The Journal of Community and Supportive Oncology

Nausea and vomiting are common and distressing symptoms in advanced cancer. Both are multifactorial and cause significant morbidity, nutritional failure, and reduced quality of life. Assessment includes a detailed history, physical examination and investigations for reversible causes. Assessment and management will be influenced by performance status, prognosis, and goals of care. Several drug classes are effective with some having the added benefit of multiple routes of administration. It is our institution’s practice to recommend metoclopramide as the first drug with haloperidol as an alternative antiemetic.

Click on the PDF icon at the top of this introduction to read the full article.

Nausea and vomiting are common and distressing symptoms in advanced cancer. Both are multifactorial and cause significant morbidity, nutritional failure, and reduced quality of life. Assessment includes a detailed history, physical examination and investigations for reversible causes. Assessment and management will be influenced by performance status, prognosis, and goals of care. Several drug classes are effective with some having the added benefit of multiple routes of administration. It is our institution’s practice to recommend metoclopramide as the first drug with haloperidol as an alternative antiemetic.

Click on the PDF icon at the top of this introduction to read the full article.

Nausea and vomiting are common and distressing symptoms in advanced cancer. Both are multifactorial and cause significant morbidity, nutritional failure, and reduced quality of life. Assessment includes a detailed history, physical examination and investigations for reversible causes. Assessment and management will be influenced by performance status, prognosis, and goals of care. Several drug classes are effective with some having the added benefit of multiple routes of administration. It is our institution’s practice to recommend metoclopramide as the first drug with haloperidol as an alternative antiemetic.

Click on the PDF icon at the top of this introduction to read the full article.

What are the ethical responsibilities of the medical staff (doctors, nurses, social workers, and chaplains) regarding thepreservation of meaningful life for their patients who are approaching the end of life (EOL)? In particular, what is the staff’sethical responsibility to initiate a conversation with their patient regarding palliative care? By subjecting traditional Jewish teachings to an ethical analysis and then exploring the underlying universal principles, we will suggest a general ethical duty toinform patients of the different care options, especially in a manner that preserves hope. The principle that we can derive from Jewish bioethics teaches that the medical staff has a responsibility to help our patients live in a way that is consistent with how they understand their task or responsibility in life. For some patients, the best way to preserve a meaningful life in which they can fulfill their sense of purpose in the time that remains is to focus on palliation. For this reason, although palliative and supportive care are provided from the time of diagnosis, it is critical we make sure our patients realize that they have the opportunity to make a decision between either pursuing additional active treatments or choosing to focus primarily on palliative therapies to maximize quality of life. The Jewish tradition and our experience in spiritual care suggest the importance of helping patients preserve hope while, simultaneously, honestly acknowledging their situation. Staff members can play a vital role in helping patients make the most of this new period of their lives.

Click on the PDF icon at the top of this introduction to read the full article.

What are the ethical responsibilities of the medical staff (doctors, nurses, social workers, and chaplains) regarding thepreservation of meaningful life for their patients who are approaching the end of life (EOL)? In particular, what is the staff’sethical responsibility to initiate a conversation with their patient regarding palliative care? By subjecting traditional Jewish teachings to an ethical analysis and then exploring the underlying universal principles, we will suggest a general ethical duty toinform patients of the different care options, especially in a manner that preserves hope. The principle that we can derive from Jewish bioethics teaches that the medical staff has a responsibility to help our patients live in a way that is consistent with how they understand their task or responsibility in life. For some patients, the best way to preserve a meaningful life in which they can fulfill their sense of purpose in the time that remains is to focus on palliation. For this reason, although palliative and supportive care are provided from the time of diagnosis, it is critical we make sure our patients realize that they have the opportunity to make a decision between either pursuing additional active treatments or choosing to focus primarily on palliative therapies to maximize quality of life. The Jewish tradition and our experience in spiritual care suggest the importance of helping patients preserve hope while, simultaneously, honestly acknowledging their situation. Staff members can play a vital role in helping patients make the most of this new period of their lives.

Click on the PDF icon at the top of this introduction to read the full article.

What are the ethical responsibilities of the medical staff (doctors, nurses, social workers, and chaplains) regarding thepreservation of meaningful life for their patients who are approaching the end of life (EOL)? In particular, what is the staff’sethical responsibility to initiate a conversation with their patient regarding palliative care? By subjecting traditional Jewish teachings to an ethical analysis and then exploring the underlying universal principles, we will suggest a general ethical duty toinform patients of the different care options, especially in a manner that preserves hope. The principle that we can derive from Jewish bioethics teaches that the medical staff has a responsibility to help our patients live in a way that is consistent with how they understand their task or responsibility in life. For some patients, the best way to preserve a meaningful life in which they can fulfill their sense of purpose in the time that remains is to focus on palliation. For this reason, although palliative and supportive care are provided from the time of diagnosis, it is critical we make sure our patients realize that they have the opportunity to make a decision between either pursuing additional active treatments or choosing to focus primarily on palliative therapies to maximize quality of life. The Jewish tradition and our experience in spiritual care suggest the importance of helping patients preserve hope while, simultaneously, honestly acknowledging their situation. Staff members can play a vital role in helping patients make the most of this new period of their lives.

Click on the PDF icon at the top of this introduction to read the full article.

Kevin P. High, MD, MS; Doug Case, PhD;  MD, David Hurd, MD; Bayard Powell, MD; Glenn Lesser, MD; Ann R. Falsey, MD; Robert Siegel, MD; Joanna Metzner-Sadurski, MD; John C. Krauss, MD; Bernard Chinnasami, MD, George Sanders, MD, Steven Rousey, MD, Edward G. Shaw, MD

*For a PDF of the full article and accompanying commentary by Paul Sloan, click on the links to the left of this introduction.

Kevin P. High, MD, MS; Doug Case, PhD;  MD, David Hurd, MD; Bayard Powell, MD; Glenn Lesser, MD; Ann R. Falsey, MD; Robert Siegel, MD; Joanna Metzner-Sadurski, MD; John C. Krauss, MD; Bernard Chinnasami, MD, George Sanders, MD, Steven Rousey, MD, Edward G. Shaw, MD

*For a PDF of the full article and accompanying commentary by Paul Sloan, click on the links to the left of this introduction.

Kevin P. High, MD, MS; Doug Case, PhD;  MD, David Hurd, MD; Bayard Powell, MD; Glenn Lesser, MD; Ann R. Falsey, MD; Robert Siegel, MD; Joanna Metzner-Sadurski, MD; John C. Krauss, MD; Bernard Chinnasami, MD, George Sanders, MD, Steven Rousey, MD, Edward G. Shaw, MD

*For a PDF of the full article and accompanying commentary by Paul Sloan, click on the links to the left of this introduction.

A bill with bipartisan sponsors has been introduced in the U.S. House of Representatives to permanently repeal Medicare's Sustainable Growth Rate formula.

Rep. Joe Heck (R-Nev.) and Rep. Allyson Schwartz (D-Penn.) unveiled their proposal at a briefing with reporters on Feb. 6. They were surrounded by supporters, including representatives from the American College of Physicians, the American Academy of Family Physicians, the American College of Osteopathic Family Physicians, and the National Coalition on Health Care.

In addition to repealing the SGR, the bill also "stabilizes the current payment system for physicians, and it institutes measures to ensure access to primary care with increased updates for primary care physicians in the short term," said Rep. Schwartz, who added that it also "aggressively" tests new payment and delivery models and rewards high value, high quality health care. 

Rep. Schwartz and Rep. Heck, an osteopathic physician trained in emergency medicine, also introduced the bill in the last Congress. But both said that they think that legislators are primed to act, in part because of the struggle to reduce health care spending and the deficit. 

If the SGR is not replaced or repealed by the end of the year, physicians will see a 27% reduction in pay beginning in January 2014. Each year the cuts are delayed merely adds more on to the final tally for fixing the formula, noted Rep. Heck. The Congressional Budget Office estimated in its latest economic outlook released on Feb. 5 that it would cost about $138 billion to permanently repeal the SGR. That's less than the $245 billion in previous CBO estimates.

"The time right now is perfect to finally pass this legislation," said Rep. Heck. 

"I think the imminent process of sequestration may add a little urgency to reform because across the board cuts are not going to get us where we need to go," said John Rother, president and CEO of the National Coalition on Health Care, an umbrella group representing medical societies, businesses, unions, health care providers, religious associations, insurers, and consumers. "And the alternative here is smarter and much more oriented toward value, and it provides a very practical and beneficial alternative to the kind of meat-axe approaches in sequestration," Mr. Rother said.

Physician groups said they are hopeful that the proposal has legs this year.

The constant uncertainty about whether SGR cuts will occur, "undermines the family doctor's ability to continue to keep doors open and to invest in their practices," said Dr. Jeffrey Cain, president of the AAFP. He praised the Heck-Schwartz bill, which had not been officially introduced in the House at press time, saying that it would put an end to "the annual question of whether physicians can continue to afford to practice in Medicare," and that it also "stabilizes the Medicare cost system and provides solutions that are based on successful and proven methods that can improve quality and incent value."

Dr. Chuck Cutler, chair-elect of the ACP Board of Regents, said that "the stability that this bill brings to the marketplace and to our practice is particularly encouraging." He also said that the ACP was happy that the bill would maintain 2013 payment levels through the end of 2014 and then provide "positive and predictable updates" through 2019.

That is especially important as physicians test out new delivery and payment models, said Dr. Cutler.

From 2015 to 2018, the bill calls for annual increases of 2.5% for primary care, preventive, and care-coordination services. All other physicians would get a 0.5% increase for the 4-year period.

By 2019, physicians who continue to use a volume-drive fee-for-service model would get a smaller increase than would those who have transitioned to new models.

In addition to the groups who participated in the briefing, the bill also is supported by the American College of Obstetricians and Gynecologists, the Society of Hospital Medicine, the American College of Rheumatology, the American College of Cardiology, the American Academy of Neurology, and the American Academy of Pediatrics.

[email protected]

On Twitter @aliciaault

A bill with bipartisan sponsors has been introduced in the U.S. House of Representatives to permanently repeal Medicare's Sustainable Growth Rate formula.

Rep. Joe Heck (R-Nev.) and Rep. Allyson Schwartz (D-Penn.) unveiled their proposal at a briefing with reporters on Feb. 6. They were surrounded by supporters, including representatives from the American College of Physicians, the American Academy of Family Physicians, the American College of Osteopathic Family Physicians, and the National Coalition on Health Care.

In addition to repealing the SGR, the bill also "stabilizes the current payment system for physicians, and it institutes measures to ensure access to primary care with increased updates for primary care physicians in the short term," said Rep. Schwartz, who added that it also "aggressively" tests new payment and delivery models and rewards high value, high quality health care. 

Rep. Schwartz and Rep. Heck, an osteopathic physician trained in emergency medicine, also introduced the bill in the last Congress. But both said that they think that legislators are primed to act, in part because of the struggle to reduce health care spending and the deficit. 

If the SGR is not replaced or repealed by the end of the year, physicians will see a 27% reduction in pay beginning in January 2014. Each year the cuts are delayed merely adds more on to the final tally for fixing the formula, noted Rep. Heck. The Congressional Budget Office estimated in its latest economic outlook released on Feb. 5 that it would cost about $138 billion to permanently repeal the SGR. That's less than the $245 billion in previous CBO estimates.

"The time right now is perfect to finally pass this legislation," said Rep. Heck. 

"I think the imminent process of sequestration may add a little urgency to reform because across the board cuts are not going to get us where we need to go," said John Rother, president and CEO of the National Coalition on Health Care, an umbrella group representing medical societies, businesses, unions, health care providers, religious associations, insurers, and consumers. "And the alternative here is smarter and much more oriented toward value, and it provides a very practical and beneficial alternative to the kind of meat-axe approaches in sequestration," Mr. Rother said.

Physician groups said they are hopeful that the proposal has legs this year.

The constant uncertainty about whether SGR cuts will occur, "undermines the family doctor's ability to continue to keep doors open and to invest in their practices," said Dr. Jeffrey Cain, president of the AAFP. He praised the Heck-Schwartz bill, which had not been officially introduced in the House at press time, saying that it would put an end to "the annual question of whether physicians can continue to afford to practice in Medicare," and that it also "stabilizes the Medicare cost system and provides solutions that are based on successful and proven methods that can improve quality and incent value."

Dr. Chuck Cutler, chair-elect of the ACP Board of Regents, said that "the stability that this bill brings to the marketplace and to our practice is particularly encouraging." He also said that the ACP was happy that the bill would maintain 2013 payment levels through the end of 2014 and then provide "positive and predictable updates" through 2019.

That is especially important as physicians test out new delivery and payment models, said Dr. Cutler.

From 2015 to 2018, the bill calls for annual increases of 2.5% for primary care, preventive, and care-coordination services. All other physicians would get a 0.5% increase for the 4-year period.

By 2019, physicians who continue to use a volume-drive fee-for-service model would get a smaller increase than would those who have transitioned to new models.

In addition to the groups who participated in the briefing, the bill also is supported by the American College of Obstetricians and Gynecologists, the Society of Hospital Medicine, the American College of Rheumatology, the American College of Cardiology, the American Academy of Neurology, and the American Academy of Pediatrics.

[email protected]

On Twitter @aliciaault

A bill with bipartisan sponsors has been introduced in the U.S. House of Representatives to permanently repeal Medicare's Sustainable Growth Rate formula.

Rep. Joe Heck (R-Nev.) and Rep. Allyson Schwartz (D-Penn.) unveiled their proposal at a briefing with reporters on Feb. 6. They were surrounded by supporters, including representatives from the American College of Physicians, the American Academy of Family Physicians, the American College of Osteopathic Family Physicians, and the National Coalition on Health Care.

In addition to repealing the SGR, the bill also "stabilizes the current payment system for physicians, and it institutes measures to ensure access to primary care with increased updates for primary care physicians in the short term," said Rep. Schwartz, who added that it also "aggressively" tests new payment and delivery models and rewards high value, high quality health care. 

Rep. Schwartz and Rep. Heck, an osteopathic physician trained in emergency medicine, also introduced the bill in the last Congress. But both said that they think that legislators are primed to act, in part because of the struggle to reduce health care spending and the deficit. 

If the SGR is not replaced or repealed by the end of the year, physicians will see a 27% reduction in pay beginning in January 2014. Each year the cuts are delayed merely adds more on to the final tally for fixing the formula, noted Rep. Heck. The Congressional Budget Office estimated in its latest economic outlook released on Feb. 5 that it would cost about $138 billion to permanently repeal the SGR. That's less than the $245 billion in previous CBO estimates.

"The time right now is perfect to finally pass this legislation," said Rep. Heck. 

"I think the imminent process of sequestration may add a little urgency to reform because across the board cuts are not going to get us where we need to go," said John Rother, president and CEO of the National Coalition on Health Care, an umbrella group representing medical societies, businesses, unions, health care providers, religious associations, insurers, and consumers. "And the alternative here is smarter and much more oriented toward value, and it provides a very practical and beneficial alternative to the kind of meat-axe approaches in sequestration," Mr. Rother said.

Physician groups said they are hopeful that the proposal has legs this year.

The constant uncertainty about whether SGR cuts will occur, "undermines the family doctor's ability to continue to keep doors open and to invest in their practices," said Dr. Jeffrey Cain, president of the AAFP. He praised the Heck-Schwartz bill, which had not been officially introduced in the House at press time, saying that it would put an end to "the annual question of whether physicians can continue to afford to practice in Medicare," and that it also "stabilizes the Medicare cost system and provides solutions that are based on successful and proven methods that can improve quality and incent value."

Dr. Chuck Cutler, chair-elect of the ACP Board of Regents, said that "the stability that this bill brings to the marketplace and to our practice is particularly encouraging." He also said that the ACP was happy that the bill would maintain 2013 payment levels through the end of 2014 and then provide "positive and predictable updates" through 2019.

That is especially important as physicians test out new delivery and payment models, said Dr. Cutler.

From 2015 to 2018, the bill calls for annual increases of 2.5% for primary care, preventive, and care-coordination services. All other physicians would get a 0.5% increase for the 4-year period.

By 2019, physicians who continue to use a volume-drive fee-for-service model would get a smaller increase than would those who have transitioned to new models.

In addition to the groups who participated in the briefing, the bill also is supported by the American College of Obstetricians and Gynecologists, the Society of Hospital Medicine, the American College of Rheumatology, the American College of Cardiology, the American Academy of Neurology, and the American Academy of Pediatrics.

[email protected]

On Twitter @aliciaault

Background Hypersensitivity reactions to chemotherapy agents occur with relatively high frequency with some of the most widely used chemotherapeutic drug classes. Desensitization using a standard 12-step protocol has been successful, but takes about 6.5 hours. Limited studies have shown that a faster protocol may also be safe.

Objective To determine when desensitization could be safely speeded up.

Methods Patients with documented HSRs (24 patients) were desensitized initially with the standard 12-step protocol for 1 or 2 treatments, for a total of 180 desensitizations. Those patients who had negative skin testing and who tolerated the desensitizations were switched to the more rapid desensitization protocol (16 patients).

Results All 16 patients were successfully desensitized, having received the full dose of their chemotherapy. Eight patients were not advanced to the rapid protocol because they had reactions during initial desensitizations or they had a positive skin test; all of them were successfully desensitized using the 12-step protocol at the slower rate of infusion. These data present criteria for defining which patients may be safely transitioned to a rapid desensitization protocol.

Limitation Most of the patients in the study (21 of 24) were women.

Conclusions Patients with HSRs to chemotherapy agents, who tolerate an initial 12-step desensitization and have a negative skin test, can be advanced to a more rapid protocol. It is likely that patients with HSRs to the taxanes can be started on the more rapid protocol without starting on the 12-step protocol.

*Click on the PDF icon at the top of this introduction to read the full article.

Background Hypersensitivity reactions to chemotherapy agents occur with relatively high frequency with some of the most widely used chemotherapeutic drug classes. Desensitization using a standard 12-step protocol has been successful, but takes about 6.5 hours. Limited studies have shown that a faster protocol may also be safe.

Objective To determine when desensitization could be safely speeded up.

Methods Patients with documented HSRs (24 patients) were desensitized initially with the standard 12-step protocol for 1 or 2 treatments, for a total of 180 desensitizations. Those patients who had negative skin testing and who tolerated the desensitizations were switched to the more rapid desensitization protocol (16 patients).

Results All 16 patients were successfully desensitized, having received the full dose of their chemotherapy. Eight patients were not advanced to the rapid protocol because they had reactions during initial desensitizations or they had a positive skin test; all of them were successfully desensitized using the 12-step protocol at the slower rate of infusion. These data present criteria for defining which patients may be safely transitioned to a rapid desensitization protocol.

Limitation Most of the patients in the study (21 of 24) were women.

Conclusions Patients with HSRs to chemotherapy agents, who tolerate an initial 12-step desensitization and have a negative skin test, can be advanced to a more rapid protocol. It is likely that patients with HSRs to the taxanes can be started on the more rapid protocol without starting on the 12-step protocol.

*Click on the PDF icon at the top of this introduction to read the full article.

Background Hypersensitivity reactions to chemotherapy agents occur with relatively high frequency with some of the most widely used chemotherapeutic drug classes. Desensitization using a standard 12-step protocol has been successful, but takes about 6.5 hours. Limited studies have shown that a faster protocol may also be safe.

Objective To determine when desensitization could be safely speeded up.

Methods Patients with documented HSRs (24 patients) were desensitized initially with the standard 12-step protocol for 1 or 2 treatments, for a total of 180 desensitizations. Those patients who had negative skin testing and who tolerated the desensitizations were switched to the more rapid desensitization protocol (16 patients).

Results All 16 patients were successfully desensitized, having received the full dose of their chemotherapy. Eight patients were not advanced to the rapid protocol because they had reactions during initial desensitizations or they had a positive skin test; all of them were successfully desensitized using the 12-step protocol at the slower rate of infusion. These data present criteria for defining which patients may be safely transitioned to a rapid desensitization protocol.

Limitation Most of the patients in the study (21 of 24) were women.

Conclusions Patients with HSRs to chemotherapy agents, who tolerate an initial 12-step desensitization and have a negative skin test, can be advanced to a more rapid protocol. It is likely that patients with HSRs to the taxanes can be started on the more rapid protocol without starting on the 12-step protocol.

*Click on the PDF icon at the top of this introduction to read the full article.