Aggressive treatments in the last week of life increase difficult symptoms during dying while longer time in hospice care appears to reduce distress at the time of death for people with advanced cancer.

As part of the Coping with Cancer study, researchers interviewed patients with advanced cancer and their caregivers.  After the patient’s death, caregivers were asked about aggressive treatments during the last week of life, measures of the overall quality of the individual’s death, and the length of hospice care.  Results were reported at the 2007 Annual Scientific Meeting of the American Geriatric Society.

Aggressive treatments were defined as:

• hospitalization in an intensive care unit
• ventilator support
• non-palliative chemotherapy
• resuscitation
• use of a feeding tube

The number of aggressive treatments received during the last week of life was associated with

• more psychological distress
• more physical distress
• a poorer quality of death
• a lower possibility of dying in the place that the patient chose

Ninety percent of patients who receive no aggressive treatments in the last week died in the place they preferred compared to only one third of those who received two or more.

Gabriel K. Silverman, one of the researchers at Carnegie Mellon University and the University of Pittsburgh School of Medicine, reported:

The more time patients spent under hospice care, the greater their quality of death. For example, patients who received at least 5 weeks of hospice care were in less physical distress in their last week of life than those who lived less than a week with hospice, and those who received no hospice at all were in the most physical distress at the end of their lives. These results suggest that when patients are actively dying, the use of aggressive treatments should be considered with caution and only pursued with the full understanding of patients or their surrogate decision makers.

Commenting on the study in an interview with Medscape, Robert Arnold M.D. Chief of the Palliative Care and Medical Ethics section of the University of Pittsburgh School of Medicine, said,

As a doctor, if I had a patient or family who wanted aggressive, life-sustaining care toward the end of their life, I would view it as a red flag warning of patient or caregiver distress. Often patients and their families are suffering, sad, or distressed at the end of life, and when dying occurs in medical settings they may hope that aggressive treatment will help the suffering, but often it doesn’t.

SOURCE:  Laurie Barclay MD, Medscape Medical News, May 3, 2007 reporting on AGS 2007 Annual Scientific Meeting: Abstract P4.

More than half of patients in a Phase II clinical trial that added Tarceva® (erlotinib) to FOLFOX and Avastin® (bevacizumab) had to discontinue the trial because of serious side effects.  Another 25% withdrew their consent, also because of difficult side effects. 

Overall, none of the 35 patients in the trial completed it so no conclusions about the effectiveness of the combination could be drawn.

The study added Tarceva to FOLFOX and Avastin, a standard initial treatment for people with advanced colorectal cancer.  The trial’s goal was to determine progression-free survival or the length of time patients being treated with the combination had no growth of tumors.

Major side effects included rash, neuropathy, and diarrhea.

Erlotinib targets and blocks the EGFR tyrosine kinase cellular pathway.  It is effective in non-small cell lung cancer and pancreatic cancer.  Side effects when given alone include mild to moderate rash and diarrhea.

Dr. J.A. Meyerhardt and colleagues in Boston, where the trial was done, concluded:

The combination of FOLFOX, bevacizumab and erlotinib led to higher than expected early withdrawal due to toxicity, limiting conclusions regarding efficacy. These findings raise concern regarding the tolerability of adding more agents to already complex combination regimens for metastatic colorectal cancer.

SOURCE:  Meyerhardt et.al., Annals of Oncology, early online access, May 2007.

Large volume polyethylene glycol (PEG) solution or oral sodium phosphate (NaP) are commonly used to cleanse the colon before colonoscopy.  Both work by pulling large amounts fluids into the bowel producing copious watery stools.  Because so much fluid is lost in the process, body electrolyte balance can be affected.

Gastroenterologists in Canada were concerned that the oral sodium phosphate might cause undetected kidney damage.  Over ten years, they measured serum creatinine, an indicator of kidney failure, immediately before colonoscopy and again before a repeat colonoscopy procedure for nearly 800 patients. Most patients had the second level analyzed between one and five years after their first measurement.

There was no difference in chronic kidney failure between  the two different colonoscopy bowel  preps over several years.  Kidney damage was found in a small percentage of patients (7.7 percent) but there was no significant difference between those who used oral sodium phosphate as a prep (6.8 percent) or those who received PEG solution (8.7 percent).

The research team found that only age and blood pressure increased risk for chronic kidney failure among patients in their study.

R Abaskharoun and colleagues writing in the Canadian Journal of Gastroenterology concluded:

Baseline creatine clearance was similiar in both the NaP and PEG groups and the absolute difference after colonoscopy did not differ. The present study concluded that the ingestion of oral NaP for colon cleansing before colonoscopy did not result in frequent renal damage that went clinically undetected.

SOURCE:  Abaskharoun et.al., Canadian Journal of Gastroenterology, Volume 21, Number 4: 227-231, April 2007.

Patients who are elderly, have cardiac problems, hypertension, or already have chronic kidney disease need to be aware that the FDA has raised concerns about a rare acute kidney failure associated with colon cleansing with sodium phosphate products including Fleet’s Phospho-soda® and Visicol® tablets.  This condition was rare and appeared shortly after colonoscopy.

Writing in the American Journal of Nephrology, Glen Markowitz and his pathology team at Columbia University reported on 21 cases of an acute kidney failure after colonoscopy preparation with oral sodium phosphate in examination of 7,400 kidney biopsies.  Sixteen of the twenty-one cases had hypertension and fourteen were being treated with an ACE inhibitor.

In the AJN article, Dr. Markowitz suggests that

Strategies to prevent the development of acute phosphate nephropathy after OSPS include rigorous attention to adequate hydration and possibly not administering ACE-I, ARB, diuretics, and NSAID on the day before and the day of the colonoscopy procedure. OSPS should be used with great caution in elderly patients.

SOURCE: Markowitz et. al,, American Journal of Nephrology, 2005.

WHAT THIS MEANS FOR PATIENTS

People preparing for colonoscopy can be reassured that overall there was no difference in the development of chronic kidney problems whether an oral sodium phosphate prep or a PEG solution was used.

However, patients with existing kidney disease or hypertension, or who are elderly or using ACE inhibitors should discuss the choice of colonoscopy prep carefully with their doctors.  Before colonoscopy, a careful medical history and review of medications — both prescription and over-the-counter — is necessary before choosing the best prep for the patient.

All patients should be staying adequately hydrated during the prep process, drinking extra clear fluids as recommended by their gastroenterologists.

PEG solutions include Colyte®, Go-Lytely®, Nu-Lytely®, and Half-Lytely®. 

Oral sodium phosphates include Fleet’s Phospho-soda® liquid, Visicol® tablets, and OsmoPrep® tablets.

This post is from C3′s Director of Operations and Communications, Judi Sohn.

We are saddened to report that Kate Murphy, who typically updates this section of the website, lost her mother to breast cancer yesterday.

On behalf of C3′s Board, staff and advocates, our deepest sympathies are extended to Kate and her family on their loss.

Cancer patients receive a number of drugs — chemotherapy, supportive care, and medicines for conditions other than cancer. In a recent study, more than one in four patients on chemotherapy were taking medications that had a risk of drug interaction.    

Four hundred chemotherapy patients completed a questionnaire listing the medications they had taken in the past four weeks.  Nearly 300 potential drug interactions were identified, ten percent of them with the possibility of causing death, another 80 percent with the risk of serious health problems.

Most potential interactions — 87 percent — involved drugs that were not anti-cancer agents including warfarin, high blood pressure agents, cortisteroids, and anticonvulsants.  However, 13 percent involved cancer treatments.  Eight percent were actually duplicate prescriptions.

Despite identifying potential risky drug interactions, the study did not go on to find out if the interactions led to serious problems.

Writing in the Journal of the National Cancer Institute, Rachel P. Riechelmann and her colleagues concluded:

Potential drug interactions were common among cancer patients and most often involved medications to treat comorbid conditions. Duplicate medications were infrequent.

SOURCE:  Riechelmann et. al., Journal of the National Cancer Institute,Volume 99, Number8, pp:592-600, April 2007.