BackgroundPalliative sedation (PS) is an intervention to treat refractory symptoms and to relieve suffering at the end of life. Its prevalence and practice patterns vary widely worldwide. The aim of our study was to evaluate the frequency, clinical indications and outcomes of PS in advanced cancer patients admitted to our tertiary comprehensive cancer center.MethodsWe retrospectively studied the use of PS in advanced cancer patients who died between March 1st, 2012 and December 31st, 2014. PS was defined as the use of continuous infusion of midazolam or neuroleptics for refractory symptoms in the end of life. This study was approved by the Research Ethics Committee of our institution (project number 2481–15).ResultsDuring the study period, 552 cancer patients died at the institution and 374 met the inclusion criteria for this study. Main reason for exclusion was death in the Intensive Care Unit. Among all included patients, 54.2% (n = 203) received PS. Patients who received PS as compared to those not sedated were younger (67.8 vs. 76.4 years-old, p < 0.001) and more likely to have a diagnosis of lung cancer (23% vs. 14%, p = 0.028). The most common indications for sedation were dyspnea (55%) and delirium (19.7%) and the most common drugs used were midazolam (52.7%) or midazolam and a neuroleptic (39.4%). Median initial midazolam infusion rate was 0.75 mg/h (interquartile range – IQR - 0.6-1.5) and final rate was 1.5 mg/h (IQR 0.9–3.0). Patient survival (length of hospital stay from admission to death) of those who had PS was more than the double of those who did not (33.6 days vs 16 days, p < 0.001). The palliative care team was involved in the care of 12% (n = 25) of sedated patients.ConclusionsPS is a relatively common practice in the end-of-life of cancer patients at our hospital and it is not associated with shortening of hospital stay. Involvement of a dedicated palliative care team is strongly recommended if this procedure is being considered. Further research is needed to identify factors that may affect the frequency and outcomes associated with PS.Electronic supplementary materialThe online version of this article (10.1186/s12904-017-0264-2) contains supplementary material, which is available to authorized users.

Cancer-related cachexia (CRC) is a multidimensional, frequent and devastating syndrome. It is mainly characterized by a loss of skeletal muscle tissue, accompanied or not by a loss of adipose tissue that leads to impaired functionality, poor quality of life, less tolerability to cancer-directed therapies, high levels of psychosocial distress, and shorter survival. Despite its clinical importance, there is a lack of effective pharmacological therapies to manage CRC. Pro-cachectic cytokines have been shown to play a critical role in its pathogenesis, providing the conceptual basis for testing anti-cytokine drugs to treat this paraneoplastic syndrome. The aim of this review was to examine the current evidence on anti-cytokines in the treatment of CRC. Several anti-cytokine agents targeting one or more molecules (i.e., TNF-alpha, IL-1 alpha, IL-6, and others) have been investigated in clinical trials for the treatment of CRC, mainly in phase I and II studies. Results have been mixed, and few drugs have demonstrated positive effects in larger phase III trials. Thalidomide, a derivative of glutamic acid with anti-inflammatory, immunomodulatory, and anti-angiogenic properties, and MABp1, a natural IgG1k human monoclonal antibody against IL-1 alpha, have shown the most prominent clinical benefits. Studies have recruited heterogeneous cancer patient populations in late disease stages, and many had issues with accrual and attrition. Anti-cytokines remain a promising treatment strategy in the treatment of CRC. Agents targeting multiple CRC cytokines and pathways, while also possessing anti-tumor effects, such as thalidomide and MABp1, have attained the most interesting outcomes, and warrant further investigation. Future studies including more homogenous populations, using valid and clinically meaningful outcome measures and testing low toxicity drugs in earlier stages of the cancer cachexia continuum might achieve better results.

221 Background: Although urine drug testing (UDT) is an effective risk monitoring tool for patients on chronic opioid therapy, there is currently no evidence to guide physicians in identifying who should have UDT, or when and how often it should be ordered. The main objective of our study was to describe the characteristics of patients who underwent random UDT and a similar cohort who underwent targeted UDT. Methods: Demographic and clinical information of 212 patients who underwent random UDT was retrospectively reviewed and compared with 88 patients who underwent targeted UDT. Targeted UDT was ordered based on the physician’s estimation of patient risk for nonmedical opioid use. All patients were eligible for random UDT regardless of their risk potential for nonmedical opioid use. Results: 212/231 (92%) eligible patients underwent random UDT. Of these 59 (28%) had abnormal results. Among 64 abnormalities detected, 14 (20%) were prescribed opioids that were absent from the urine, 19 (30%) were unprescribed opioids that were present, and 32 (50%) were illicit drugs (91% marijuana). 38/88(43%) of targeted patients had abnormal results. Among 49 abnormalities detected, 13 (27%) were prescribed opioids that were absent from the urine, 15 (31%) were unprescribed opioids that were absent, and 21 (43%) were illicit drugs (71% marijuana). UDT abnormalities were significantly higher in the targeted group than the random group (43.2% vs. 27.8%, p=0.01). There were no significant differences in demographic and clinical characteristics between random and targeted patients with abnormal UDT findings. UDT abnormality was independently associated with age (OR= 0.97 per year, 95% CI: 0.95-0.99, p=0.012), female gender (OR=0.47, 95% CI: 0.28-0.81, p=0.006), anxiety (OR=1.11per point, 95% CI: 1.01-1.22, p=0.039), and appetite (OR= 1.14 per point, 95% CI: 1.04-1.26, p=0.006). Conclusions: More than 1 in 4 cancer patients who underwent random UDT had abnormal results. UDT abnormality in randomly selected patients were no different from targeted patients. Further studies are needed to guide clinical practice regarding standardization of UDT ordering among patients with cancer.

There is limited information on best practices regarding urine drug testing (UDT) during long-term opioid therapy for cancer pain. 1 Practices involve random UDT 1 or UDT based on risk for nonmedical opioid use. 2 The main objective of this study was to report the frequency of abnormal UDT findings among patients who underwent random vs targeted testing.

Thirty-seven percent of advanced cancer patients receiving PC inaccurately perceived their disease curable. These patients were more likely to have earlier PC referrals. An accurate perception of curability was associated with passive DCP. Further studies are needed to test effective communication strategies to mitigate this misperception.