Journal Article Annotations
2018, 3rd Quarter
Psycho-Oncology & Palliative Care
Annotations by Elie Isenberg-Grzeda, MD; and Carlos Fernandez-Robles, MD
October 2018
- Potential role of bupropion sustained release for cancer-related fatigue: a double-blind, placebo-controlled study
- Use of antidepressant medications moderates the relationship between depressive symptoms and hospital length of stay in patients with advanced cancer
- Effects of existential interventions on spiritual, psychological, and physical well-being in adult patients with cancer: systematic review and meta-analysis of randomized controlled trials
Also of interest:
- Bush SH, Lawlor PG, Ryan K, et al: Delirium in adult cancer patients: ESMO Clinical Practice Guidelines
Ann Oncol 2018; 29(Supplement_4):iv143-iv165
The European Society of Medical Oncology recently published clinical practice guidelines for the treatment of delirium in cancer patients. These guidelines provide a comprehensive overview of best practices in delirium screening, assessment, and diagnosis, management of patients with reversible causes of delirium, and both pharmacologic and nonpharmacologic options for prevention and treatment of delirium. The guidelines are unique to cancer in a number of ways. For instance, the section on the management of reversible causes lists a number of common cancer-specific etiologies and recommends treatments, for example, by administering dexamethasone to patients with delirium secondary to suspected brain tumors. In the section on managing refractory delirium in the actively dying patient, the authors review a number of strategies specific to this often-encountered patient population within psycho-oncology. As with many clinical practice guidelines, these are at times limited by the dearth of evidence in the literature. Still, the guidelines are an important publication for anyone working in the field of psycho-oncology.
PUBLICATION #1 — Psycho-Oncology & Palliative Care
Potential role of bupropion sustained release for cancer-related fatigue: a double-blind, placebo-controlled study
Ashrafi F, Mousavi S, Karimi M
Abstract: Asian Pac J Cancer Prev 2018; 19(6):1547-1551
BACKGROUND: Cancer-related fatigue (CRF) is very common and can be experienced at all stages of disease and in survivors. CRF causes patients more distress than pain or nausea and vomiting. Different pharmacologic interventions have been evaluated for the management of CRF. The purpose of this study was to determine the efficacy of bupropion sustained release (SR) as a treatment for fatigue in patients with cancer.
METHODS: In this randomized, double-blind, placebo-controlled trial, patients with fatigue due to cancer were randomly assigned to either 150mg daily of bupropion SR or matching placebo. The primary endpoint was the changes in average daily fatigue from baseline to week 4 using the Functional Assessment of Chronic Illness-therapy- Fatigue (FACIT-F) questionnaire.
RESULTS: 40 patients were randomly assigned to treatment with bupropion SR or placebo (20 in each group). Analysis of covariance (ANCOVA) showed a significant improvement in fatigue and quality of life in the bupropion group compared to baseline (P=0.000). Secondary outcome, including depression, severity of fatigue and performance status didn’t show significant difference between groups. Generally, bupropion SR was tolerated well.
CONCLUSION: Four weeks of 150 mg bupropion SR improve fatigue significantly in cancer patients. Bupropion has potential as an effective and safe pharmaceutical agent for treating CRF.
On PubMed: Asian Pac J Cancer Prev 2018; 19(6):1547-1551
Annotation
Type of study: Randomized control trial
The finding: Four-week treatment with bupropion SR 150mg improved fatigue and quality of life but not depression in patients with active cancer experiencing fatigue.
Strength and weaknesses: The strengths lay on its design; this is a randomized, double-blind placebo-controlled trial, that uses a well-validated tool to measure fatigue. The investigators considered non-adherence to treatment and removed those participants with less than 80% compliance. They also controlled for the presence of depression. However, the study does have a small sample size (N=40). There is a significant degree of variability in regards to the cancer types, and authors only make a distinction about solid and non-solid tumors. They do not compare groups based on stage and treatments received.
Relevance: Cancer-related fatigue is one of the most frequent symptoms patients face, and it is responsible for a large portion of disability and reduced quality of life during treatment. Given the limited pharmacological interventions available, this is an early effort to look past stimulants when considering treatments for fatigue.
PUBLICATION #2 — Psycho-Oncology & Palliative Care
Use of antidepressant medications moderates the relationship between depressive symptoms and hospital length of stay in patients with advanced cancer
Wong RL, El-Jawahri A, D’Arpino SM, et al
Abstract: Oncologist 2018 Aug 6 (Epub ahead of print)
BACKGROUND: Among patients with cancer, depressive symptoms are associated with worse clinical outcomes, including greater health care utilization. As use of antidepressant medications can improve depressive symptoms, we sought to examine relationships among depressive symptoms, antidepressant medications, and hospital length of stay (LOS) in patients with advanced cancer.
MATERIALS AND METHODS: From September 2014 to May 2016, we prospectively enrolled patients with advanced cancer who had an unplanned hospitalization. We performed chart review to obtain information regarding documented depressive symptoms in the 3 months prior to admission and use of antidepressant medications at the time of admission. We compared differences in hospital LOS by presence or absence of depressive symptoms and used adjusted linear regression to examine if antidepressant medications moderated these outcomes.
RESULTS: Of 1,036 patients, 126 (12.2%) had depressive symptoms documented prior to admission, and 288 (27.8%) were taking antidepressant medications at the time of admission. Patients with depressive symptoms experienced longer hospital LOS (7.25 vs. 6.13 days; p = .036). Use of antidepressant medications moderated this relationship; among patients not on antidepressant medications, depressive symptoms were associated with longer hospital LOS (7.88 vs. 6.11 days; p = .025), but among those on antidepressant medications, depressive symptoms were not associated with hospital LOS (6.57 vs. 6.17 days; p = .578).
CONCLUSION: Documented depressive symptoms prior to hospital admission were associated with longer hospital LOS. This effect was restricted to patients not on antidepressant medications. Future studies are needed to investigate if use of antidepressant medications decreases LOS for patients hospitalized with advanced cancer and the mechanisms by which this may occur.
IMPLICATIONS FOR PRACTICE: This study investigated the prevalence of documented depressive symptoms in patients with advanced cancer in the 3 months prior to an unplanned hospitalization and the prevalence of use of antidepressant medications at time of hospital admission. The relationship of these variables with hospital length of stay was also examined, and it was found that documented depressive symptoms were associated with prolonged hospital length of stay. Interestingly, antidepressant medications moderated the relationship between depressive symptoms and hospital length of stay. These findings support the need to recognize and address depressive symptoms among patients with advanced cancer, with potential implications for optimizing health care utilization.
On PubMed: Oncologist 2018 Aug 6 (Epub ahead of print)
Annotation
Type of study: Cohort study (prospective observational study)
The finding: The presence of untreated depressive symptoms before hospital admission was associated with longer hospital length of stay.
Strength and weaknesses: This is an overall well-designed study. The prospective design, clearly defined population, and large sample size facilitate achieving the study’s goals; furthermore, it addresses a topic relevant to psychiatrists, oncologists, and administrators. Among the weaknesses, we highlight the fact that investigators relied on chart review, and no interviews were conducted. This limits the reliability of the results and makes it difficult to assess severity and duration of symptoms, duration of treatment with antidepressants, and patient adherence. Additionally, other non-antidepressant treatments for depression were not included in the final analysis.
Relevance: Depressive symptoms are highly prevalent among patients with cancer, and increases with illness severity and complications. This study further highlights the importance of adequate treatment of depressive symptoms and its impact on overall care. In a rapidly changing environment where health care payers are focusing increasingly on cost-effective treatments, this study should alert hospital administrators to the role of mental health providers in cancer institutions.
PUBLICATION #3 — Psycho-Oncology & Palliative Care
Effects of existential interventions on spiritual, psychological, and physical well-being in adult patients with cancer: systematic review and meta-analysis of randomized controlled trials
Bauereiß N, Obermaier S, Özünal SE, Baumeister H
Abstract: Psychooncology 2018 Jun 29 (Epub ahead of print)
OBJECTIVES: To synthesize the evidence of existential interventions in adult patients with cancer.
METHODS: Embase, MEDLINE, CENTRAL, CINAHL, PsycINFO, PSYNDEX, and the WHO ICTRP were searched up until 26 January 2018. Eligibility criteria for studies were (1) adult patients with cancer, (2) evaluation of existential interventions, (3) compared with active/non-active control, (4) assessing relevant spiritual, psychological, or physical outcomes, and (5) conducted as randomized controlled trials. Standardized mean differences (Hedges’ g) were calculated, and meta-analyses were conducted using random effects models. Effects were aggregated within four time horizons (post-treatment; ≤3 months; ≤6 months; >6 months). Heterogeneity was assessed by forest plots and I2 . Risk of bias was assessed using the Cochrane Risk of Bias Tool. This review has been registered with Prospero (CRD42016042895).
RESULTS: A total of 3461 records were identified, of which 30 unique studies (3511 participants) were included in the review and 24 studies were included in meta-analyses. Existential interventions showed significant effects on existential well-being (g = 0.52; CI[0.13; 0.91; k = 10; I2 = 85%) and quality of life (g = 0.21; CI[0.01; 0.42]; k = 17; I2 = 75%) at post-treatment, on hope at post-treatment (g = 0.43; CI[0.12; 0.74]; k = 12; I2 = 86%) and after 6 months (g = 0.25; CI[0.02; 0.48]; k = 3; I2 = 0%) and on self-efficacy at post-treatment (g = 0.50; CI[0.09; 0.90]; k = 2; I2 = 0%). No significant effects were found on the remaining outcomes and time points. Significant moderator effects were found for professional background of therapists, intervention concept, number of sessions, and setting.
CONCLUSIONS: This systematic review and meta-analysis provides evidence that adult patients with cancer across all stages and types benefit from existential interventions. Future research should strive towards a higher standardization in particular with respect to outcome assessments.
On PubMed: Psychooncology 2018 Jun 29 (Epub ahead of print)
Annotation
Type of study: Systematic review and meta-analysis
The finding: In their meta-analysis of existential interventions for cancer patients, the authors found that existential interventions improve existential well-being and quality of life in the short term. Hope is improved in the short term and at 6-months post intervention. Self-efficacy is improved in the short term. The authors noted that the impact of existential interventions on depression and anxiety became significant after they excluded studies that had baseline differences in outcome measures (indicating that the studies may not have been randomized well).
Strength and weaknesses: The main strengths are in the study design, i.e., meta-analysis, which followed standard design and methods, except that data were extracted by a single author. Other strengths are that the authors included a wide-range of interventions, and they did not restrict the patient population to a specific stage of cancer. As such, the findings may be applicable to a wide range of cancer patients. In addition, the authors excluded religious interventions with the explicit goal of focusing on existential (and not religious) distress. Other limitations include publication bias and the fact that there may be ongoing studies in this area which are still underway (and thus not yet published).
Relevance: Existential distress is prevalent among cancer patients, and this study adds to the growing body of literature promoting the use of existential interventions to help with a number of outcomes in cancer patients. This study suggests that patients of all cancer stages may benefit from these interventions. The study also lists a number of methodological recommendations for researchers planning to design studies of existential interventions.
