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What's new in palliative care
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What's new in palliative care
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2017. | This topic last updated: Nov 16, 2017.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

GENERAL PRINCIPLES OF PALLIATIVE CARE

New ASCO guideline aims to improve communication skills (September 2017)

The way in which serious news is conveyed can substantially influence the emotional response to the news, beliefs and attitudes toward the medical staff, and how patients view their future. While there are no consistent findings from randomized interventional studies that show better patient outcomes after modifying communication skills to deliver serious news, a number of studies have shown that clinician communication skills can be improved by training. A 2017 guideline from the American Society of Clinical Oncology (ASCO) recommends communication skills training for oncologists and presents best practices for core communication skills when clinicians are communicating with patients and their loved ones about goals of care, prognosis, treatment options, and end of life care (table 1) [1]. (See "Discussing serious news", section on 'Can communication skills be taught and learned?'.)

SYMPTOM MANAGEMENT

Thalidomide for delayed nausea and vomiting after highly emetogenic chemotherapy (November 2017)

Neurokinin-1 receptor (NK1R) antagonists prevent delayed emesis from highly emetogenic chemotherapy (HEC), but are not available worldwide. In a randomized trial in patients receiving HEC, thalidomide (100 mg twice daily on days 1 to 5) was compared with placebo; all patients received palonosetron on day 1 and dexamethasone on days 2 through 4 [2]. Patients receiving thalidomide had better control of acute and delayed nausea and vomiting but higher rates of sedation, dizziness, constipation, and dry mouth. An NK1R antagonist is preferred for patients receiving HEC, but the combination of thalidomide plus palonosetron and dexamethasone is an option for prevention of delayed emesis in patients who lack access to NK1R antagonists. (See "Prevention and treatment of chemotherapy-induced nausea and vomiting in adults", section on 'Thalidomide'.)

Vaginal dehydroepiandrosterone for genitourinary symptoms in postmenopausal cancer survivors (October 2017)

Treatment of genitourinary syndrome of menopause (GSM) in survivors of estrogen-sensitive malignancies is challenging because vaginal estrogen may be contraindicated. In a randomized trial comparing two doses of vaginal dehydroepiandrosterone (DHEA) with a nonhormonal vaginal moisturizer in postmenopausal cancer survivors (primarily breast cancer), all three groups reported similar improvement in dyspareunia and vaginal dryness symptoms at 12 weeks, but only the higher dose DHEA group reported significant improvement in sexual function over baseline on a validated sexual health measure [3]. Vaginal DHEA holds promise as a GSM treatment for breast cancer survivors, but safety concerns remain because it increases serum estrogen levels. (See "Treatment of genitourinary syndrome of menopause (vulvovaginal atrophy)", section on 'Women with breast cancer'.)

Updated guideline on bone-modifying agents for metastatic breast cancer (October 2017)

In conjunction with Cancer Care Ontario, the American Society of Clinical Oncology has issued a focused guideline update on the role of bone-modifying agents (BMAs) in metastatic breast cancer [4]. Evidence is not sufficient to support the choice of one BMA over another; options for zoledronic acid now include every-12-week dosing as an alternative to monthly treatment, and BMAs should not be used alone for management of bone pain, given their modest analgesic benefit. (See "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors", section on 'Dosing interval' and "Osteoclast inhibitors for patients with bone metastases from breast, prostate, and other solid tumors", section on 'Overview of the approach to osteoclast inhibition'.)

Methylphenidate for apathy in patients with Alzheimer disease (October 2017)

Apathy is a common and understudied symptom of dementia that can emerge early in the disease course and contribute to functional impairment and caregiver burden. In a randomized trial of 77 patients with mild Alzheimer disease (AD), methylphenidate improved apathy scores compared with placebo over a 12-week treatment period [5]. Adverse effects were similar between groups. These results add support to low-dose methylphenidate as an option in patients with persistent and distressing apathy despite a cholinesterase inhibitor and treatment of depression. (See "Management of neuropsychiatric symptoms of dementia", section on 'Apathy'.)

Misuse of prescribed opioids (September 2017)

Misuse of prescribed opioid drugs is a major source of escalating rates of opioid use disorder and opioid overdose in the United States. The 2015 National Survey on Drug Use and Health estimated that among the 92 million US adults prescribed opioid drugs in the prior year, almost 13 percent reported prescription opioid misuse, and 2 percent reported having a prescription opioid use disorder [6]. Misuse reported by study subjects included taking higher or more frequent doses than prescribed and buying or using opioids prescribed to someone else. (See "Prescription drug misuse: Epidemiology, prevention, identification, and management", section on 'Misuse'.)

Opana ER withdrawn from the US market (July 2017)

A long-acting abuse-deterrent formulation of oxymorphone, Opana ER, is being voluntarily withdrawn from the United States (US) market at the request of the US Food and Drug Administration due to concerns related to injection abuse, including reports of thrombotic microangiopathy (TMA) when the oral formulation is injected intravenously (IV) [7-9]. The TMA is thought to be due to an inert component that was added to the formulation to make it crush-resistant and thus deter IV injection. Generic extended-release oxymorphone products remain on the US market. (See "Cancer pain management with opioids: Optimizing analgesia", section on 'Oxycodone, hydrocodone, hydromorphone, and oxymorphone' and "Drug-induced thrombotic microangiopathy", section on 'Drugs of abuse'.)

Safe storage of prescription opioids (May 2017)

Although safe storage of prescription opioid medications (eg, locked cabinet) is recommended, it infrequently occurs. In a United States nationally representative survey of over 1000 adults with prescription opioid use in the past 12 months, only 9 percent reported safe storage of their medications [10]. In further analysis of those adults with children younger than 18 years of age in the household, safe storage was reported in less than one-third of households with young children and 12 percent of households with children older than six years of age [11]. These results support the need for anticipatory guidance by health care providers, emphasizing opioid safe storage and how it may limit opioid misuse and overdose, especially in households with children and adolescents. Further research should focus on developing and implementing effective means of secure storage in households. (See "Opioid intoxication in children and adolescents", section on 'Safe storage'.)

SELECTED END-STAGE CONDITIONS

Nomogram to estimate survival in advanced pancreatic cancer (November 2017)

Second-line therapy may improve survival in advanced pancreatic cancer (APC), although the best way to predict which patients will benefit is not established. An analysis of data from 462 consecutive patients with APC treated at a single institution identified nine factors (age, smoking status, liver metastases, performance status, pain, jaundice, ascites, duration of first-line chemotherapy, and second-line treatment regimen) that independently influenced survival and were used to develop a prognostic model which discriminated three groups [12]. Benefit from second-line chemotherapy was higher in the better prognostic groups. The model is the basis for a nomogram to estimate individual survival probabilities following first-line chemotherapy for APC, which may assist in clinical decision making. (See "Chemotherapy for advanced exocrine pancreatic cancer", section on 'Second-line therapy'.)

END OF LIFE AND HOSPICE CARE

Immigrant status and end-of-life care in the intensive care unit (October 2017)

Immigration status may be a factor that impacts care at the end of life. In a population-based study from Ontario that examined location of death and intensity of care received in the last six months of life, immigrants (residents <30 years) were more likely to be admitted to the intensive care unit (ICU), die in the ICU, and receive more aggressive care (including mechanical ventilation, dialysis, and feeding tube placement) than long-standing residents [13]. Rates of ICU death varied among different nationalities but were highest in Southern Asians and lowest in Western and Northern Europeans. Further studies are required to understand the factors underlying this association, but they may include health literacy, cultural preferences, and communication barriers. (See "Palliative care: Issues in the intensive care unit in adults", section on 'Barriers' and "Palliative care: The last hours and days of life", section on 'Place of death'.)

Lorazepam plus haloperidol for persistent agitated delirium (September 2017)

Haloperidol is standard therapy for the symptomatic management of agitated delirium in medically ill patients. In a randomized trial, 90 patients with advanced cancer who were admitted to an acute palliative care unit and had persistent agitated delirium despite scheduled haloperidol were assigned to receive a single intravenous dose of lorazepam or placebo [14]. The lorazepam group had lower RASS (Richmond Agitation-Sedation Scale) scores at eight hours, required less rescue neuroleptics, were perceived to be more comfortable by blinded caregivers and nurses, and had similar survival to the placebo group (68 versus 73 hours). For palliative care patients with persistent agitated delirium despite the use of haloperidol, we suggest a single dose of intravenous lorazepam rather than haloperidol alone. (See "Palliative care: The last hours and days of life", section on 'Delirium'.)

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REFERENCES

  1. Gilligan T, Coyle N, Frankel RM, et al. Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol 2017; 35:3618.
  2. Zhang L, Qu X, Teng Y, et al. Efficacy of Thalidomide in Preventing Delayed Nausea and Vomiting Induced by Highly Emetogenic Chemotherapy: A Randomized, Multicenter, Double-Blind, Placebo-Controlled Phase III Trial (CLOG1302 study). J Clin Oncol 2017; 35:3558.
  3. Barton DL, Sloan JA, Shuster LT, et al. Evaluating the efficacy of vaginal dehydroepiandosterone for vaginal symptoms in postmenopausal cancer survivors: NCCTG N10C1 (Alliance). Support Care Cancer 2017.
  4. Van Poznak C, Somerfield MR, Barlow WE, et al. Role of Bone-Modifying Agents in Metastatic Breast Cancer: An American Society of Clinical Oncology-Cancer Care Ontario Focused Guideline Update. J Clin Oncol 2017; :JCO2017754614.
  5. Padala PR, Padala KP, Lensing SY, et al. Methylphenidate for Apathy in Community-Dwelling Older Veterans With Mild Alzheimer's Disease: A Double-Blind, Randomized, Placebo-Controlled Trial. Am J Psychiatry 2017; :appiajp201717030316.
  6. Han B, Compton WM, Blanco C, et al. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med 2017; 167:293.
  7. http://endo.com/news-events/press-releases?c=123046&p=irol-newsArticle&ID=2284981 (Accessed on July 11, 2017).
  8. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm562401.htm (Accessed on July 11, 2017).
  9. Hunt R, Yalamanoglu A, Tumlin J, et al. A mechanistic investigation of thrombotic microangiopathy associated with IV abuse of Opana ER. Blood 2017; 129:896.
  10. Kennedy-Hendricks A, Gielen A, McDonald E, et al. Medication Sharing, Storage, and Disposal Practices for Opioid Medications Among US Adults. JAMA Intern Med 2016; 176:1027.
  11. McDonald EM, Kennedy-Hendricks A, McGinty EE, et al. Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children. Pediatrics 2017; 139.
  12. Vienot A, Beinse G, Louvet C, et al. Overall Survival Prediction and Usefulness of Second-Line Chemotherapy in Advanced Pancreatic Adenocarcinoma. J Natl Cancer Inst 2017; 109.
  13. Yarnell CJ, Fu L, Manuel D, et al. Association Between Immigrant Status and End-of-Life Care in Ontario, Canada. JAMA 2017; 318:1479.
  14. Hui D, Frisbee-Hume S, Wilson A, et al. Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial. JAMA 2017; 318:1047.
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