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1/ What are the benefit and harms of interventions to treat breathlessness (dyspnea) in people with advanced cancer?
We explore non-pharmacologic interventions in @JAMAOnc #supponc #pallonc
A tweetorial... https://jamanetwork.com/journals/jamaoncology/fullarticle/2773116
We explore non-pharmacologic interventions in @JAMAOnc #supponc #pallonc
A tweetorial... https://jamanetwork.com/journals/jamaoncology/fullarticle/2773116
2/ This article is co-published with a more comprehensive @PCORI @AHRQNews report including both non-pharmacologic and pharmacologic interventions.
It forms the basis of an upcoming @ASCO guideline on this topic.
https://www.pcori.org/research-results/2019/interventions-breathlessness-patients-advanced-cancer-systematic-review-update
It forms the basis of an upcoming @ASCO guideline on this topic.
https://www.pcori.org/research-results/2019/interventions-breathlessness-patients-advanced-cancer-systematic-review-update
3/ Breathlessness is a common, distressing, and debilitating symptom.
Often, treatment of the underlying cause (such as cancer) is not beneficial, feasible, or aligned with goals of care.
Targeted symptom-focused interventions may then be helpful.
photo credit: @unsplash
Often, treatment of the underlying cause (such as cancer) is not beneficial, feasible, or aligned with goals of care.
Targeted symptom-focused interventions may then be helpful.
photo credit: @unsplash
4/ But people with advanced cancer and breathlessness are often vulnerable, with limited time and ability to recover.
A decisional dilemma arrives:
Do the potential advantages of palliative interventions likely outweigh their harms?
photo credit: @unsplash
A decisional dilemma arrives:
Do the potential advantages of palliative interventions likely outweigh their harms?
photo credit: @unsplash
5/ Charged by @AHRQNews, @PCORI, and @ASCO, we conducted a systematic review of RCTs and observational studies with a concurrent comparison group evaluating benefits and/or harms of interventions to treat breathlessness.
6/ Breathlessness is often accompanied by and made worse by anxiety. It also limits functional capacity and affects QOL.
These 4 (breathlessness, anxiety, functional status, QOL) were the 4 key outcomes.
We also explored secondary outcomes.
These 4 (breathlessness, anxiety, functional status, QOL) were the 4 key outcomes.
We also explored secondary outcomes.
7/ RESULTS
First, a general paucity of studies. Since inception, only 50 qualifying studies (48 RCTs, 2 cohort studies).
Most small size, short-term follow-up, high attrition (representing underlying population).
Most common cancer type: lung cancer #lcsm
cc: @JackWestMD
First, a general paucity of studies. Since inception, only 50 qualifying studies (48 RCTs, 2 cohort studies).
Most small size, short-term follow-up, high attrition (representing underlying population).
Most common cancer type: lung cancer #lcsm
cc: @JackWestMD
8/ Several non-pharmacological interventions were effective for breathlessness:
Fans to the face vs usual care/ sham (SOE: Moderate)
Bilevel ventilation vs supplemental oxygen (SOE: Low)
in the inpatient setting over minutes to hours.
Fans to the face vs usual care/ sham (SOE: Moderate)
Bilevel ventilation vs supplemental oxygen (SOE: Low)
in the inpatient setting over minutes to hours.
9/ Blowing air to the face for 5 minutes was the most effective intervention (SMD -2.09).
10/ In the outpatient setting, acupressure and reflexology, and multicomponent interventions (combining activity and rehabilitation with behavioral, psychosocial, and integrative medicine) brought relief lasting for a few weeks to months.
11/ Re: pharmacologic interventions, no drugs demonstrated benefit.
Opioids were not more effective than placebo (SOE: Moderate).
Different doses or routes of administration did not differ in effectiveness (SOE: Low).
Opioids were not more effective than placebo (SOE: Moderate).
Different doses or routes of administration did not differ in effectiveness (SOE: Low).
12/ Anxiolytics were not more effective than placebo (SOE: low).
Evidence for other pharmacological interventions was limited.
Evidence for other pharmacological interventions was limited.
13/ In essence, some non-pharm interventions worked, pharm ones did not.
This is not crazy. We know limited data support the use of opioids (and drugs in general) to treat breathlessness.
Excellent podcast on this topic ( @EWidera @AlexSmithMD) https://www.geripal.org/2020/01/opioids-for-breathlessness-podcast-with.html
This is not crazy. We know limited data support the use of opioids (and drugs in general) to treat breathlessness.
Excellent podcast on this topic ( @EWidera @AlexSmithMD) https://www.geripal.org/2020/01/opioids-for-breathlessness-podcast-with.html
14/ A 2016 Cochrane review found insufficient evidence for benefits of opioids versus placebo for improving dyspnea in advanced cancer (and COPD), with low-quality evidence and very short-term studies.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011008.pub2/full
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011008.pub2/full
15/ These findings should catalyze a shift in how we approach and treat breathlessness, away from a medicalized approach using drugs, to a more comprehensive assessment and attempting non-pharmacologic interventions, such as fan therapy, first.
16/ Clinical practice and guidelines must evolve.
Non-pharm first! Fans to the face are cheap.
An upcoming @ASCO guideline on this topic recently completed public comment.
Non-pharm first! Fans to the face are cheap.
An upcoming @ASCO guideline on this topic recently completed public comment.
17/ We must recognize the limitations of drugs, and that many things we do may not have good evidence.
18/ Thanks to funders/sponsors ( @AHRQNews, @PCORI, and @ASCO), reviewers, and co-authors.
Most of all, thank to two people who became close(r) friends during this work.
Most of all, thank to two people who became close(r) friends during this work.
19/ @dhjutsw1 told me you need one person during fellowship/ early faculty, to have lunch with, to share ideas with, to chat about sports and science and food.
That person for me through fellowship has been @ramsedhom
This is us at the @sandiegozoo (= #ASCOQLTY19)
That person for me through fellowship has been @ramsedhom
This is us at the @sandiegozoo (= #ASCOQLTY19)
20/ The other is Dr. Sydney Dy. Lucky to have her a mentor.
This is us at the Dipor Bil lake in Guwahati, Assam, India in Feb 2020 at #IAPCON19
This is us at the Dipor Bil lake in Guwahati, Assam, India in Feb 2020 at #IAPCON19
21/ Hoping this work helps people with cancer breathe better.
We also hope it raises awareness, and establishes we have a long way to go in treating breathlessness.
We need more #supponc #pallonc research.
We also hope it raises awareness, and establishes we have a long way to go in treating breathlessness.
We need more #supponc #pallonc research.
