ASCO: Palliative and supportive care interventions increase comfort in advanced cancer patients

Two studies presented at the 2020 American Society of Clinical Oncology (ASCO) Annual Meeting highlighted MD Anderson’s commitment to holistic patient-centered palliative and supportive care. Both studies examine ways to proactively improve comfort for patients with advanced cancers experiencing uncontrolled cancer-related symptoms.

Neuroleptic rotation for refractory agitation in cancer patients with delirium in the acute palliative care unit: A double-blind randomized clinical trial (abstract 12006)

In a single-center clinical trial comparing treatments for agitation in cancer patients with terminal delirium, researchers found that neuroleptics, more commonly known as antipsychotics, reduced agitation and improved comfort for patients suffering from delirium in the last days of life.

“This therapeutic effect is of great importance in the palliative care unit setting when agitation can be extremely distressing and patient comfort is paramount,” says principal investigator David Hui, M.D., associate professor of Palliative Care Medicine. “This is a timely finding because there is currently much debate and confusion about whether clinicians should be using these medications in patients with delirium. Our study highlights that neuroleptics may be useful for a specific indication in selected patients”

The double-blind, randomized trial, published in The Lancet Oncology, compared the effectiveness of multiple neuroleptic strategies in patients admitted to the palliative and supportive care unit experiencing refractory agitation, despite treatment with a low dose of the neuroleptic haloperidol. Patients who met the clinical trial’s criteria were treated with one of three strategies:

• An escalation in the dose of haloperidol,
• Rotation from haloperidol to chlorpromazine, another antipsychotic drug, or
• Combined treatment with both chlorpromazine and haloperidol

The results of the study found that patient agitation ranked on the Richmond Agitation-Sedation Scale (RASS) significantly decreased within 30 minutes of treatment with all three strategies and continued throughout the next 24 hours. Observations by caregivers and nurses found that a majority of patients appeared to be more comfortable after receiving the treatments.

Median survival was 73 hours for the patients and did not differ between the groups. While the treatments showed similar benefits among the groups, the rotation group experienced significantly fewer episodes of breakthrough restlessness.

“As a secondary finding, neuroleptic rotation to chlorpromazine seems to provide steadier agitation control in our setting requiring fewer dose escalation and as needed doses than simply increasing the dose of haloperidol or combination strategy,” says Hui. However, “more research is needed to confirm these findings,” he adds.

Integrating PROs with prognostic value into oncologic care: High ESAS global distress score associated with lower overall survival in advanced cancer patients (abstract 12021)

Metastatic cancer patient data pulled from MD Anderson’s Palliative Care unit database suggests patient-reported outcomes in advanced cancer patients can offer clinicians valuable insight into disease prognostication and clinical decision making.

As research suggests, integrating a patient’s understanding of their own symptoms is an effective strategy in making informed clinical decisions. However, “Despite compelling data supporting their use, patient reported outcomes are not widely integrated into routine cancer care,” says Ishwaria Subbiah, M.D., assistant professor of Palliative Care Medicine.

One solution to increasing the broader use of patient-reported outcomes is to utilize more streamlined methods of reporting. All patients in MD Anderson’s Palliative Care Practice complete the Edmonton Symptom Assessment System (ESAS). The ESAS, allows patients to rate common symptoms, such as pain, fatigue, nausea, drowsiness, appetite, sleep, dyspnea, well-being, anxiety and depression, on a scale of 0 to 10. The assessment is fast and easy to complete, making it an efficient tool for patients with a high symptom burden, explains Subbiah.

The research, led by Subbiah, analyzed the answers provided by the patients on the severity of their cancer-related symptoms on the Edmonton Symptom Assessment System. Using the patient’s responses, the researchers calculated each individual’s Global Distress Score (GDS), which quantified the overall burden from cancer-related symptoms that a particular patient was experiencing at that time. Patients carrying a high burden of symptoms, as demonstrated by a high Global Distress Score, were found to have lower overall survival when compared to those with more mild to moderate symptoms and corresponding lower GDS.

Of the 333 patients’ data included in the research, the overall survival period for patients reporting low symptom burden was 13.1 months, compared to 3.7 months for patients reporting high symptom burden, regardless of the age of the patients.

“With the rapidly increasing integration of technology into health care, we have to be thoughtful of what is asked of our patients and ensure that every element of a patient’s digital experience results in a meaningful improvement in their clinical outcomes and overall patient experience,” says Subbiah. “Conducting proactive symptom monitoring approach using a patient-reported outcomes survey like the ESAS can provide information that helps us as clinicians personalize the care to that patient by addressing symptoms that are impacting their quality of the life the most, while concurrently providing information such as the GDS, which carry a highly prognostic value that can inform health care decision making for patients with advanced cancers.”