scale that could be scored in the original metric. METHODS: We used data from 24 European cancer studies conducted in 10 different languages (n = 8242). Item selection was based on analyses by item response theory (IRT). Based on the IRT results, a simple scoring algorithm was developed to predict the original 4-item EF sum scale score from a reduced number of items. RESULTS: Both a 3-item and a 2-item version (item 21 'Did you feel tense?' and item 24 'Did you feel depressed?') predicted the total score with excellent agreement and very little bias. In group comparisons, the 2-item scale led to the same conclusions as those based on the original 4-item scale with little or no loss of measurement efficiency. CONCLUSION: Although these results are promising, confirmatory studies are needed based on independent samples. If such additional studies yield comparable results, incorporation of the 2-item EF scale in an abbreviated version of the QLQ-C30 for use in palliative care research settings would be justified. The analyses reported here demonstrate the usefulness of the IRT-based methodology for shortening questionnaire scales