Journal Article Annotations
2019, 3rd Quarter
Annotations by Elie Isenberg-Grzeda and Carlos Fernandez-Robles
The finding: The authors conducted a systematic review of the literature to identify patients prescribed clozapine who were being initiated on chemotherapy. The authors identified 27 cases published in the literature. Among 14 patients, Clozapine was continued while patients were concomitantly prescribed chemotherapy; in the remaining 13 patients, clozapine was discontinued or substituted for another antipsychotic sometime during chemotherapy treatment. Among the 13 cases who discontinued clozapine, 12 developed a serious relapse of their psychiatric disease, necessitating the reintroduction of clozapine. Among the 14 cases who continued clozapine for the duration of chemotherapy, only one case developed severe complications from neutropenia (coagulase negative staph bactermia). In total, 11 patients completed a full course of chemotherapy, and 10 were reported to be in remission.
Strength and weaknesses: The strengths of article lie in the application of proper systematic review methodology. The main weaknesses reflect the limitations common to case reports—recall bias, missing data, lack of a control group—as well as the small sample size.
Relevance: Clozapine is one of the most effective antipsychotics available and is a mainstay of treatment for patients with severe mental illness. Among the possible side-effects of clozapine is the risk of potentially life-threatening agranulocytosis. Chemotherapy can be myelosuppressive, and little guidance is offered to help clinicians decide whether to discontinue clozapine in favor of chemotherapy. The results of this study suggest that among patients initiating chemotherapy, outcomes are more favourable when clozapine is continued. Frequent monitoring for neutropenia and relapse of psychiatric symptoms are crucial.
Type of study: (http://ebm.bmj.com/content/early/2016/06/23/ebmed-2016-110401): Systematic Review.
Higher adherence to antidepressants is associated with decrease of all-cause mortality in cancer patients.
Strength and weaknesses:
The major strength lies on the size of the sample and is prospective observational nature that relies on objective data rather than individual reports. The results are tied to missing information on the database, such as ability to discriminate for specific cause of death, or the cancer stage.
Depression is highly prevalent among cancer patients and negatively impact both psychosocial and medical outcomes. Studies looking at the impact of antidepressant use in this population yield mixed results; however, these analyses did not take into account the actual adherence of the patients to antidepressant therapy, a fact that could have limited the validity of the results. This study looked at a nationwide cohort of patients who had been prescribed antidepressants and found that adherence to the medication was associated with decreased risk of all-cause mortality during the 4-year follow up period. This finding was consistent for patients diagnosed with cancer, and it held after further stratification by cancer-type except for patients with melanoma. This benefit, while incremental related to the level of adherence, seems to have a ceiling effect as high adherence did not have additional benefits compared to moderate adherence. In light of these findings, all providers must increase efforts to enhance patients’ adherence to antidepressants.
Type of study: Nationwide Cohort Study
A substantial portion of patients uses the Internet to obtain additional education about their cancer. Contrary to what most physician’s beliefs, not all internet interactions are harmful, and in fact, many can empower patients and when appropriately leveraged can positively impact the relationship with their providers.
Strength and weaknesses:
Excellent comprehensive methodology, the fact that clinicians at the Institut Català d’ Oncologia in Barcelona conduct it, allowed for the inclusion of studies both in English and Spanish. Adequate stratification allowed for a fruitful discussion and increased the precision of the conclusions. The limitations emerged from those of the papers included, this is a relatively new area of exploration, and papers lack theoretical basis, samples are small, diversity is limited, and many rely on self-report instruments, which makes difficult to compare them.
Access to information changes any field drastically. We are in the midst of the internet revolution, and the internet is transforming patient care, and this practice by itself is evolving rapidly. Patients not only are obtaining information but are also seeking to connect with other patients. Physicians have an almost universal negative view on the practice when not guided by a healthcare provider; however, this review shows that it has very positive impacts in the majority of cases in particular in younger, highly functional patients. As providers of oncologic care, it is critical to understand this trend and embrace the digital transformation. It is a tool not limited to the mere provision of information, but to meet the need for connection and experience sharing. Taking a step forward and developing a digital strategy should be part of all service development in the future, as it will enhance the care, match new needs, and strength a collaboration between professionals and patients.
Type of study: Systematic review of the literature