American Academy of Hospice and Palliative Medicine (AAHPM): Annual Assembly

VANCOUVER, B.C. – Precedex (dexmedetomidine), a drug used for years by intensivists and anesthesiologists for sedation, is increasingly being recognized as a valuable palliative care tool, according to Dr. Ellen M. Flanagan.

The alpha-2 agonist is an opioid-sparing analgesic that does not depress respiratory function; an anxiolytic with benzodiazepine-like activity but less risk of delirium and disinhibition; and a sedative from which patients can be aroused, among other properties, said Dr. Flanagan, an anesthesiologist at Duke University, Durham, N.C., with a special interest in palliative and end-of-life care.

Precedex "is incredible. It has really got some pretty profound implications for those patients who are having horrible deaths [with] intractable pain, agitation, and delirium." When standard drugs are "not sufficient to control symptoms, Precedex could do the trick," she said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

Intensive-care doctors and anesthesiologists use the drug routinely. More than 4.5 million vials have been administered since the Food and Drug Administration approved it in 1999 to sedate intubated and mechanically ventilated ICU patients. The drug received a second indication in 2008 for sedation of nonintubated patients before or during surgical and other procedures.

But "it’s a new drug to most palliative care physicians," Dr. Flanagan said.

Part of the reason is that Precedex has not been studied in palliative care patients. To date, case reports offer the strongest evidence of palliative efficacy, she said.

Dr. Flanagan and her colleagues hope to change the situation. Their investigational new drug application was approved by the FDA for a study in nine advanced cancer patients in the final week of life.

The team will assess the drug’s impact as an add-on to standard therapy for pain, agitation, delirium, communication capacity, dyspnea, vomiting, and oral secretions. The team is currently negotiating funding with Hospira, the drug’s maker, and other possible sources.

For now, the best dose, duration, and symptom targets for palliative care remain uncertain, she said.

Still, nurse practitioner Jennifer Gentry, palliative care services clinical coordinator at Duke and copresenter with Dr. Flanagan, said she has seen Precedex ease end-of-life suffering when other drugs failed to do so adequately, and enable reductions in opioid use so patients could be extubated and allowed to die in hospice or other comfortable settings, instead of the ICU.

Meanwhile, studies in other populations have shown good effect, Dr. Flanagan said.

In a study of postoperative pain control in 100 women following hysterectomy, women given Precedex required 29% less morphine and reported less pain and nausea on the first postoperative day. Sedation was similar between the morphine alone and morphine-plus-Precedex groups (Br. J. Anaesth. 2009;102:117-22).

In another trial of mechanically ventilated ICU patients, 54% of 244 patients given Precedex 0.2-1.4 mcg/kg per hour experienced delirium, but 76.6% of 122 given midazolam 0.02-0.1 mg/kg per hour became delirious. Precedex patients were able to be extubated a median of 1.9 days sooner, as well (JAMA 2009;301:489-99).

In general, the drug provides arousable sedation, which "I think is one of the most incredible things about it. Instead of just titrating morphine until the patient is unconscious, the patient can be sedated so they look like they’re sleeping, and you shake their shoulder and all of a sudden they are awake. When the family comes in and wants to talk, you may be able to arouse that patient" for meaningful communication, Dr. Flanagan said.

Precedex is expensive, however, at about $58/100 mcg, or about $600 per day. It’s coming off patent in 2013, so less-expensive generic formulations may soon be available, she said.

The drug’s side effects include dry mouth, hypotension, and bradycardia. For the study, "we did a lot of work with the FDA to try to set up parameters trying to figure out what [bradycardia and hypotension] might be due to drug and what might be due to the natural trajectory of death," Dr. Flanagan said.

Dr. Flanagan said she has no financial interests in Precedex.

VANCOUVER, B.C. – Precedex (dexmedetomidine), a drug used for years by intensivists and anesthesiologists for sedation, is increasingly being recognized as a valuable palliative care tool, according to Dr. Ellen M. Flanagan.

The alpha-2 agonist is an opioid-sparing analgesic that does not depress respiratory function; an anxiolytic with benzodiazepine-like activity but less risk of delirium and disinhibition; and a sedative from which patients can be aroused, among other properties, said Dr. Flanagan, an anesthesiologist at Duke University, Durham, N.C., with a special interest in palliative and end-of-life care.

Precedex "is incredible. It has really got some pretty profound implications for those patients who are having horrible deaths [with] intractable pain, agitation, and delirium." When standard drugs are "not sufficient to control symptoms, Precedex could do the trick," she said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

Intensive-care doctors and anesthesiologists use the drug routinely. More than 4.5 million vials have been administered since the Food and Drug Administration approved it in 1999 to sedate intubated and mechanically ventilated ICU patients. The drug received a second indication in 2008 for sedation of nonintubated patients before or during surgical and other procedures.

But "it’s a new drug to most palliative care physicians," Dr. Flanagan said.

Part of the reason is that Precedex has not been studied in palliative care patients. To date, case reports offer the strongest evidence of palliative efficacy, she said.

Dr. Flanagan and her colleagues hope to change the situation. Their investigational new drug application was approved by the FDA for a study in nine advanced cancer patients in the final week of life.

The team will assess the drug’s impact as an add-on to standard therapy for pain, agitation, delirium, communication capacity, dyspnea, vomiting, and oral secretions. The team is currently negotiating funding with Hospira, the drug’s maker, and other possible sources.

For now, the best dose, duration, and symptom targets for palliative care remain uncertain, she said.

Still, nurse practitioner Jennifer Gentry, palliative care services clinical coordinator at Duke and copresenter with Dr. Flanagan, said she has seen Precedex ease end-of-life suffering when other drugs failed to do so adequately, and enable reductions in opioid use so patients could be extubated and allowed to die in hospice or other comfortable settings, instead of the ICU.

Meanwhile, studies in other populations have shown good effect, Dr. Flanagan said.

In a study of postoperative pain control in 100 women following hysterectomy, women given Precedex required 29% less morphine and reported less pain and nausea on the first postoperative day. Sedation was similar between the morphine alone and morphine-plus-Precedex groups (Br. J. Anaesth. 2009;102:117-22).

In another trial of mechanically ventilated ICU patients, 54% of 244 patients given Precedex 0.2-1.4 mcg/kg per hour experienced delirium, but 76.6% of 122 given midazolam 0.02-0.1 mg/kg per hour became delirious. Precedex patients were able to be extubated a median of 1.9 days sooner, as well (JAMA 2009;301:489-99).

In general, the drug provides arousable sedation, which "I think is one of the most incredible things about it. Instead of just titrating morphine until the patient is unconscious, the patient can be sedated so they look like they’re sleeping, and you shake their shoulder and all of a sudden they are awake. When the family comes in and wants to talk, you may be able to arouse that patient" for meaningful communication, Dr. Flanagan said.

Precedex is expensive, however, at about $58/100 mcg, or about $600 per day. It’s coming off patent in 2013, so less-expensive generic formulations may soon be available, she said.

The drug’s side effects include dry mouth, hypotension, and bradycardia. For the study, "we did a lot of work with the FDA to try to set up parameters trying to figure out what [bradycardia and hypotension] might be due to drug and what might be due to the natural trajectory of death," Dr. Flanagan said.

Dr. Flanagan said she has no financial interests in Precedex.

VANCOUVER, B.C. – Precedex (dexmedetomidine), a drug used for years by intensivists and anesthesiologists for sedation, is increasingly being recognized as a valuable palliative care tool, according to Dr. Ellen M. Flanagan.

The alpha-2 agonist is an opioid-sparing analgesic that does not depress respiratory function; an anxiolytic with benzodiazepine-like activity but less risk of delirium and disinhibition; and a sedative from which patients can be aroused, among other properties, said Dr. Flanagan, an anesthesiologist at Duke University, Durham, N.C., with a special interest in palliative and end-of-life care.

Precedex "is incredible. It has really got some pretty profound implications for those patients who are having horrible deaths [with] intractable pain, agitation, and delirium." When standard drugs are "not sufficient to control symptoms, Precedex could do the trick," she said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

Intensive-care doctors and anesthesiologists use the drug routinely. More than 4.5 million vials have been administered since the Food and Drug Administration approved it in 1999 to sedate intubated and mechanically ventilated ICU patients. The drug received a second indication in 2008 for sedation of nonintubated patients before or during surgical and other procedures.

But "it’s a new drug to most palliative care physicians," Dr. Flanagan said.

Part of the reason is that Precedex has not been studied in palliative care patients. To date, case reports offer the strongest evidence of palliative efficacy, she said.

Dr. Flanagan and her colleagues hope to change the situation. Their investigational new drug application was approved by the FDA for a study in nine advanced cancer patients in the final week of life.

The team will assess the drug’s impact as an add-on to standard therapy for pain, agitation, delirium, communication capacity, dyspnea, vomiting, and oral secretions. The team is currently negotiating funding with Hospira, the drug’s maker, and other possible sources.

For now, the best dose, duration, and symptom targets for palliative care remain uncertain, she said.

Still, nurse practitioner Jennifer Gentry, palliative care services clinical coordinator at Duke and copresenter with Dr. Flanagan, said she has seen Precedex ease end-of-life suffering when other drugs failed to do so adequately, and enable reductions in opioid use so patients could be extubated and allowed to die in hospice or other comfortable settings, instead of the ICU.

Meanwhile, studies in other populations have shown good effect, Dr. Flanagan said.

In a study of postoperative pain control in 100 women following hysterectomy, women given Precedex required 29% less morphine and reported less pain and nausea on the first postoperative day. Sedation was similar between the morphine alone and morphine-plus-Precedex groups (Br. J. Anaesth. 2009;102:117-22).

In another trial of mechanically ventilated ICU patients, 54% of 244 patients given Precedex 0.2-1.4 mcg/kg per hour experienced delirium, but 76.6% of 122 given midazolam 0.02-0.1 mg/kg per hour became delirious. Precedex patients were able to be extubated a median of 1.9 days sooner, as well (JAMA 2009;301:489-99).

In general, the drug provides arousable sedation, which "I think is one of the most incredible things about it. Instead of just titrating morphine until the patient is unconscious, the patient can be sedated so they look like they’re sleeping, and you shake their shoulder and all of a sudden they are awake. When the family comes in and wants to talk, you may be able to arouse that patient" for meaningful communication, Dr. Flanagan said.

Precedex is expensive, however, at about $58/100 mcg, or about $600 per day. It’s coming off patent in 2013, so less-expensive generic formulations may soon be available, she said.

The drug’s side effects include dry mouth, hypotension, and bradycardia. For the study, "we did a lot of work with the FDA to try to set up parameters trying to figure out what [bradycardia and hypotension] might be due to drug and what might be due to the natural trajectory of death," Dr. Flanagan said.

Dr. Flanagan said she has no financial interests in Precedex.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.

VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.

The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.

She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.

The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.

The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.

Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.

About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.

The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.

The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.

Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.

"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.

The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.

Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.

Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.

She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).

No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.

"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.

A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.

For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).

Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.

"We just don’t know," Dr. Casey said.

Dr. Casey said she had no relevant financial disclosures.