Lessons from the Literature

2021; Volume 22, No 3, March

Under My Microscope

Dr. Tania Pastrana. Used with permission.

By Dr. Tania Pastrana
IAHPC Research Advisor

A randomised, double blind, placebo-controlled trial of megestrol acetate or dexamethasone in treating symptomatic anorexia in people with advanced cancer

Currow DC, Glare P, Louw S, Martin P, Clark K, Fazekas B, Agar MR. Sci Rep 2021; 11(1): 2421.

Corticosteroids have had broad use in palliative care; however, the evidence to guide treatment decisions is scarce, as stated in a recent systematic review.1

An Australian research team led by David Currow examined a frequent and distressing symptom for patients and their loved ones—loss of appetite. This study assessed the two most frequently used medications for anorexia in advanced cancer, comparing them with a placebo. Do you use one of them in your everyday praxis?

The team conducted a multisite, double blind, parallel arm, randomized (1:1:1) study with 190 patients over four weeks, comparing megestrol acetate (480 mg/day) with dexamethasone (4 mg/day) and placebo for their short-term effect on appetite in people with cancer anorexia. Responders were defined as improving ≥ 25% over the baseline.

Primary outcomes (at day 7) showed no statistical difference in the three arms; however, the direction of benefit regarding anorexia favored megestrol. Neither drug was found to have an effect on in either performance status or quality of life (secondary outcomes). Almost all participants reported an adverse effect or effects, being most frequent with dexamethasone. The study concluded was that there was no benefit over placebo, with anorexia improving in all three arms.

I appreciate the collaborative aspect of the study, which involved the participation of 12 centers covering 23 institutions across Australia, as well as the reporting of “conclusive negative findings/results.”2

References
  1. 1. Hardy J, Haywood A, Rickett K, Sallnow L, Good P. Practice Review: Evidence-based quality use of corticosteroids in the palliative care of patients with advanced cancer. Palliat Med 2021. DOI: 10.1177/0269216320986717
  2. 2. Joober R, Schmitz N, Annable L, Boksa P. Publication Bias: What are the challenges and can they be overcome? J Psychiatry Neurosci. 2012; 37(3): 149-152.

Full text

This multisite, double blind, parallel arm, fixed dose, randomised placebo controlled phase III study compared megestrol acetate 480 mg/day with dexamethasone 4 mg/day for their net effects on appetite in people with cancer anorexia. Patients with advanced cancer and anorexia for ≥ 2 weeks with a score ≤ 4 (0–10 numeric rating scale (NRS) 0 = no appetite, 10 = best possible appetite) were recruited. Participants received megestrol 480 mg or dexamethasone 4 mg or placebo daily for up to 4 weeks. Primary outcomes were at day 7. Responders were defined as having a ≥ 25% improvement in NRS over baseline. There were 190 people randomised (megestrol acetate n = 61; dexamethasone n = 67, placebo n = 62). At week 1 (primary endpoint), 79·3% in the megestrol group, 65·5% in the dexamethasone group and 58·5% in the placebo group (p = 0.067) were responders. No differences in performance status or quality of life were reported. Treatment emergent adverse events were frequent (90·4% of participants), and included altered mood and insomnia. Hyperglycemia and deep vein thromboses were more frequent when on dexamethasone than the other two arms. There was no difference in groups between the three arms, with no benefit seen over placebo with anorexia improving in all arms.


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Media Watch: Research in LMICs

The articles below are selected from Barry R. Ashpole’s weekly report, Media Watch.

Using Virtual Learning to Build Pediatric Palliative Care Capacity in South Asia: Experiences of implementing a teleteaching and mentorship program (Project ECHO)

JCO Global Oncology 2021; 7: 210-222. In low- and middle-income countries, where 98% of the children needing palliative care (PC) reside, access to PC services is often very limited. Virtual learning, which brings training and mentorship directly to learners, can improve access to educational opportunities for staff in resource-limited settings. The authors describe the design, implementation, challenges, and subsequent modifications of teleteaching and mentorship program, as well as the impact of the program for participants and for pediatric PC service delivery in South Asia. Project ECHO (Extension for Community Healthcare Outcomes) consisted of biweekly videoconference sessions with didactic teaching and case-based discussions. The program focused on engaging participants in meaningful learning by focusing on opportunities for participant interaction through teachings and case discussions. DOI: 10,1200/GO.20.00481

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Grief and Bereavement in Parents after the Death of a Child in Low- and Middle-Income Countries

Children 2020; 7(5): 1. While great strides have been made in improving childhood mortality, millions of children die each year with significant health-related suffering. More than 98% of these children live in low- and middle-income countries (LMICs). Efforts have been made to increase access to pediatric palliative care (PPC) services to address this suffering in LMICs through policy measures, educational initiatives, and access to essential medicines. However, a core component of high-quality PPC that has been relatively neglected in LMICs is grief and bereavement support for parents after the death of their child. This includes describing bereavement research in high-income countries (HICs), including its definition, adverse effect upon parents, and supportive interventions, followed by a review of the literature on health-related grief and bereavement in LMICs, specifically around perinatal death, infant mortality, infectious disease, interventions used, and perceived need. DOI: 10.3390/children7050039

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Community health workers in palliative care provision in low-income and middle-income countries: A systematic scoping review of the literature

BMJ Global Health, 2020;5(5):e002368. The 13 studies included in this review all took place in sub-Saharan African countries or in India. Despite the limited evidence base, the authors found that community health workers (CHWs) have several roles in palliative care (PC) provision in low-income and middle-income (LMIC) settings. These include raising awareness in the community, provision of pain management services, home-based care delivery and visitation, and provision of psychological support and spiritual guidance. Several areas of weakness were also identified, including a lack of details surrounding the training and ongoing support of CHWs, as well as the financial costs associated with deploying CHWs in the provision of PC services. There is a need for countries to develop their own specific guidelines for the roles CHWs should play in PC, so that any initiatives are appropriate for the context in which they are being implemented. DOI: 10.1136/bmjgh-2020-002368

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Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.


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