Journal Article Annotations
2018, 3rd Quarter
Annotations by Elie Isenberg-Grzeda, MD; and Carlos Fernandez-Robles, MD
Also of interest:
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.
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.
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.
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.