To Be In Pain Or Not: research to improve cancer-related pain management

Cancer is a growing problem. In the Netherlands, the twenty years prevalence of cancer is rising during the years. In 1990, 223 540 persons were living with cancer (twenty years prevalence). In 2002, the twenty years prevalence was 386 361 persons, and in 2010 540 371 persons. The prevalence of cancer increased with 3% – 3.5% per year since 1990. This increase was mainly provoked by an increase in the national population, especially elderly. In cancer patients, pain is one of the most frequent and feared symptoms. Pain can interfere with all aspects of daily life and pain relief is an important component of patients’ quality of life. The prevalence of cancer-related pain remained stable over the years, although the knowledge on pain treatment did improve. For cancer patients with all disease stages, the studies before 1990 showed that the prevalence of cancer-related pain varied between 41% - 72%4-5, of whom 35% scored their pain as moderate to severe (pain intensity score ≥ 5). The studies between 1990 and 2005 showed a prevalence between 28% - 87%, of whom between 23% - 65% scored their pain as moderate to severe, and studies after 2005 reported a prevalence of 52% - 72%, of whom between 20% - 56% scored their pain as moderate to severe. The prevalence of pain in cancer patients is related to the stage of cancer. The review of Van den Beuken et al. showed that the prevalence of cancer-related pain was 33% (95% Confi dence Interval (CI) 21-46%) in cancer patients after curative treatment (n=726); 59% (95% CI 44-73%) in patients during anti-cancer treatment (n=1408); and 64% (95% CI 58-69%) in patients with advanced disease (n=9763). Cancer-related pain can be caused by (a) the direct growth and penetrat

Development and feasibility of a web application to monitor patients’ cancer-related pain

Background: In the outpatient setting, pain management is often inadequate in patients with cancer-related pain, because of patient- and professional-related barriers in communication and infrequent contacts. The internet may provide new opportunities for monitoring these patients. Purpose: The purpose of this study was to investigate whether internet monitoring of cancer-related pain in outpatients was feasible. Methods: We developed an internet application that contained a pain diary, eConsult, and patient pain education. In the pain diary, patients scored their pain intensity (0–10 Numeric Rating Scale) and analgesic use daily and their side effects twice a week. Feasibility was defined as the percentage of diaries patients completed during the first 6 weeks. Results: We included 100 outpatients. Sixteen were not evaluable due to cognitive problems (2); withdrawal of participation (2); internet problems (2), or because they were too ill (10). During the first 6 weeks, 60% of 84 evaluable patients completed their diary for at least 65% of the days (median number of diaries, 21; range, 3–42) and asked for a median of five eConsults (range, 0–37). Patients most frequently used an eConsult for questions about pain or side effects, how to use their analgesics and to improve their self-management. Over the 6-week period, current pain intensity decreased from 3.3 (SD = 2) to 2.5 (SD = 1.6, p = 0.005), and worst pain intensity decreased from 5.7 (SD = 2) to 3.8 (SD = 2.0, p < 0.001). Conclusion: Internet monitoring of pain is feasible in most outpatients with cancer-related pain. The frequent use of the pain diary in the majority of patients indicates that those patients felt confident with the regular assessment of pain

Home Telemonitoring Improved Pain Registration in Patients With Cancer

Introduction: For adequate pain treatment in patients with cancer, it is important to monitor and evaluate pain regularly. Although the numeric rating scale (NRS) is implemented in hospitals in the Netherlands, pain is still not systematically registered during outpatient consultations. The aim of this study was to assess whether home telemonitoring increases pain registration in medical records of outpatients with cancer. Methods: Patients with cancer were included in the intervention group (IG) when they visited the outpatient clinic. They received a short message service and an interactive voice response on their mobile phones 3 times a week, asking them to provide their pain score (NRS). When the reported NRS pain score was ≥5, a specialized oncology nurse adapted the pain treatment when necessary. Outcomes were compared to a control group (CG) without home telemonitoring. In both groups, medical records were analyzed and data on pain and analgesics were collected. Results: In each group, the medical records of 54 patients were analyzed on 3 consecutive outpatient visits. In the CG, pain registration or its absence was described in 60 visits (37.0%). In the IG, pain registration or its absence was reported in 83 visits (51.2%). Patients in the IG received a prescription for analgesics significantly more often (36/54 patients [66.6%]) than did patients in the CG (18/54 patients [33.3%]), P < 0.01). Conclusion: Home telemonitoring for patients with cancer significantly increases registration of pain and prescriptions of analgesics in outpatient medical records. Home telemonitoring helps to increase the awareness of pain and its managemen

Cut points on 0-10 numeric rating scales for symptoms included in the edmonton symptom assessment scale in cancer patients: A systematic review

Context: To improve the management of cancer-related symptoms, systematic screening is necessary, often performed by using 0-10 numeric rating scales. Cut points are used to determine if scores represent clinically relevant burden. Objectives: The aim of this systematic review was to explore the evidence on cut points for the symptoms of the Edmonton Symptom Assessment Scale. Methods: Relevant literature was searched in PubMed, CINAHL®, Embase, and PsycINFO®. We defined a cut point as the lower bound of the scores representing moderate or severe burden. Results: Eighteen articles were eligible for this review. Cut points were determined using the interference with daily life, another symptom-related method, or a verbal scale. For pain, cut point 5 and, to a lesser extent, cut point 7 were found as the optimal cut points for moderate pain and severe pain, respectively. For moderate tiredness, the best cut point seemed to be cut point 4. For severe tiredness, both cut points 7 and 8 were suggested frequently. A lack of evidence exists for nausea, depression, anxiety, drowsiness, appetite, well-being, and shortness of breath. Few studies suggested a cut point below 4. Conclusion: For many symptoms, there is no clear evidence as to what the optimal cut points are. In daily clinical practice, a symptom score ≥4 is recommended as a trigger for a more comprehensive symptom assessment. Until there is more evidence on the optimal cut points, we should hold back using a certain cut point in quality indicators and be cautious about strongly recommending a certain cut point in guidelines

Development and validation of search filters to find articles on palliative care in bibliographic databases

Background: Healthcare professionals and researchers in the field of palliative care often have difficulties finding relevant articles in online databases. Standardized search filters may help improve the efficiency and quality of such searches, but prior developed filters showed only moderate performance. Aim: To develop and validate a specific search filter and a sensitive search filter for the field of palliative care. Design: We used a novel, objective method for search filter development. First, we created a gold standard set. This set was split into three groups: term identification, filter development, and filter validation set. After creating the filters in PubMed, we translated the filters into search filters for Ovid MEDLINE, Embase, CINAHL, PsychINFO, and Cochrane Library. We calculated specificity, sensitivity and precision of both filters. Results: The specific filter had a specificity of 97.4%, a sensitivity of 93.7%, and a precision of 45%. The sensitive filter had a sensitivity of 99.6%, a specificity of 92.5%, and a precision of 5%. Conclusion: Our search filters can support literature searches in the field of palliative care. Our specific filter retrieves 93.7% of relevant articles, while 45% of the retrieved articles are relevant. This filter can be used to find answers to questions when time is limited. Our sensitive filter finds 99.6% of all relevant articles and may, for instance, help conducting systematic reviews. Both filters perform better than prior developed search filters in the field of palliative care

Hydration and symptoms in the last days of life

Objectives: At the end of life oral fluid intake is often reduced. Consensus about the most appropriate management for terminally ill patients with limited oral fluid intake is lacking. The objective of this study is to investigate to what extent the amount of fluid intake, preceding and during the dying phase, is related to the occurrence of death rattle and terminal restlessness. Methods: A multicentre prospective observational study was performed. Data on the occurrence of death rattle and terminal restlessness, fluid intake and opioid use of patients expected to die within a few days or hours were collected. Results: 371 patients were included. Death rattle was reported at least once in 40% (n=149) of patients during the dying phase. Death rattle occurrence was not associated with the amount of fluid intake during the days before dying. Terminal restlessness was reported in 26% of patients (n=96). Terminal restlessness was not associated with a lower amount of fluid intake during the days before dying. Terminal restlessness during the last 24 hours of life was associated with a higher amount of fluid (ie, >250 mL/day) during 48-25 hours before death. Conclusions: Caution with fluid intake to prevent development of death rattle does not seem to be necessary. Our study suggests that a higher amount of fluid intake during 48-25 hours before death may be associated with the occurrence of terminal restlessness during the last 24 hours of life. These results suggest that actively providing dying patients with artificial fluid may not be beneficial

Self-management of patients with advanced cancer

BACKGROUND: Patients with advanced cancer are increasingly expected to self-manage. Thus far, this topic has received little systematic attention. AIM: To summarise studies describing self-management strategies of patients with advanced cancer and associated experiences and personal characteristics. Also, to summarise attitudes of relatives and healthcare professionals towards patient self-management. DESIGN: A systematic review including non-experimental quantitative and qualitative studies. Data were analysed using critical interpretive synthesis. Included studies were appraised on methodological quality and quality of reporting. DATA SOURCES: MEDLINE, Embase, Cochrane Central, PsycINFO, CINAHL, Web of Science and Google Scholar (until 11 June 2019). RESULTS: Of 1742 identified articles, 31 moderate-quality articles describing 8 quantitative and 23 qualitative studies were included. Patients with advanced cancer used self-management strategies in seven domains: medicine and pharmacology, lifestyle, mental health, social support, knowledge and information, navigation and coordination and medical decision-making (29 articles). Strategies were highly individual, sometimes ambivalent and dependent on social interactions. Older patients and patients with more depressive symptoms and lower levels of physical functioning, education and self-efficacy might have more difficulties with certain self-management strategies (six articles). Healthcare professionals perceived self-management as desirable and achievable if based on sufficient skills and knowledge and solid patient-professional partnerships (three articles). CONCLUSION: Self-management of patients with advanced cancer is highly personal and multifaceted. Strategies may be substitutional, additional or even conflicting compared to care provided by healthcare professionals. Self-management support can benefit from an individualised approach embedded in solid partnerships with relatives and healthcare professionals

Evaluation of a nursing aftercare intervention for patients with head and neck cancer treated with chemoradiation

Head and neck cancer (HNC) patients treated with chemoradiation have to rediscover their life after recovering from severe side-effects and build-up self-confidence. To assist patients in this, an aftercare intervention to support patients’ self-management was implemented. This study aimed to evaluate the feasibility and first effects

Validation of the Dutch Version of the Breakthrough Pain Assessment Tool in Patients With Cancer

Context: Essential for adequate management of breakthrough cancer pain is a combination of accurate (re-)assessment and a personalized treatment plan. The Breakthrough Pain Assessment Tool (BAT) has been proven to be a brief, multidimensional, reliable, and valid questionnaire for the assessment of breakthrough cancer pain. Objectives: The aim of this study was to examine the validity and reliability of the Dutch Language version of the BAT (BAT-DL) in patients with cancer. Methods: The BAT was forward-backward translated into the Dutch language. Thereafter, the psychometric properties of the BAT-DL were tested, that is factor structure, reliability (internal consistency and test-retest reliability), validity (content validity and construct validity), and the responsiveness to change. Results: The BAT-DL confirmed the two-factor structure in 170 patients with cancer: pain severity/impact factor and pain duration/medication efficacy factor. The Cronbach's alpha coefficient was 0.72, and the intraclass correlation for the test-retest reliability was 0.81. The BAT-DL showed to be able to differentiate between different group of patients and correlated significantly with the Brief Pain Inventory. In addition, the BAT-DL was capable to detect clinically important changes over time. Conclusion: The BAT-DL is a valid and reliable questionnaire to assess breakthrough pain in Dutch patients with cancer and is a relevant questionnaire for daily practice

Influence of aprepitant and localization of the patch on fentanyl exposure in patients with cancer using transdermal fentanyl

__Background and Objectives:__ The cutaneous fentanyl patch is widely used to treat continuous pain in patients with cancer. Its use is hampered by a high inter- and intrapatient pharmacokinetic variability. Factors that influence this pharmacokinetic variability are largely unclear. The aim of these studies was to test if common patient variables, i) the use of the moderate CYP3A4 inhibitor aprepitant and ii) the localization of the fentanyl patch (upper arm versus thorax) influence systemic exposure to fentanyl in patients with cancer using a transdermal fentanyl patch. __Results:__ The AUC0-6 h of fentanyl was 7.1% (95% CI: -28% to +19%) lower if patients concurrently used apre