EAPC - ipac

410 EAPC Abstracts
35 Oral Presentation
Cachexia
A novel Cachexia Classification for Palliative Cancer Care:
Synthesis of systematic literature review and nominal experts’
focus group
Authors: Florian Strasser Dept. Internal Medicine & Palliative Care Centre
Oncological Palliative Medicine, Section Oncology SWITZERLAND
Aurelius Omlin Oncological Palliative Medicine, Cantonal Hospital
St. Gallen SWITZERLAND
Jochen Walker Oncological Palliative Medicine and Surgery, Cantonal
Hospital St.Gallen SWITZERLAND
David Blum Oncological Palliative Medicine, Cantonal Hospital St.Gallen
SWITZERLAND
Ken Fearon Surgical Oncology, Royal Infirmary of Edinburgh Edinburgh
UNITED KINGDOM
repesenting the EPCRC
Background: The current definition of cancer cachexia (weight loss,
anorexia) does poorly guide practice. To monitor clinical decisions, alleviate
suffering and develop tailored anti-cachexia interventions, a novel cachexia
classification system, adjusted for palliative care, is required. Methods: A
SLR (1976–2007) was performed (Pubmed, Cochrane, Embase, PsycINFO,
CinAhl; search strings: cachexia, cancer, classification). Inclusion criteria:
system or factor to classify patients with cachexia or to predict response to
anticachectic treatment. Data extraction (2 raters) applied a formalized list,
considering results of the first FG. Scoring for quality (Hawker) is done.
Nominal FG of 12 academic cachexia experts discussed in 2 rounds “Which
factors guide clinical decision making for cachexia management in daily
practice” Key findings from the first round and the SLR were presented in
the second round. Collaboration with a non-cancer specific wasting/cachexia
consensus group was achieved. The final synthesis includes eligibility criteria
and stratification factors from registered anti-cachexia trials and applies
a structured Delphi-type review process. Results: Of 9817 citations,
126 papers (7 systems, 112 factors; 7913 patients [50% GI, 20% lung cancer])
were included. 4 systems combined anthropometrics (AM), nutritional
intake (NI), symptoms (SY) and inflammation (INF), 2 systems AM/NI and
either SY or INF, 1 added REE and hormones. All systems challenge the old
definition. Of the single factors, AM, INF, muscle strenght and ghrelin classify
cachexia in most studies, whereas NI, SY, metabolic alterations, REE,
and leptin are variably reported. Responders in 84 anticachexia trials were
not identified by factors. Consensus appears in cachexia as ongoing loss of
muscle mass with 3 domains: depleted muscle protein, decreased ability to
eat, and a catabolic drive. Symptoms are in all domains. Conclusions: A
novel, pragmatic CCS-PC hold promise for care and research.
36 Invited Lecture
Systematic Reviews – what they can and what they can’t do
Systematic reviews: an essential tool or a fashionable foible
Authors: Lukas Radbruch Department of Palliative Medicine University of
Aachen GERMANY
Research in palliative care faces many barriers, among them physical frailty
and cognitive impairment as well as a general reluctance of clinical staff to
recruit patients, as clinical trials are felt to be in contradiction with the holistic,
caring philosophy of palliative care. Sample sizes of published studies
are small, with wide variations in the study populations. This has led to an
increasing use of systematic review in an attempt to collate high quality
information from these studies. The use of systematic reviews is also fostered
by the rise of evidence-based medicine (EBM), as systematic reviews
are on the top of the scoring lists of EBM. Systematic reviews allow for a
quick and comprehensive apprehension of the available literature.
However, there are some drawbacks to the new fashion of EBM. User as
well as authors of systematic reviews often forget that the absence of evidence
does not equal the evidence of absent efficacy. Many reviews start
high with elaborate search strategies and inclusion criteria, and end modestly
with only a few papers (which could not be compared) found useful for
their remit. Many reviews end with the stereotypical statement: there is not
enough evidence. There is an inherent danger from this position, as it may
lead decision makers to focus on those treatments only which have been
proven effective with EBM. This means that decisions focus on systematic
reviews and the randomized trials that generated them, and users forget that
other evidence is also acknowledged in EBM, though on a lower level.
Even the much maligned expert opinion is part of EBM, if no (randomized)
trials are available. There may be good reasons why there are no randomized
trials. For example the evidence from randomized trials on the efficacy
of morphine is scarce, but running such a trial today would be unnecessary
and inacceptable from an ethical point of view. We have to take care
that we use systematic reviews where we need them, but not as a means to
end all discussions.
37 Invited Lecture
Systematic Reviews – what they can and what they can’t do
Cochrane reviews in palliative care: where is the evidence
Common errors and problems with systematic reviews in palliative
care and how to overcome
Authors: Phil J. Wiffen Churchill Hospital, Pain Research Unit Pain,
Palliative & Supportive Care CRG UNITED KINGDOM
This lecture will present an overview of what we currently have in terms of
systematic reviews and controlled trials. Current challenges include a lack
of suitable data for analysis, continued use of practices that have been
shown to be ineffective or have little supporting evidence, challenges of
extrapolation of results from outside palliative care and imperfect methodology
to get the best from qualitative data. The goal of developing a systematic
review for the major issues in palliative care is not an impossible dream
but will need to stimulate a higher standard of research and development of
collaborative research groups that can recruit larger numbers of participants
for trials.
38 Invited Lecture
Systematic Reviews – what they can and what they can’t do
Drug treatment of cancer-related fatigue. An example of a
Cochrane review and of the problems with extrapolating
results from cancer to palliative care
Authors: Paddy Stone Division of Mental Health St George’s Hospital
Medical School UNITED KINGDOM
This presentation will discuss the difficulties of using the results of a
Cochrane systematic review in routine clinical practice. The presentation
will be illustrated with the example of a recently conducted review and
meta-analysis of randomised controlled trials for patients with cancerrelated
fatigue (full results presented elsewhere). The author will explain
how the review group settled on inclusion and exclusion criteria for the systematic
review. These were based on a study quality standard requiring randomisation
of treatment as a minimum. The impact of using different search
strategies will be discussed. The chosen search strategy identified over
5000 abstracts with 116 being short-listed for potential inclusion. Only
45 studies fully met the inclusion criteria. It was decided only to analyse
studies that used multi-item outcome measures – thus 27 trials were included
in the meta-analysis. The rigorous criteria used in Cochrane reviews led
to the exclusion of drug treatments examined only in phase 2 studies. Many
studies of palliative care patients fell into this category and were excluded
at the screening stage. The discussion of selected results will focus on how
the findings can be applied in clinical practice. The populations studied
were mainly receiving active treatment. The majority of the data comes
from trials of anaemic cancer patients receiving erythrocyte colony growth
factors such as erythropoietin. It is unclear how these results can be applied
to a palliative care population without further study. The author will discuss