Context The current state of palliative care in cancer centers is not known. Objective We conducted a survey to determine the availability and degree of integration of palliative care services, and to compare between National Cancer Institute (NCI) and non-NCI cancer centers in the United States. Design, Setting, and Participants Between June and October 2009, we surveyed both executives and palliative care clinical program leaders, where applicable, of 71 NCI cancer centers and a random sample of 71 non-NCI centers regarding their palliative care services. Executives were also asked about their attitudes toward palliative care. Main Outcome Measure Availability of palliative care services in the cancer center, defined as the presence of at least one palliative care physician. Results We sent 142 and 120 surveys to executives and program leaders, with response rates of 71% and 82%, respectively. NCI cancer centers were significantly more likely to have a palliative care program (50/51 (98%) vs. 39/50 (78%), P=0.002), at least one palliative care physician (46/51 (90%) vs. 28/50 (56%), P=0.04), an inpatient palliative care consultation team (47/51 (92%) vs. 28/50 (56%), P<0.001), and an outpatient palliative care clinic (30/51 (59%) vs. 11/50 (22%), P<0.001). Few centers had dedicated palliative care beds (23/101 (23%)) or an institution-operated hospice (37/101 (36%)). The median reported durations from referral to death were 7 (Q1–Q3 4–16), 7 (Q1–Q3 5–10), and 90 (Q1–Q3 30–120) days for inpatient consultation teams, inpatient units, and outpatient clinics, respectively. Research programs, palliative care fellowships, and mandatory rotations for oncology fellows were uncommon. Executives were supportive of stronger integration and increasing palliative care resources. Conclusion Most cancer centers reported a palliative care program, although the scope of services and the degree of integration varied widely. Further efforts to consolidate existing infrastructure and to integrate palliative care in cancer centers are warranted.

BM and SREs are frequent in patients with malignant PHEO/sPGL. SREs often develop shortly after the diagnosis of BM; severe pain is the most frequent SRE. These patients should be followed long-term by a multidisciplinary team to promptly identify the need for medical or surgical intervention.

Sixty-one percent of patients with a diagnosis of delirium by a palliative care specialist were missed by the primary referring team. Patients with MD were frequently referred for pain. Universal screening of cancer patients for delirium is recommended.

Context Approximately 80% of patients with advanced cancer report pain and receive opioids. Information is limited about deviations from prescribed opioid doses and barriers to pain control, but poor opioid adherence has been reported in 49%–70% of patients. Objectives To evaluate the frequency and severity of self-reported opioid deviation and barriers to opioid pain management in outpatients with advanced cancer. Methods We surveyed 198 patients and collected pain scores (0–10), prescribed opioid dose, confidential patient-reported opioid prescription dose and intake (as long as there was no severe opioid deviation), barriers to pain management (Barriers Questionnaire-II [BQ-II]) scores, and adherence scores. Opioid deviation was defined as <70% or >130% of the prescribed dose. Results Median patient age was 55 years; 91 (46%) were female. Median pain intensity and morphine equivalent daily dose were 4 (interquartile range [IQR]=3–7) and 120 mg (IQR=45–270mg), respectively. Prescribed and patient-reported prescribed doses were highly correlated for regular (r=0.90, P<0.001) and regular plus breakthrough opioid intake (r=0.94, P<0.001). Nineteen (9.6%) patients deviated. Deviation was more frequent in males (P=0.039) and non-Whites (P=0.0270). Non-White patients had higher scores on the BQ-II than White patients (P=0.038). Low adherence scores were significantly associated with higher BQ-II scores (1.99±0.80) for lower motivation score vs. 1.61±0.77 for higher score, P=0.007; and 2.13±0.79 for lower knowledge score vs. 1.57±0.72 for higher score, P=0.001. Conclusion Very few patients reported dose deviations, which were mostly towards lower dose. More research is necessary to better characterize the frequency and predictors of opioid deviation in this population.

The majority of caregivers of patients with advanced cancer considered themselves spiritual and religious. Despite this, there is high prevalence of spiritual pain in this population. Caregivers with spiritual pain experienced worse psychological distress and worse QOL. These findings support the importance of spiritual assessment of and spiritual support for caregivers in this setting.

The current state of the palliative oncology literature is unclear. We examined and compared the quantity, research design, and research topics of palliative oncology publications in the first 6 months of 2004 with the first 6 months of 2009. We systematically searched MEDLINE, PsychInfo, EMBASE, ISI Web of Science, and CINAHL for original studies, review articles, and systematic reviews related to "palliative care" and "cancer" during the

Background: Recent reports suggest that high doses of methadone may prolong QTc interval and occasionally cause torsades de pointes; however, few of these studies involved the palliative care population. Objective: The purpose of this study was to determine the effect of initiation of methadone on QTc interval in patients with cancer pain seen at the palliative care setting. Methods: We enrolled 100 patients with cancer in this prospective study. Patients were followed clinically and electrocardiographically for QTc changes at baseline, 2, 4, and 8 weeks. Contributing factors for QTc prolongation such as medications, cardiovascular diseases, and electrolytes disturbances were documented. QTc prolongation was defined as greater than 430 ms in males and greater than 450 ms in females, and significant QTc prolongation was defined as QTc interval greater than 25% increase from baseline or 500 ms or more. Results: Electrocardiographic (ECG) assessments were available for 100, 64, 41, and 27 patients at baseline, 2-, 4-, and 8-week follow-up, respectively. At baseline prior to initiation of methadone, 28 (28%) patients had QTc prolongation. Clinically significant increase in QTc occurred in only 1 of 64 (1.6%) patients at week 2, and none at weeks 4 and 8. There was no clinical evidence of torsades de pointes, ventricular fibrillation, or sudden death. QTc prolongation was more frequent among patients with increased baseline QTc interval. Conclusions: Baseline QTc prolongation was common, whereas significant QTc interval 500 ms or more after methadone initiation rarely occurred, with no evidence of clinically significant arrhythmias. This study supports the safety of methadone use for pain control in patients with advanced cancer in the palliative care setting.

BACKGROUND:Methadone is an effective and inexpensive opioid for cancer pain treatment. It has been reported as difficult to use in the outpatient setting because of its variable relative potency and long half-life. The purpose of this study was to determine the outcome of methadone initiation or rotation for cancer pain treatment in outpatient settings. METHODS: Chart review was done of 189 consecutive patients who underwent methadone initiation or rotation at the authors' palliative care outpatient center. Data were collected regarding demographic and clinical characteristics, symptoms, and opioid side effects at baseline and for 2 follow-up visits (F1, F2). Failure was defined as methadone discontinuation by the palliative care physician or patient's hospitalization for uncontrolled pain or methadonerelated side effects at F1. RESULTS: One hundred (53%) initiations and 89 (47%) rotations were conducted. Success rates for methadone initiation and rotation were 82 of 89 (92%) and 85 of 100 (84%), respectively. Mean (standard deviation) age was 60 (11) years. One hundred (53%) patients were women, 138 (73%) were white, and 182 (96%) had solid cancers. The main reason for rotation was pain (65 of 89 patients, 47%). Median (interquartile range, IQR) pain scores (Edmonton Symptom Assessment Scale/0-10) were 6 (5-8), 4 (3-6), and 3 (2-5) at baseline, F1, and F2, respectively (P < .0001). Median (IQR) daily methadone dose for initiation and rotation was 10 (5-15) mg and 15 (10-30) mg at F1 (P < .0001) and 10 (8-15) mg and 18 (10-30) mg at F2 (P < .0001), respectively. Constipation and nausea improved (P < .005) after initiation/rotation to methadone. Frequency of sedation, hallucinations, myoclonus, and delirium did not increase after initiation/rotation to methadone. CONCLUSIONS: Outpatient methadone initiation and rotation for cancer pain treatment were safe, with high success rates and low side effect profiles. Cancer 2010;116:520-8.