Download Ana Maria Hermosa Garcia

EPCCS STUDY: SYMPTOM BURDEN IN
ADVANCED LUNG CANCER PATIENTS
Dr. Ana Maria Hermosa Garcia, MD
Palliative Care Program, Royal Alexandra Hospital
25th Annual Palliative Education and Research Days
October 28th, 2014
Disclosures
 Ana Maria Hermosa Garcia – postdoctoral fellow
 This project was grant-funded by Alberta Innovates –
Health Solutions
 Investigators: Konrad Fassbender, Vickie Baracos, Sharon
Watanabe, Robin Fainsinger, Cheryl Nekolaichuk, Ann Huot,
Quincy Chu
 Amount: $ 89.930
 Term: April 1, 2011 – November 1, 2013
Acknowledgements
 Alberta Innovates - Health Solutions funding
 Investigators: Konrad Fassbender, Vickie Baracos, Sharon
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Watanabe, Robin Fainsinger, Cheryl Nekolaichuk, Ann Huot,
Quincy Chu
Research Coordinator: Danielle Baron
Research Nurse: Asifa Mawani
Summer Student: Lisa Fainsinger, Caitlyn Vail
Thank-you to the clinicians and staff for the Cross Cancer Institute
clinics
Thank-you to the patients and their families for their generous
participation
Background
Methods
Results
Conclusions
Background 1:
Advanced Lung Cancer Patients Profile
• 13.5% of all cancer diagnosis in Canada
• Leading cause of cancer deaths (27%)
• Only 15% cases are detected at early stage
• 85% Non-Small Cell Lung cancer (squamous cell ca,
adenoca., large cell ca)
• 5 years survival rate for NSCL cancer (17%)
• Metastatic= 3.6% 5 y survival
http://www.cancer.ca/~/media/cancer.ca/CW/publications/Canadian%20Cancer%20Statistics/canad
ian-cancer-statistics-2013-EN.pdf
Background 2:
Advanced Lung Cancer Patients Profile
• >90% patients
will experience ≥2 symptoms
• Fatigue, loss of appetite, dyspnea, chest pain
(>80% patients); cough ~50%
• Symptoms are more severe 0-3 m prior to death
• QoL is paramount since life expectancy is short
1. Hirsh V. Are the data on quality of life and patient reported outcomes from clinical trials of metastatic non-small-cell lung
cancer important? World J Clin Oncol. Nov 10, 2013; 4(4): 82–84.
2. Lutz S. et al. Symptom frequency and severity in patients with metastatic or locally recurrent lung cancer: a prospective
study using the Lung Cancer Symptom Scale in a community hospital. J Palliat Med 2001 Summer;4(2):157-65.
Background 3:
Care trajectory for cancer patients
Old concept
Modern concept
Murray S. et al. Illness trajectories and palliative care. BMJ 2005; 330; 1007-1011
(adapted from Lynn and Adamson 2003)
Background 4:
Care trajectory for advanced lung ca
Death
Diagnosis
MEDICAL/RADIATION ONCOLOGIST
• Chemotherapy combination
•
(etoposide/vinorelbine/permetrexed/
gemcitabine ± cisplatin or carboplatin ±
paclitaxel)
• ± Radiation therapy
End
of
Life
PALLIATIVE CARE TEAM
• Placement support: Hospice
• Community Liaison (no further tx)
• Symptom control ±
poor performance status
Background 5: Edmonton Symptom Assessment
System (ESAS-r)
1. Bruera E et al.The Edmonton Symptom Assessment System(ESAS):a simple method for the assessment of palliative care patients.JPalliatCare.1991;7(2):6-9
2. Watanabe SM et al.A multicenter study comparing two numerical versions of the ESAS in palliative care patients. J Pain Symptom Manage. 2011 Feb;41(2):456-68
Background 6:
Early integration of Palliative Care
 American Society Clinical Oncology guidelines (1)
 PC should be “considered early in the course of illness” for any patient with
metastatic cancer and/or high symptom burden.
 European Society Medical Oncology guidelines (2)
 “Early palliative-care intervention is recommended”, in parallel with
standard oncologic care.
 Guidelines of professional/expert bodies: Fraser Health,
Canadian Virtual Hospice, Edmonton Program, Champlain
1. Smith T. et al. ASCO Provisional Clinical Opinion: The Integration of Palliative Care into Standard Oncology Care. Journal of
Clinical Oncology, Vol 30, Issue 8 (March), 2012: 880-887
2. Peters S. et al. Metastatic Non-Small-Cell Lung Cancer:ESMO Clinical Practice Guideline.Ann Oncol 2012;23(Suppl 7):vii56-vii64
Research question
 Since high symptom burden is one criterion for
referral for pain and symptom management,
what is the severity and trajectory of the
symptoms experienced by advanced lung
cancer patients?
Methods 1: Prospective study
 Inclusion criteria:
 Lung cancer Stages IIIB/IV
 Medical Oncology Clinics CCI from Aug 2012 until Nov 2013
 Available for assessment every 3-5 weeks, ongoing
 Demographics (age, gender), treatment, standardized
assessment and symptom burden data (Edmonton
symptom assessment system –ESAS-) (also QoL,
MMSE, biomarkers – for future analysis).
 Statistical analysis.
Methods 2: Consort Diagram
Pain & Symptom
Clinic
Lung Clinic
Recruitment
Total patients in clinic (n=353)
Total patients in clinic* (n=244)
Total approached (n=57)
Total approached (n=96)
Declined (n=30)
Declined (n=25)
Consented (n=27)
Consented (n=71)
Enrollment
Lost < to baseline (n=):4
•Deceased (n=1)
Failed MMSE (n=2)
Withdrew (n=1)
Received baseline assessment (n=27)
Received baseline assessment (n=67):
Follow-Up
Lost during follow-up (n=6):
Final Pain & Symptom cohort
(at least baseline + 1 FU)
n=24
Cogn impaired (n=1)
Self-withdrawal (n=2)
Failure to do visits (n=1)
No longer eligible (n=1)
Deceased (n=1)
Total Cohort (n=85)
Final Lung cohort
(at least baseline + 1 FU)
n=61
Results 1: Demographics
N
Age
Range
Mean
SD
Total patients
67
28-82
64
± 10.5
Male
Female
34
33
28-81
48-82
65
63
± 9.6
± 11.3
Sex
Performance
Status at
inclusion
80 ± 10
(70-100)
• Patients were assessed every 3-5 weeks
• N of assessments per patient between 1-18, mean 5.6
• 67 patients with a total of assessments= 370
Results 2: Symptom prevalence
(67 patients with a total of 370 assessments)
N
Min.
Max.
Mean
SD
TIREDNESS
371
0
10
2.78
±2.50
DROWSINESS
368
0
10
1.95
±2.49
LACK OF APPETITE
370
0
10
1.73
±2.7
DYSPNEA
372
0
10
1.95
±2.5
WELLBEING
370
0
10
2.12
±2.23
PAIN
372
0
8
1.20
±1.79
DEPRESSION
372
0
10
0.84
±1.65
NAUSEA
372
0
9
0.42
±1.31
ANXIETY
371
0
8
0.92
±1.56
Results 3: Prevalence of high symptom scores ≥7
(n=23 of 67 patients (34%))
SYMPTOMS
(ESAS-r)
PATIENTS WITH
SYMPTOM SCORES ≥ 7
AT ANY TIME
%
34.3%
N
23/67
TIREDNESS
28.4%
19
DROWSINESS
20.9%
14
LACK OF APPETITE
19.4%
13
DYSPNEA
17.9%
12
WELLBEING
16.4%
11
PAIN
10.4%
7
DEPRESSION
8.9%
6
NAUSEA
8.9%
6
ANXIETY
7.5%
5
Results 3: Repeated severe symptoms:
patients with 2 consecutive high scores ≥7
SYMPTOMS
(ESAS-r)
PATIENTS WITH PERSISTENT
SYMPTOM SCORES ≥ 7
%
19.3%
N
13/67
TIREDNESS
8.7%
6
DROWSINESS
4.5%
3
LACK OF APPETITE
4.5%
3
DYSPNEA
10.4%
7
WELLBEING
1.5%
1
3%
2
1.5%
1
NAUSEA
0
0
ANXIETY
1.5%
1
PAIN
DEPRESSION
•19.3% of patients with
multiple/persistent
episodes of severe
symptoms.
•Is this a generality?
•Can these symptoms
be resolved?
Results 4: Survival comparison
• Median overall survival was
11 months
(95% CI 8-13 months)
• Median survival in the
persistent high symptoms
group was 7 months,
versus 11 months in the
no persistent high
symptoms group (p=0.47,
fig.1); compared by Log
Rank test
Conclusions
 Overall symptom severity in this sample is moderate however
34.3% of patients had a high symptom score at some point
of their disease trajectory.
 There is also a significant group of patients with repeated
high symptom scores (19.3%) potentially affecting quality
of life. Moderate symptom scores need to be explored.
 More research is required to develop and validate
algorithms, identifying opportunities for improved symptom
treatment.
THANKS!!!
ANY QUESTIONS???