Indian Journal of Palliative Care
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   Table of Contents - Current issue
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October-December 2019
Volume 25 | Issue 4
Page Nos. 485-596

Online since Friday, October 11, 2019

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EDITORIAL  

Institute-based sustainable palliative care program: A unique initiative of “cancer treatment center program” p. 485
Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_173_19  PMID:31673199
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ORIGINAL ARTICLES Top

The psychosocial and spiritual experiences of patients with advanced incurable illness in Bangladesh: A cross-sectional observational study Highly accessed article p. 487
Megan E Doherty, Liam Power, Rubayet Rahman, Lailatul Ferdous, Kazi M Akter, Sayeda Sharmin Quadir, Sadia Sharmin, Emily Evans, Farzana Khan
DOI:10.4103/IJPC.IJPC_113_19  PMID:31673200
Context: The psychosocial and spiritual needs of individuals with life-limiting conditions in low- or middle-income countries have not been well described. Understanding these needs is important to providing holistic palliative care. Aim: This study aims to better understand the psychosocial and spiritual needs and supports of patients with advanced, incurable illness in Bangladesh. Subjects and Methods: Individuals with advanced incurable illnesses (advanced cancer and HIV/AIDS) from a wide geographical distribution across Bangladesh were interviewed about their health status, emotional and spiritual experiences with their illness, coping and support systems, and greatest needs and fears. Results: We interviewed 221 individuals with incurable cancer (82%) or HIV/AIDS (18%). Self-reported health status was poor or very poor for 48%, and 44% reported feeling unhappy all of the time. The majority (61%) rated their current level of unhappiness as 10/10. Spouses (50%), children (15%), and parents (13%) were the most common caregivers. Money and medical care were equally the most common needs (46%). Participants' greatest fears were for the future of their children (38%), being in pain (29%), and dying (28%). Conclusions: There is a significant burden of psychosocial and spiritual concerns among patients with advanced incurable illness in Bangladesh, with sadness being very frequent and of high intensity. Family and friends provide significant emotional and practical support to patients who are seriously ill, but very few patients access any professional support for these concerns.
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Pain severity and adequacy of pain management in terminally ill patients with cancer: An experience from North Palestine p. 494
Haneen Mallah, Raghda Mousa, Nisreen Bani Fadl, Samar Musmar, Somedeb Ball, Kenneth Nugent
DOI:10.4103/IJPC.IJPC_39_19  PMID:31673201
Aim: Chronic pain is common in terminally ill patients with cancer and affects their quality of life. In this study, we wanted to evaluate pain severity and the adequacy of prescribed analgesics in terminally ill patients with cancer in North Palestine. Methods: We conducted a cross-sectional descriptive study in North Palestine on 77 terminally ill patients with cancer. Pain experience was evaluated with Brief Pain Inventory-Short Form (BPI-SF). Pain management index (PMI) was calculated to determine the adequacy of interventions. The relationships between adequacy of pain management and socioeconomic and clinical factors were analyzed by the covariance method. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS version 15.0 [SPSS Inc., Chicago, USA]). Results: Fifty-nine patients (76.6%) reported moderate-to-severe pain. According to the PMI, only 64.9% of the patients received adequate pain management. Thirty-five patients (45%) wanted additional treatment or an increase in the dose of pain medications. Although men and women reported similar pain severities, women were more likely to be inadequately treated (P = 0.027). Pain severity was significantly less in patients who received health-care services at least once in the last month before the interview, compared to those without recent access to health care (P = 0.024). Conclusion: There is substantial inadequacy in pain management in patients with cancer. The BPI-SF should be routinely used to evaluate pain severity, and analgesics should be prescribed equitably without discrimination with regard to gender and socioeconomic status of patients.
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Low-dose oral ketamine as a procedural analgesia in pediatric cancer patients undergoing bone marrow aspirations at a resource-limited cancer hospital in India p. 501
Spandana Rayala, Melker Kyander, Vikranth Haridass, Gayatri Palat, Axel Ström, Thomas Wiebe, Eva Brun, Mikael Segerlantz
DOI:10.4103/IJPC.IJPC_110_19  PMID:31673202
Aim: Many pediatric cancer patients undergo repeated bone marrow aspirations (BMAs) for diagnostic and treatment evaluation purposes. Full anesthesia is the standard of care during this procedure in high-income countries. At hospitals with low resources in low/middle-income countries many children undergo these painful procedures without sufficient pain relief. This study aimed to evaluate the usefulness of low-dose oral ketamine as a procedural analgesic in a low-resource pediatric cancer care department. Materials and Methods: Pediatric patients, 4–15 years of age, who underwent BMAs between September 31 and November 30, 2018, were invited to participate. The study was designed as a placebo-controlled, single-blinded trial with three trial groups. Group K received 1.0 mg/kg of ketamine and Group KM received 1.0 mg/kg ketamine with an addition of 0.2 mg/kg midazolam, mixed in juice 30 min before procedures. Group P received placebo consisting of plain juice. All three groups also received the hospital's current standard treatment for procedural pain in BMAs. Patients and caregivers assessed the procedural pain, as did the performing doctors. For the patients, Faces Pain Scale – Revised was used and the Numeric Rating Scale-11 for caregivers and doctors. Results: A total of 87 patients were included in the study distributed with 29 in Group K, 29 in Group KM, and 29 in Group P. Seven patients were excluded, one patient denied participation and the remaining did not meet the inclusion criteria. There was no significant difference between the pain reported by the groups. A total of 69% patients in Group KM and 35% in Group K had somnolence reported as a side effect compared to 14% in Group P. Conclusion: We found no significant effects on the procedural pain in any of the treatment groups compared to placebo. There were only mild side effects. The doses of ketamine might be insufficient for this painful and stressful procedure.
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Effect of perioperative pregabalin on incidence of chronic postmastectomy pain syndrome: A prospective randomized placebo-controlled pilot study p. 508
Saurabh Vig, Vinod Kumar, Surayanarayana Deo, Swati Bhan, Seema Mishra, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_85_19  PMID:31673203
Background: Breast cancer is the most common malignancy among women. Chronic pain after breast surgeries is a well-known entity and is mainly neuropathic in nature. The primary aim of this study was to assess the effect of pregabalin given as preventive analgesic on the incidence of chronic postmastectomy pain. Methods: A randomized control trial (RCT) was performed on 80 patients. Patients were allocated into two groups. Group 1 received pregabalin (Lyrica, Pfizer) 75 mg. BD starting from the morning of surgery and continued for 1 week. Group 2 received placebo capsules at identical time intervals. Patients were followed up for 3 months postoperatively. Incidence, severity, and location of chronic pain were recorded. The primary objective was to evaluate the effect of perioperative oral pregabalin on the incidence of chronic postmastectomy pain (at 3 months postoperatively). Results: Of the 80 patients enrolled, 71 patients completed the study and were assessed for final outcomes. Incidence of chronic pain was comparable in both groups, with 16 out of 35 patients in Group 1 (44.7%) and 20 out of 36 patients in Group 2 (55.6%) reported chronic pain (P = 0.407). There was no difference between the severity of chronic pain (numeric rating scale ≥ 4) in both groups (P = 0.307). Incidence of adverse effects was comparable in both groups. Conclusion: This RCT shows that perioperative pregabalin may not have a role in the prevention of chronic pain after breast surgeries.
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Symptom palliation in advanced gallbladder cancer: An institutional experience p. 514
Amit Gupta, Sweety Gupta, Udit Chauhan, Utkarsh Kumar, Nidhi Sharma, Rachit Ahuja, Deepak Rajput, Manoj Gupta
DOI:10.4103/IJPC.IJPC_94_19  PMID:31673204
Aim: Palliation of symptoms of patients with advanced carcinoma gallbladder (GB). Materials and Methods: Sixty-two newly diagnosed patients of unresectable advanced and metastatic GB cancers were enrolled, and following clinicoradiological assessment patients were considered for palliative symptom management. Results: The most common presenting symptom was pain in 57 (92%) patients. Obstructive jaundice was observed in 29 (46.7%) patients. Patients were considered for percutaneous biliary drainage/internal stenting, therapeutic ascitic tapping, and pain control. Patients with good performance status were considered for palliative chemotherapy. Conclusion: Patients with advanced carcinoma GB were managed with various palliative procedures with the aim to improve the quality of life of patients because of jaundice, loss of appetite, nausea, pain, etc. Symptoms are distressing for patients.
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Nurses' strategies for conscience-based care delivery: A qualitative study p. 517
Madineh Jasemi, Sima Purteimor, Roghaieh Esmaili Zabihi, Masumeh Hemmati Maslak Pak, Samereh Eghtedar
DOI:10.4103/IJPC.IJPC_65_19  PMID:31673205
Introduction: Conscience is the core of ethical values. It helps nurses protect patients' rights and provide quality dignified care. Therefore, assessing nurses' strategies for conscience-based care may help facilitate conscience-based care delivery. Aim: This study aimed to explore nurses' strategies for conscience-based care delivery. Methods: This qualitative study was conducted in 2018 on twelve hospital nurses purposively recruited from four teaching hospitals in Urmia, Iran. Data were collected through in-depth interviews and inductively analyzed through conventional content analysis. Ethical Considerations: This study was approved by the Ethics Committee of Urmia University of Medical Sciences. All the participants were informed of the aim of the study and a written consent was obtained from each of them. Participation in the study was entirely voluntary and the participants could withdraw at any stage of the study. Results: Participants' strategies for conscience-based care delivery were grouped into two main themes, namely self-empowerment for clinical role performance and attempt to deliver care beyond the routines. Conclusion: Clinical self-empowerment and attempt to deliver care beyond the routines are nurses' main psychosocial strategies for conscience-based care delivery. Mentorship programs are recommended for the development of nurses' time management and clinical skills and thereby, empower them for conscience-based care delivery. Moreover, continuing education programs and curricular revisions are recommended to strengthen their religious beliefs.
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Bleomycin in Hodgkin's lymphoma – A boon or a bane? – A retrospective study of bleomycin pulmonary toxicity in Hodgkin's lymphoma p. 523
Chethana Babu K Udupa, Prakashini Koteshwar, Karthik S Udupa
DOI:10.4103/IJPC.IJPC_107_19  PMID:31673206
Introduction: Hodgkin's lymphoma (HL) is one of the most curable malignancies with cure rates of above 85% across all stages. Bleomycin containing regimen is routinely employed in the treatment of HL. Pulmonary toxicity due to this drug is the most feared side effect in these regimens where the mortality rate is approximately 2%–3%. We have conducted this study to assess the genetic susceptibility among the Indian HL patients to bleomycin pulmonary toxicity (BPT). Materials and Methods: In a retrospective study conducted at a tertiary care hospital from South India between January 2013 and May 2019, we reviewed 100 HL patients who were treated with bleomycin-containing regimen (adriamycin, bleomycin, vinblastine, and dacarbazine or cyclophosphamide, vincristine, procarbazine, and prednisone/adriamycin, bleomycin, and vinblastine) for BPT. Results: A total of 100 patients with HL who had received bleomycin-containing regimen were analyzed, which included 23 females and 77 males. Twenty-nine patients had BPT and five deaths were attributed to the same. Radiology reports showed that 15 patients had acute BPT and eight patients had chronic changes. Four patients had rare findings of bleomycin-induced lung damage and computed tomography of the chest could not be done for two patients, whose chest X-ray showed features suggestive of BPT. Conclusion: The incidence of bleomycin induced pulmonary toxicity and mortality was significantly higher in our study compared to that of other Western studies. This could be probably due to the increased susceptibility of the Indian patients to bleomycin induced lung damage. In a highly curable cancer such as HL, it is unacceptable to have such a high life-threating toxicity. Hence, an alternative chemotherapy regimen without bleomycin is to be explored which would prevent toxicity and hence the compromise on survival.
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Conventional fractionation versus quad shot in advanced head-and-neck cancers: A randomized controlled trial p. 527
Akansha Choudhary, Ajay Gupta
DOI:10.4103/IJPC.IJPC_209_18  PMID:31673207
Context: A significant number of patients with head-and-neck cancers have an incurable disease with limited life expectancy. The objective of the present study was to compare two different short courses of hypofractionated palliative radiotherapy regimens to evaluate symptoms, disease response, and acute toxicity. Materials and Methods: Previously untreated 50 patients of Stage IV B and IV C head and neck cancers were randomized to receive conventional hypofractionated palliative radiotherapy 30 Gy/10 fractions/2 weeks (control group) or Quad Shot regimen (study group) 14 Gy in 4 fractions given twice a day at least 6 h apart for 2 consecutive days. This regimen was repeated at 4 weekly intervals for a further two courses if there was no tumor progression. Results: Symptom relief was similar among the two schedules for pain (60.86 vs. 57.17), dysphagia (60.86 vs. 52.17%), and hoarseness (43.85 vs. 38.09%). Overall response (that is partial response and stable disease) was seen in majority (>70%) of the patients in both the groups. Treatment was very well tolerated with no patient experiencing more than Grade 3 toxicity in the control group and Grade 2 toxicity in the study group. Conclusions: Quad Shot regimen is an effective hypofractionated palliative radiotherapy schedule with minimal toxicity, good symptom relief, and response rate as compared to conventionally used regimen (30 Gy/10 fractions/2 weeks).
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Emergency department visits by head-and-neck cancer patients p. 535
Akshat Malik, Vivek Sukumar, Ameya Pai, Aseem Mishra, Sudhir Nair, Devendra Chaukar, Pankaj Chaturvedi
DOI:10.4103/IJPC.IJPC_57_19  PMID:31673208
Aim: This study was conducted to assess the disease status of head-and-neck cancer patients visiting the emergency department (ED) and their reason for presentation. We wanted to analyze if these visits could be avoided by incorporating any changes in our clinical practice. Methods: This was a retrospective analysis of head-and-neck cancer patients attending the ED at a tertiary care cancer center in 2017. Clinical details were noted from the electronic medical records, and descriptive statistics was calculated. The analysis was performed using SPSS version 21 software. Results: Three hundred and thirty-nine head-and-neck cancer patients attended the ED. Of these, 80.2% were males and 48.1% of patients had oral cavity cancers. About 37.2% required palliative care treatment. Nearly, 47.2% of patients presented during their initial evaluation period. About 22.7% required hospital admission and only 14.7% required any sort of emergency intervention. Conclusion: Majority of visits to ED could have been avoided with better counseling of the patients and their attendants.
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Aggressive care at the end of life; Where are we? p. 539
Amrallah A Mohammed, Omar Al-Zahrani, Reham A Salem, Fifi Mostafa Elsayed
DOI:10.4103/IJPC.IJPC_59_19  PMID:31673209
Background: Although, efforts to encourage palliative care only for terminal patients, aggressive end-of-life care (EOL) care still common for those probably to die shortly. Aim: Multicenter experiences to investigate where did we stand in this era? Patients and Methods: A retrospective study included patients with advanced solid tumors. The presence of one or more of the following indicators in the last month of life (LM) referred to aggressive EOL care: emergency department (ED) visits ≥ twice, admission to the hospital through ED, death in critical care units (CCUs), and palliative chemotherapy (PC) at the past 2 weeks before death. Results: A total of 435 patients, 51.5% were men with a median age of 62 years (range: 17–108), were included in the study. Most of the patients (89.2%) belonged to Group II; they had attended ED at least twice (60%), approximately 53% admitted to the hospital through ED, 31% received PC-LM with 41% of them had at the past 2 weeks before death, 13% died in the CCUs, and more than half of them (53%) survived <2 weeks. Kaplan–Meier estimator revealed that median survival was 30 days in Group I versus 13 days in Group II (odds ratio: 1.63; 95% confidence interval: 1.20–2.21; P = 0.002). The median survival was statistically significantly associated with PC-LM ≥14 days and the admission mode. There was no statistically significant association with age, sex, and primary cancer sites. Conclusion: The majority of our patients continue with anticancer treatments they possibly do not need and associated with poor survival.
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The concept of do not resuscitate for students in King Abdulaziz University Hospital p. 544
Bashaer Abdulrahim Alsaati, Maram Nader Aljishi, Sunds Salah Alshamakh, Nujood Salah Banjar, Hadeel Ahmed Basharaheel, Rawan Saleh Alamri
DOI:10.4103/IJPC.IJPC_78_19  PMID:31673210
Introduction: Do not resuscitate (DNR) is a medical procedure for patients who are suffering from critical, untreatable, and irreversible disease where the patient's life is predicted to end. DNR is considered a sensitive decision for patients and their relatives, as well as physicians. Aim: This study is aimed to assess the knowledge and attitude of medical students and interns toward the DNR order and the factors affecting their attitude at the King Abdulaziz University Hospital (KAUH) in Jeddah. Methods: Nonintervention cross-sectional study was conducted among 429 medical students (preclinical and clinical years) and interns who were given an online questionnaire between May and June in 2016 at KAUH in 18 Kingdom of Saudi Arabia. Results: Our study indicates that most of the participants (73.2%) were familiar with DNR order; however, more than half of them (58.3%) did not take any lecture or session on DNR. Large proportion of medical students had the opinion that attending a lecture or session on DNR would help them discuss it more skillfully with the patients and their relatives. More than half of the participants (55%) believed that there is a Fatwa that regulates DNR on the Islamic level. Conclusion: Participants, who were interns, were more familiar with the term DNR, whereas the 2nd-year medical students were less familiar with DNR. Considering the variation in the knowledge of participants about DNR, we conclude that additional lectures and sessions about DNR should be added to the medical school curriculum to make the students more confident and able in handling the DNR discussions.
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End-of-life milieu of critically sick children admitted to a pediatric hospital: A comparative study of survivors versus nonsurvivors p. 550
Asmita Das, Bhavneet Bharti, Prahbhjot Malhi, Sunit Singhi
DOI:10.4103/IJPC.IJPC_60_19  PMID:31673211
Objective: The aim of this study was to describe end-of-life (EOL) milieu among caregivers of children who died in the hospital and to compare their psychosocial, spiritual, and financial concerns with caregivers of children who survived. Materials and Methods: Sixty caregivers of children (30 survivors and 30 nonsurvivors), admitted in the pediatric intensive care unit and general pediatric unit, were recruited over a period of 1 year. Mixed qualitative methods were used to collect information from parents on EOL care perspectives. Results: Demographic, disease, and treatment-related characteristics were not significantly different between nonsurvivor and survivor groups. The caregivers of nonsurvivors versus survivors showed no significant differences as regards optimal care (76.67% vs. 56.67%), social support (76.6% vs. 66.67%), and frequent recitation of scriptures (30.77% vs. 45.83%). Mean medical expenditure among children receiving EOL care was Rs. 40,883 (range: Rs. 800–5 lakhs). Regression results revealed that for every 1 day of increase in hospital stay, cost of hospitalization for dying children increased by Rs. 3000 (P = 0.0001). Medical insurance was reported by only minority of the cases (5%). Several themes emerged in the focus group discussions with care providers which highlighted the importance of communication and need for emotional, social, and financial support. EOL decision was taken in only two of the nonsurviving children. Conclusions: The study offers useful insight about social, financial, and religious “end-of-life” needs among terminally sick children and thereby sensitizes the health-care providers to optimize their care at this niche period.
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The city of hope quality of life stoma questionnaire: Malayalam translation and validation p. 556
L Mayadevi, BS Geetha Kumary, Mira Wagh Sudam, Faheem Abdulla, Bharat Veerabhadran, Madhu Muralee, Sajeed Abdul Rahuman, Preethi Sarah George, K Chandramohan, Marcia Grant
DOI:10.4103/IJPC.IJPC_81_19  PMID:31673212
Background: Malayalam is the language spoken by 38.5 million people worldwide. There is no specific instrument to measure stoma-related quality of life (QOL) in Malayalam language. Aim: This study was designed to translate and validate the city of hope QOL (COH-QOL) Ostomy Questionnaire, which is a robust tool developed in English language. Materials and Methods: The instrument was translated to Malayalam, abiding by internationally accepted translation methodology. Trained interviewer ( first author) administered the questionnaire to patients with stoma, who were visiting the stoma clinic. The reliability of the subscales and the total scores were established by calculating correlation coefficients. Convergent and divergent validity were evaluated by calculating Pearson's correlations of each item with its own scale and other scales. Results: Cronbach's alpha coefficients for all subscales were 0.70 or more. Similarly, split-half coefficients also were more than 0.70, which were acceptable. All subscales met the minimum acceptable standards of convergent and discriminant validity. Discriminant validity of all scores was less than convergent validity which suggests that there was no overlap between various constructs in measuring the same traits. The validation study of Malayalam translation of COH stoma questionnaire has shown that the tool is valid and reliable. Conclusion: The validation study of Malayalam translation of City of Hope Stoma questionnaire has shown the tool is valid and reliable.
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Cancer pain, anxiety, and depression in admitted patients at a tertiary care hospital: A prospective observational study p. 562
Anshika Arora, Sunil K Saini, Vipul Nautiyal, SK Verma, Meenu Gupta, BP Kalra, Mushtaq Ahmad
DOI:10.4103/IJPC.IJPC_4_19  PMID:31673213
Context: Pain is the most common symptom in admitted cancer patients. The association between the severity of cancer pain and distress symptoms such as depression and anxiety is a subject of research. Aims: The aim is to study the prevalence of pain, anxiety, and depression in admitted cancer patients and determine the association between pain and anxiety and depression at a tertiary cancer care institute. Settings and Design: This was prospective observational study. Subjects and Methods: We enrolled 393 cancer inpatients prospectively after written informed consent. Their disease details, presence, severity, and character of pain were recorded. Numerical Pain Scale was used for pain scores, self-reporting Hospital Anxiety and Depression Scale for anxiety and depression. Statistical Analysis Used: Normal data were analyzed with parametric, nonnormal with nonparametric methods, and categorical with the Chi-square test. Results: The prevalence of moderate-to-severe pain was 41.5%, anxiety 20.3%, and depression 24.8%. Proportion of patients with anxiety and depression was 9.2% and 17.7% in patients with no pain; about 32.8% and 36.7% with severe pain, respectively (P < 0.000). In patients with no depression 6% had anxiety; with depression 44.9% had anxiety (P < 0.000). Odd's ratio to have anxiety and depression was 4.44 (95% confidence interval [CI] 2.0318–9.7024) and 2.92 (95% CI 1.5739–5.4186), respectively, in patients with pain as compared to no pain (P < 0.00). There was a positive correlation between pain, anxiety, and depression scores. Conclusions: There is strong association between the presence and severity of pain and distress symptoms such as anxiety and depression in admitted cancer patients.
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A cross-sectional web-based survey of medical practitioners in India to assess their knowledge, attitude, prescription practices, and barriers toward opioid analgesic prescriptions p. 567
Shalini Singh, Shiv Prasad, Sushma Bhatnagar, Rakesh Lal, Nandan Choudhary, Malvinder Singh Sahi
DOI:10.4103/IJPC.IJPC_83_19  PMID:31673214
Context: Inadequate training of medical practitioners is a key factor responsible for inappropriate use of opioid analgesics. Aims: We assessed the current knowledge, attitude, prescribing practices, and barriers perceived by the Indian medical practitioners in three tertiary care hospitals toward the use of opioid analgesics. Subjects and Methods: Web-based survey of registered medical practitioner employed at three chosen tertiary health care institutions in New Delhi. Statistical Analysis Used: Descriptive analysis of survey responses was carried out. Comparative analysis was done using Chi-square test, independent samples t-test, and Pearson correlation coefficient. Results: The response rate was 10.4% (n = 308). Two-thirds of the participants (61.7%) had never received formal pain management training, and 86.7% participants would like further training. Most participants (71.1%) agreed that opioids should be prescribed in cancer pain, while 26.3% agreed that opioids should be prescribed in noncancer pain. Half of the participants agreed that SOS (if necessary) dosing schedule (48.4%), low dosage (61.7%), and short duration of use (51.4%) could decrease the harmful effect of opioids. Lack of information about opioid-related policies and addiction potential were identified as the most common barriers to prescribing opioids. Those seeing more patients with chronic noncancer pain come across opioid misuse and diversion more often (P = 0.02). Those who understood addiction were more likely to agree that patients of chronic cancer pain with substance use disorders should be prescribed opioid analgesics (P < 0.01). Conclusions: Indian medical practitioners felt the need for formal pain management training. There is a lack of consensus on how to manage the pain using opioid analgesics. Tough regulations on medical and scientific use of opioids are the most commonly reported barrier to prescribing them.
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Symptom interference and relation between the domains of quality of life among cancer patients of tertiary care hospital p. 575
Malathi G Nayak, Anice George, YN Shashidhara, Baby S Nayak
DOI:10.4103/IJPC.IJPC_139_19  PMID:31673215
Introduction: Quality of life (QOL) should be considered as the main outcome measure for patient with advanced cancer. QOL of cancer patients is affected by several factors. Objectives: The objective of the study was to assess the symptom interference and the relation between the domains of QOL among cancer patients. Methodology: An exploratory survey conducted among 768 patients diagnosed as Stage III or IV of cancer of breast/cervix/head and neck/gastrointestinal tract/lung/colorectal. Data were collected using pretested reliable structured interview questionnaire. Results: Out of 768 cancer patients, symptoms burden was interfered completely in their relationship with others among 445 (57.9%), sleep among 491 (63.9%), and QOL among 433 (56.4%). The domains of QOL were general well-being, physical well-being, psychological well-being, familial relationship, sexual and personal abilities, cognitive well-being, economic well-being, informational support, doctors' cooperation, and body image. Since the data were not following the normal distribution, Spearman rho was computed to assess the relationship between the domains. The data revealed that there is a positive statistically significant correlation between the domains of general well-being of the participants with physical wellbeing (r = 0.265, P = 0.001), psychological well-being (r = 0.195, P = 0.001), sexual and personal abilities (r = 0.278, P = 0.001), and body image (r = 0.168, P = 0.001). The study inferred that cancer patients with good cognitive well-being and high economic status had a sense of positive body image. Conclusion: Cancer patients have poor QOL in physical and psychological domains. QOL of patients is affected by the symptoms suffering during the treatment and diagnosis. Symptoms need to be managed effectively to improve the QOL of cancer patients.
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PERSPECTIVES Top

Principles of management of extremity skeletal metastasis p. 580
Srinath Gupta, Ashish Gulia, Vineet Kurisunkal, Mishil Parikh, Sanjay Gupta
DOI:10.4103/IJPC.IJPC_90_19  PMID:31673216
Understanding the epidemiology of extremity skeletal metastasis and the factors deciding the treatment decision-making are essential in developing a diagnostic and treatment strategy. This leads to optimum care and reduces disease-related burden. With the evolution of medical, radiation therapy, and surgical methods, cancer care has improved the quality of life for patients with improved survival and functional status in patients with skeletal metastasis. Based on the currently available literature, we have described a step-wise evaluation and management strategy of metastatic extremity bone disease. The present review article addresses various aspects and related controversies related to evaluation, staging, and treatment options in the management of extremity bone metastasis. This article also highlights the role of multidisciplinary involvement in management of extremity skeletal metastasis.
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Current asbestos exposure and future need for palliative care in India p. 587
Abhijeet Vasant Jadhav, Nilesh C Gawde
DOI:10.4103/IJPC.IJPC_51_19  PMID:31673217
Asbestos-related diseases (ARDs) are incurable but entirely preventable. Due to India's continuing use of asbestos, ARD patients will increase to a high number in the next three to four decades. This will increase the burden on palliative care system which is in nascent stage presently. Palliative care is the mainstay of the management of ARDs. Unfortunately, the burden on palliative care is likely to increase due to multiple factors contributed by India's demographic and economic changes. In the near future, there will be at least 12.5 million ARD patients and 1.25 million asbestos-related cancer patients worldwide, and half of these will be in India. It is high time to introspect about our ability to engage with this future problem. The paper also discusses the organization of this future problem of ARDs and possible action points toward future access to palliative care for ARD patients.
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CASE REPORT Top

Audio-visual hallucinations in a patient poststem cell transplant p. 592
Astha Koolwal Kapoor, G Naresh, Atul Sharma, Sushma Bhatnagar
DOI:10.4103/IJPC.IJPC_43_19  PMID:31673218
Tramadol is the most common weak opioid used today. It has unique pharmacology and is notorious for numerous side effects as well as drug interactions. Patients undergoing stem cell transplant are susceptible to polypharmacy as a result of the generous use of antibiotics and symptom management drugs. Here, we describe a case where concurrent use of tramadol and fluconazole can cause hallucinations as a result of drug interaction.
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LETTERS TO EDITOR Top

Lidocaine 5% patch in localized neuropathic pain p. 594
Abhijit S Nair, Srinivasa Shyam Prasad Mantha, Mohammad Azharuddin, Basanth Kumar Rayani
DOI:10.4103/IJPC.IJPC_99_19  PMID:31673219
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Sublingual buprenorphine: A feasible alternative for treating breakthrough chronic pain p. 595
Abhijit S Nair, Srinivasa Shyam Prasad Mantha, Kodisharapu Praveen Kumar, Basanth Kumar Rayani
DOI:10.4103/IJPC.IJPC_41_19  PMID:31673220
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