Network Five: Medical oncology

Network Five: Episode 7 – Medical oncology

ParticipantsProfessor Nicholas Wilcken, Sarah Rashid, Bratati Karmakar, Harry Hong, Dr Pramod Chandru, Shreyas Iyer, Caroline Tyers, and Kit Rowe

Part 1

In this episode, we first explore if dexmedetomidine has a role in managing hyperactive delirium at the end of life. Presenter: Sarah Rashid, physician trainee at Westmead Hospital

• Thomas B, Lo WA, Nangati Z, Barclay G. Dexmedetomidine for hyperactive delirium at the end of life: An open-label single arm pilot study with dose escalation in adult patients admitted to an inpatient palliative care unit. Palliat Med. 2021 Apr;35(4):729-737

Take-Home Points:

• There is minimal evidence even behind our standard of care for these patients (midazolam, neuroleptics, and barbiturates). 
• This paper encourages us to think laterally about what medications can be used for these patients. 
• Terminal delirium is distressing for patients and their families, and at present, our treatments provide comfort but at the expense of wakefulness and interaction.
• More research needs to be done into agents such as dexmedetomidine which could allow for a better-sedated experience.
• More research also needs to be done into the experience of the dying process for patients and their families. 
• Families have large effects on the management of dying patients, and thus there is limited value in doing a study without measuring outcomes for both the patients and their families. 

Part 2

In this second part of the series, we discuss the toxic effects of immune checkpoint inhibitors (that are used to treat a variety of malignancies). Presenter: Harry Hong – ED senior resident medical officer, at Westmead Hospital

• Wang DY et al. Fatal Toxic Effects Associated With Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis. JAMA Oncol. 2018 Dec 1;4(12):1721-1728

Take-Home Points:

• These drugs for some cancers have completely revolutionized treatment (they are not going away!). 
• It is important to remember that the rate of fatal adverse events with these agents is still very low (particularly when compared with other oncology treatments). 
• This data gives us information for what to be vigilant for when caring for these patients (particularly those presenting with non-specific symptoms and recent commencement on these agents). 
• Take colitis seriously; it can be fatal. 
• We are all learning; this is a new class of drugs with completely different toxicity to what we are used to – if in doubt ask the medical oncologist! 

Part 3

In this final part of the series on oncology, we learn about the concept of frailty and review some tools that can be used to assess it. Presenter: Bratati Karmakar, physician trainee at Napean Hospital.

• Biganzoli L et al. Screening for Frailty in Older Patients With Early-Stage Solid Tumors: A Prospective Longitudinal Evaluation of Three Different Geriatric Tools. J Gerontol A Biol Sci Med Sci. 2017 Jul 1;72(7):922-928.

Take-Home Points:

• Recognizing frailty is important and it can be conveniently assessed at the bedside with tools such as VES-13 (but standardized frailty assessment tools need to be developed). 
• Comorbid conditions do not indicate the presence or absence of frailty in isolation.
• Physical disability is not a reflection of frailty. 
• Whilst frailty increases with age, it is not a consequence of aging. 
• Shared language is important for information to be clinically relevant. 

These episodes were produced with help of HETI’s Emergency Medicine Training Network 5. Please send us an email to let us know what you thought. You can contact us at [email protected]