By Jeffrey Norris
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Steven Pantilat |
"Treating illness means treating the whole patient," says Steven Pantilat, the physician who directs the UCSF Adult Palliative Care Service at the UCSF Medical Center at Parnassus. About half of the patients who consult with members of the service are cancer patients.
Palliative care is aimed at making patients more comfortable and at improving their quality of life through symptom management, counseling and caregiving. At UCSF, palliative care is available to patients undergoing active treatment, as well as to patients who have exhausted all curative treatment options.
Physical symptoms are not the only quality-of-life concerns in cancer. Cancer raises fear-provoking psychosocial issues. Coping with pain and debility or with thoughts of possible death commonly triggers anxiety, depression or a spiritual crisis for the patient and family.
UCSF is one of six Robert Wood Johnson Foundation-supported Palliative Care Leadership Centers nationwide. Groups from hospitals across the country come to UCSF to spend two days learning how to set up their own palliative care services. The leadership center also offers mentoring by email and occasional in-person meetings to members of these hospital groups as they develop their new services.
Outpatient Palliative Care Pilot
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Michael Rabow |
Over the past two years, Cancer Center member and palliative care physician Michael Rabow has developed and put into operation a symptom management consultation service at the UCSF Comprehensive Cancer Center to help outpatients with cancer cope with both symptoms and psychosocial issues. Rabow began the pilot program by teaming up with UCSF urologic surgeons and oncologists to provide services for patients who are undergoing aggressive treatment for cancer, as well as for patients who have exhausted curative options.
For example, a prostate cancer patient may be coping with incontinence or sexual dysfunction. Surprisingly, Rabow has found that men with localized prostate cancer are as likely to be depressed and anxious as men with metastatic prostate cancer, which has a much worse prognosis.
"There's no one who walks through the doors of the Cancer Center who isn't worried about what the disease means for their lives, their livelihood and their survival," Rabow says. "We have the chance to do leading work nationally to make sure that outpatients have the option to receive these services."
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Christine Miaskowski |
Symptom Management Research
Christine Miaskowski and Marylin Dodd, both Cancer Center members and professors of physiological nursing, have been conducting National Institutes of Health (NIH)-funded studies on pain and symptom management for many years.
In a study of women with breast cancer, Dodd recently found that exercise can help reduce fatigue symptoms even when patients start exercising before chemotherapy treatments have been completed.
In a separate, ongoing study, Dodd is investigating whether an antibiotic mouthwash that protects against infection can help heal mouth and digestive tract sores in head and neck cancer patients. This radiation therapy side effect, called mucositis, can be painful enough to cause patients not to eat.
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Marylin Dodd |
In her own research, Miaskowski found that patients who were in pain with cancer that had metastasized to bone had difficulties managing pain at home - they took about half the pain relief medication prescribed. Reasons included difficulty in obtaining medications and information on how to use them. But Miaskowski determined that medication side effects, especially constipation, are the leading barrier that prevents patients from taking adequate medication to ensure better pain relief.
In a follow-up study, patients were assigned by chance to receive either standard treatment or an educational program and skills training to better manage their pain. The educational program taught patients to take pain medications on a regular schedule and how to manage medication side effects. The experimental group reported about 30 percent less pain.
Miaskowski is currently following up on results from another line of research inquiry. From studies of patients with breast, prostate, lung and brain cancer, she has discovered that symptoms such as fatigue, depression, pain and loss of sleep cluster together. Focusing on fatigue, Miaskowski and colleagues have found that - among several clinical and demographic variables examined - age alone appears to be associated with fatigue. Surprisingly, on average, younger people report more fatigue.
During cancer treatment, patients appear to cluster into distinct subgroups according to the degree to which they report these symptoms over time. This leads Miaskowski to propose that genetic variables affect susceptibility to such symptoms. She plans to investigate this possibility in future research studies in collaboration with UCSF molecular geneticist Brad Aouizerat.
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Donald Abrams |
Osher Center for Integrative Medicine
Donald Abrams, director of clinical programs of the Osher Center for Integrative Medicine, is starting an NIH-funded study to investigate interactions of opioids and marijuana in the management of pain. Abrams previously found that cannabis is helpful in relieving nerve pain in patients with AIDS.
In another study, Abrams' Osher colleagues Wolf Mehling and Brad Jacobs found that patients benefited from massage and acupuncture in the weeks following cancer surgery. Abrams and his team now plan to investigate massage and wound healing in cancer patients who undergo surgery in abdominal regions.
"I think there is a great potential between the Cancer Center and the Osher Center to advance integrative therapies for symptom management," Abrams says.
Miaskowski and Abrams are leading efforts to develop a new Cancer Center program in symptom management, palliative care and survivorship to bolster research efforts and the translation of findings into clinical practice.
Related Links:
UCSF Medical Center: Palliative Care Service
UCSF Comprehensive Cancer Center
UCSF School of Nursing Research Center for Symptom Management
Osher Center for Integrative Medicine
Endowed Chair in Palliative Care Brings Solace to Terminally Ill Patients
UCSF Philanthrophy Insider, November 2005
Physicians Can Help Family Members Caring for Dying Loved Ones
UCSF News Release, January 27, 2004
