Defining refractory pain in cancer for clinicians and researchers

Managing pain in people with cancer remains a challenge, especially in those referred to as having refractory pain. But what is refractory or intractable pain? Until there is a standard definition there is the risk that: a) clinically, new medications are continuously added, each with diminishing returns in reducing pain, and each with an increasing likelihood of toxicity as the only noticeable change; and b) in research, there will be differing baselines for the operational definition of refractory, making it difficult to adopt the findings into practice, or to compare clinical trials in any systematic way

Team Networking in Palliative Care

“If you want to travel quickly, go alone. But if you want to travel far, you must go together”. African proverb. The delivery of palliative care is often complex and always involves a group of people, the team, gathered around the patient and those who are close to them. Effective communication and functional responsive systems of care are essential if palliative care is to be delivered in a timely and competent way. Creating and fostering an effective team is one of the greatest challenges for providers of palliative care. Teams are organic and can be life giving or life sapping for their members

Placebo and nocebo effects in randomized controlled trials: the implications for research and practice

Placebo and nocebo effects are known to contribute significantly to the response to symptom control, including analgesia. Clinical trial methodologies using placebo controls are designed to identify the magnitude of these effects in the research context. An adequately powered, randomized, double-blind, placebo-controlled trial of ketamine in cancer pain has recently been reported, which demonstrated no net clinical benefit for ketamine over and above that of placebo. Rates of placebo and nocebo responses were high. The setting of a clinical trial provides an opportunity to quantify the nonpharmacologic aspects of patient responses to analgesia, raising important clinical and ethical issues for practice. The findings of the ketamine study are analyzed in the context of a methodological discussion of placebo and nocebo effects, what is known about the biological and psychological bases for each of these, and their implications for a clinical trial design in the palliative care setting. Along with reviewing the use of ketamine after this negative trial, clinicians need to remain aware of the strength and significance of both placebo and nocebo responses in their own practices and the biopsychosocial complexity of why and how patients actually respond to pain management strategies. The results of this study strongly reinforce the importance of the therapeutic relationship and the context of care

Multidisciplinary Prognostication Using the Palliative Prognostic Score in an Australian Cancer Center

Context Accurate prognostication is important in oncology and palliative care. A multidisciplinary approach to prognostication provides a novel approach, but its accuracy and application is poorly researched. In this study, we describe and analyze our experience of multidisciplinary prognostication in palliative care patients with cancer. Objectives To assess our accuracy of prognostication using multidisciplinary team prediction of survival (MTPS) alone and within the Palliative Prognostic (PaP) Score. Methods This retrospective study included all new patients referred to a palliative care consultation service in a tertiary cancer center between January 2010 and December 2011. Initial assessment data for 421 inpatients and 223 outpatients were analyzed according to inpatient and outpatient groups to evaluate the accuracy of prognostication using MTPS alone and within the PaP score (MTPS-PaP) and their correlation with overall survival. Results Inpatients with MTPS-PaP group A, B, and C had a median survival of 10.9, 3.4, and 0.7 weeks, respectively, and a 30-day survival probability of 81%, 40%, and 10%, respectively. Outpatients with MTPS-PaP group A and B had a median survival of 17.3 and 5.1 weeks, respectively, and a 30-day survival probability of 94% and 50%, respectively. MTPS overestimated survival by a factor of 1.5 for inpatients and 1.2 for outpatients. The MTPS-PaP score correlated better than MTPS alone with overall survival. Conclusion This study suggests that a multidisciplinary team approach to prognostication within routine clinical practice is possible and may substitute for single clinician prediction of survival within the PaP score without detracting from its accuracy. Multidisciplinary team prognostication can assist treating teams to recognize and articulate prognosis, facilitate treatment decisions, and plan end-of-life care appropriately. PaP was less useful in the outpatient setting, given the longer survival interval of the outpatient palliative care patient group

Reply to K. Jackson et al and W. Leppert

We thank Jackson et al and Leppert for the opportunity to respond to their concerns regarding our article. Our main point of contention is the belief, on the part of Jackson et al, that unblinded, nonrandomized, prospective audits can give a true indication of the efficacy or toxicity of a drug. Open-label studies do not meet the specific scientific definition of control. The gross underestimation and overestimation of effects in uncontrolled trials, especially studies that involve small numbers of participants, have been well documented. This issue is particularly emphasized by the high placebo response rate (27%) demonstrated in our blinded, randomized controlled trial

Establishment and preliminary outcomes of a palliative care research network

Objective: The difficulties in conducting palliative care research have been widely acknowledged. In order to generate the evidence needed to underpin palliative care provision, collaborative research is considered essential. Prior to formalizing the development of a research network for the state of Victoria, Australia, a preliminary study was undertaken to ascertain interest and recommendations for the design of such a collaboration. Method:: Three data-collection strategies were used: a cross-sectional questionnaire, interviews, and workshops. The questionnaire was completed by multidisciplinary palliative care specialists from across the state (n = 61); interviews were conducted with senior clinicians and academics (n = 21) followed by two stakeholder workshops (n = 29). The questionnaire was constructed specifically for this study, measuring involvement of and perceptions of palliative care research. Results:: Both the interview and the questionnaire data demonstrated strong support for a palliative care research network and aided in establishing a research agenda. The stakeholder workshops assisted with strategies for the formation of the Palliative Care Research Network Victoria (PCRNV) and guided the development of the mission and strategic plan. Significance of results:: The research and efforts to date to establish the PCRNV are encouraging and provide optimism for the evolution of palliative care research in Australia. The international implications are highlighted

Ketamine in the management of cancer pain: reply to K. Jackson et al and W. Leppert

We thank Jackson et al and Leppert for the opportunity to respond to their concerns regarding our article. Our main point of contention is the belief, on the part of Jackson et al, that unblinded, nonrandomized, prospective audits can give a true indication of the efficacy or toxicity of a drug. Open-label studies do not meet the specific scientific definition of control. The gross underestimation and overestimation of effects in uncontrolled trials, especially studies that involve small numbers of participants, have been well documented. This issue is particularly emphasized by the high placebo response rate (27%) demonstrated in our blinded, randomized controlled trial