Thursday, May 8, 2008

Peaceful acceptance of cancer; Chemo neuropathy; 'Slow medicine'

Two from Cancer:

First is a paper discussing a scale developed to measure peaceful acceptance of a cancer diagnosis. This comes from the Coping With Cancer Study (previous publication here) and the paper describes the development and some of the validation of their scale ('PEACE') which attempts to measure both 'peaceful acceptance' of an illness (e.g. asks things like To what extent do you feel you have made peace with your illness?) and 'struggle with an illness' (asks about what extent a patient feels their life is over as they now know it, what extent they feel it's unfair they have cancer, etc.). They also give some of the findings of the CWCS that I'll note.

First they found that answers to a single item on the peaceful acceptance subscale (to what extent do you believe a sense of inner peace and harmony?) strongly correlated to the entire peaceful acceptance score (i.e. it could be used as a quick and dirty substitute for it). They also report that patients' self-reported awareness of having a terminal illness (all patients in the study had advanced/incurable cancer) was not related to peaceful acceptance of their illness (peaceful acceptance scores were similar between those who acknowledged or didn't acknowledge being terminally ill). (This is similar to findings they reported in the prior publication I mentioned above.) They did find however that patients' reported 'struggle' with an illness was higher in those with a terminal illness acknowledgment (as were, interestingly, rates of advance care planning & living will completion). As you'd expect, reporting being strongly 'spiritual' had a protective effect all around. Higher symptom scores were associated with lower peaceful acceptance and higher struggle.

The conclusion I'd love to make from this is that we have it right in palliative care: honest disclosure of prognosis/terminally ill status doesn't 'hurt' people, symptoms do, so let's keep on telling the truth and treating symptoms. This is one study of course, and I shouldn't overplay these results, but I think from a didactic/rhetorical standpoint it is helpful/welcome to behold some data suggesting that knowing your prognosis doesn't affect your ability to feel peaceful about your condition/lot in life. (These were of course people who freely acknowledged/admitted to having a terminal illness - one wonders how many of them were told this or just figured it out for themselves.)

Of course there's more struggle, but of course there is, and one cannot take away the 'human condition part of the human condition,' so to speak. I think I've blabbed on this blog before that I think the CWCS is one of the most interesting recent research projects out there; it seems to me to be a big leap forward in this type of research (understanding how/why terminally ill patients understand, cope with (or not), their illness and how that affects the sort of care they get) and I hope there will be further publications from the study.

ResearchBlogging.orgMack, J.W., Nilsson, M., Balboni, T., Friedlander, R.J., Block, S.D., Trice, E., Prigerson, H.G. (2008). Peace, Equanimity, and Acceptance in the cancer experience (PEACE). Cancer DOI: 10.1002/cncr.23476

Second is a randomized, controlled trial of lamotrigine for chemotherapy associated peripheral neuropathy. It involved 131 patients (mean age 61 years; about 2/3 had finished their chemotherapy) with painful chemotherapy induced peripheral neuropathy with at least 4/10 pain; they were started on lamotrigine (titrated to 150 mg bid over 8 weeks) or matching placebo and were followed for 10 weeks total (only two weeks on the max dose). The results weren't good for lamotrigine: pain was a little better in both groups and both primary and secondary pain outcomes were identical between groups. Lamotrigine had more side effects and more drop outs due to them (this approached but didn't reach statistical significance).

A couple things here: people weren't on the maximum dose of lamotrigine that has been studied and shown to be effective (at least 400mg), however there really was not even a hint of a dose response curve here - it's not that lamotrigine looked a little better but didn't achieve statistical significance - lamotrigine's curve never departed from placebo's (actually it looked a little worse for a bit). I don't use lamotrigine and I'm not sure if 2 weeks on the max dose is enough; however the total time on active treatment was 10 weeks without a hint of benefit (and if this drug takes more than 10 weeks to work is this something we'd want to use anway?).

This did get me thinking: what are people using out there as the 2nd line antiepileptic adjuvant (after gabapentin or pregabalin which I'm assuming most people are using - one or the other - as their 1st line AED adjuvants)? It also got me thinking: has anything been shown to be an effective therapy for painful CIPN (in a controlled trial)? EPERC recently published this Fast Fact about it and my recollection when I was editing it is that there's a dearth of controlled data.

The New York Times has a story about 'slow medicine,' focusing on a care-model being developed at a nursing home in New Hampshire. 'Slow medicine' really means deliberately and pro-actively defining care-limitations up front in elderly patients in light of their goals and prognosis (i.e. it's also 'good medicine' and shares palliative care's ethos of 1) honesty about prognosis, 2) focusing on care goals, and 3) explicitly giving people all their care options including limitations on testing/hospital level care/etc.). This is a really telling excerpt:

Kendal begins by asking newcomers whether they want to be resuscitated or go to the hospital and under what circumstances. “They give me an amazingly puzzled look, like ‘Why wouldn’t I?’ “ said Brenda Jordan, Kendal’s second nurse practitioner.
She replies with CPR survival statistics: A 2002 study, published in the journal Heart, found that fewer than 2 percent of people in their 80s and 90s who had been resuscitated for cardiac arrest at home lived for one month. “They about fall out of their chairs when they find out the extent to which we’ll go to let people choose,” Ms. Jordan said.

"Fall out of their chairs...": apparently these patients weren't used to being offered options/choices about their care.

Thanks to Kathleen Jacobs, RN for alerting me to this article.

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