08.04.2016

Cancer treatment guidelines europe

PSA determination should not be used as a population-wide mass screening test for the early detection of prostate cancer in asymptomatic males. A brochure has been developed on the potential benefits and risks of the use of a PSA determination for the early detection of prostate cancer for the public. The use of a PSA test is also recommended for men with moderate or severe symptoms of prostatism in whom treatment is contemplated. A PSA determination is recommended for any man, with a life expectancy of 10 years or more, found to have a prostatic nodule on a digital rectal examination (DRE). A PSA determination is recommended for any man, with a life expectancy of 10 years or more, where there is an increased suspicion of prostate cancer.
A serum PSA determination may be considered for any man over the age of 40 years with a life expectancy of 10 years or more, who has a higher risk of prostate cancer.
The use of a PSA test is recommended for men with moderate or severe symptoms of prostatism in whom treatment is contemplated. It is important that the laboratory store the specimen appropriately if free PSA is to be measured. The committee recommends the use of the PSA test to monitor patients with established cancer. Total PSA determination should be used to monitor for residual or recurrent PC after treatment by any of the current modalities except brachytherapy, where its role if any, is not yet established. Currently there is no evidence that indicates benefit from ultrasensitive PSA measurements.
In monitoring therapy, and in diagnosis, screening and staging of prostate cancer, Prostatic Acid Phosphatase (PAP) offers no benefit in addition to PSA. Note : These guidelines were prepared at the request of the Ministry of Health and Long-Term Care. A hormonal disorder caused by prolonged exposure to the hormone cortisol, Cushing’s syndrome is usually more common in women.
Treatment can involve the gradual withdrawal of cortisone-type drugs and drug treatment to suppress adrenal gland function. Michael Blake, founder of Startup Lounge, a private networking event for early-stage entrepreneurs and investors, says that most entrepreneurs will “reach a point where their faith in their venture is tested, because they’re stuck. Most mentors appreciate that they’re paying back what was paid forward when they were starting out, by passing on their collected wisdom to the next generation of entrepreneurs.
Some entrepreneurs might be interested in having their mentor make a financial investment in their company.
Papparelli says that “The biggest fear of any entrepreneur is death by what he or she doesn’t know. Most mentors, though, aren’t invested in the company, they’re invested in their proteges, and they want their proteges to be successful no matter what venture they’re engaged in.
Mentors have tremendous value to entrepreneurs because they have knowledge and experience in a particular area of business.
But eventually, most entrepreneurs accrue enough wisdom and experience to outgrow their need for a mentor’s business advice. According to the USDA, eating healthier is one of the most common New Year’s resolutions in the US. For students at BU, Sargent Choice makes eating healthier easy: just look for the Sargent Choice sticker at the GSU and Breadwinners or choose Sargent Choice options in the dining halls. Nowadays, most of the foods that we eat are mixed with artificial flavors and because of this we can easily get sick.
It has been 5 years since the publication of this Clinical Practice Guideline and it is subject to updating. Delirium is defined as an acute confusional state resulting from diffuse brain dysfunction.
A) Alteration of consciousness with reduction of the capacity to focus, maintain or direct attention. B) Change in cognitive functions (memory, orientation, language) or perceptive alteration that is not explained by the existence of prior or developing dementia. C) Presentation in a period of time (hours or days) and tendency to fluctuate throughout the day. Delirium must be suspected whenever there is an acute change in behaviour, the cognitive state or the state of alert of the patient, above all when there is dementia, recent surgery, auditory or visual handicap, consumption of alcohol, possibility of alteration of sodium, use of certain drugs, etc.
The intensity of the manifestations is very variable, so some light forms that appear as unease or difficulty to reconcile sleep, for example, may go unnoticed, as the symptoms are attributed to other circumstances of the patient. The CAM-ICU (188) is recommended in intensive care units or in patients who are unable to communicate verbally. It is important to identify the factors that cause or precipitate delirium, as they determine the need to use additional tests and the correct treatment.
Monitoring the symptoms, an essential aspect of PC, may prevent the appearance of delirium, as the inadequate control of some symptoms, such as pain, may trigger the problem.
This feature is usually obtained from an observer (family member or nursing staff) and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient’s baseline? This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? This feature is shown by a positive response to the following question: Was the patient’s thinking disorganised or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Opioids, benzodiazepines, tricyclic antidepressants, anticholinergic (oxybutynin, tolterodin), SSRI, neuroleptics, antihistamines, orthopramides, anticonvulsants (primidone, phenobarbital, phenytoin), antiParkinsonians. The treatment of delirium includes the simultaneous application of aetiological measures, general measures and symptomatic treatment.
The basis of its treatment is the correction, if possible, of the precipitating causes indicated above (table 15). The evaluation of the use of certain drugs that may precipitate or worsen the delirium is especially important. The joint work with the family environment and patient’s carers must provide adequate behavioural patterns and information and favour an environment that will contribute to the improvement of the manifestations and reduce their impact.
Investigating the pharmacological treatment poses ethical problems in these patients, as the RCTs compared with placebo are not acceptable (184). However, neuroleptics (above all haloperidol), benzodiazepines (midazolam or other such as lorazepam, clonazepam or diazepam) (189) or artificial hydration have been widely used in these patients.
There is a specific Cochrane SR on delirium in PC (190), but it is based on one single RCT in patients with HIV-AIDS. Some authors propose the association of lorazepam with haloperidol in the cases of delirium with anxiety or unrest, which could contribute to a reduction of the risk of extrapyramidal effects of the haloperidol (191). In the cases of delirium with intense unease the use of levomepromazine and, alternatively, midazolam (191) is recommended. Haloperidol is efficient in controlling delirium in patients in EOLP, with good tolerance (190). Lorazepam can be useful as an additional therapy to haloperidol in the case of delirium with anxiety or unease. There is insufficient evidence about hypodermoclysis in delirium; it can be useful if it is a side effect of opioids (151). The initial care of a patient with delirium should include the identification and treatment of the triggering causes, with special attention to the consumption of certain drugs (opioids); appropriate information to relations and carers and the evaluation of the need for pharmacological symptomatic treatment. Levomepromazine or, alternatively, midazolam can be used in delirium with non-controlled intense unease. Hypodermoclysis can be used if delirium produced by opioids is suspected in dehydrated patients.
It is advisable to reserve the use of atypical antipsychotics for selected cases where haloperidol is contraindicated or is not tolerated. Insomnia is a heterogeneous disorder that includes the difficulty in initiating sleep (initial insomnia), maintaining sleep (intermediate insomnia) awaking too early (late insomnia) and non-restorative sleep. C) Sleep disturbance causes significant impairment of daytime functioning (asthenia) or marked distress.


Sleep is altered in 50% or more of patients suffering from advanced cancer (193) and can reach 70%, depending on the baseline disease and care area (79).
Insomnia can appear as a reflection of the complex psychological reactions that take place in people who are in the EOLP, due to a deficient control of the symptoms, and as a result of treatments. The main problem with detecting insomnia lies in not asking patients and, when they complain, overlooking it due to therapeutic nihilism or ignorance of the professional. When the patient mentions difficulties maintaining sleep the precipitating factors of the awakenings must be sought.
The treatment of insomnia is multifactoral, due to the numerous causes that contribute to its appearance. Identify problems or affairs that have worried them during the day before going to bed, trying to address them with an active solution approach. Avoid stimulating medications or other substances (caffeine, nicotine) above all during the hours prior to going to bed. Maintain adequate pain relief during the night, preferably with medium-long lifespan analgesics.
Although there are many trials about the efficiency of treatments (psychological and pharmacological) in the general population, research in patients in PC is limited, above all in the case of non-pharmacological measures. Studies on the efficiency of these treatments have always excluded patients with other illnesses, so it is not known if their results can be generalised to the area of PC. With respect to pharmacological treatment, benzodiazepines are the most commonly used drugs. Some sedative antidepressants (amitriptyline, trazodone, mirtazapine) can also be used as hypnotics, especially in patients with depression symptoms, although the sedative and anticholinergic side effects also limit their use (see appendix 5). In any case, the treatment must be individualised depending on the patient (life prognosis, risk of pharmacological accumulation or interaction, etc.). Attempt to correct the predisposing factors to insomnia or those trigger it, when possible. An initial approach is recommended via a cognitive-behavioural strategy in all patients with insomnia.
The prescription of benzodiazepine or a benzodiazepine receiver agonist is recommended for patients who do not respond well to non-pharmacological treatment or who cannot wait for its application. In cases of associated depression or lack of response to benzodiazepines, anti-depressants with sedative action can be used to treat insomnia. Somatic symptoms: muscular strain, trembling, palpitations, lack of stability, abnormal perspiration, diarrhoea, polyuria, etc. Anxiety can appear as a normal state when it is proportional in intensity and duration to the cause that generated it; it is even an adaptative state, which permits being alert and responding adequately in difficult circumstances. The following are risk factors for the development of an anxiety disorder during palliative treatment: having previously suffered an anxiety disorder, the presence of anxiety when cancer was diagnosed, intense pain, functional limitation, age (more risk in young people), poor social support network and worsening of the illness. C) The anxiety and worry are associated with three (or more) of the following six symptoms (some of which have persisted for more than six months). D) Anxiety, worry or physical symptoms provoke clinically significant distress or social and labour impairment, or impairment of other important areas of the person’s activity. E) These problems do not appear during the course of a mood disorder, a psychotic disorder or a generalised development disorder. The treatment of anxiety in patients in EOLP depends on the cause, how it occurs and the context in which the consultation takes place (189).
A Cochrane SR (198) on this topic did not identify any RCTs carried out in PC so the recommendations are based on consensus and the extrapolation of tests on the general population.
When the anxiety symptoms are slight, proportional and they appear in response to an identifiable factor, psychological support and the monitoring of the adaptative response are usually sufficient (197). Although there is scientific evidence in favour and against their efficiency, basic non-pharmacological interventions to treat anxiety in patients in the end-of-life phase include support psychotherapy and cognitive-behavioural psychotherapy. The pharmacological treatment of anxiety of patients in end-of-life phase includes the rational and individualised use of benzodiazepines (BZD), neuroleptics, antidepressants, antihistamines and opioids (189). Although there are no specific RCTs in PC, BZDs are the basis of the pharmacological treatment. Tricyclic, heterocyclic and second-generation antidepressants can be efficient in anxiety that accompanies depression and in panic disorders.
The treatment of anxiety requires an individual assessment of the patient in EOLP that includes the possible triggering causes, their adaptive state, the stage of the disease, associated treatments and the patient’s preferences.
The psychological support measures for the patient and family are the first thing that must be provided after the individual assessment.
Pharmacological treatments are recommended when the psychological support is not sufficient.
In the case of anxiety associated with depression, delirium, dyspnoea or intense pain, tricyclic antidepressants, haloperidol or opioids, respectively can be used.
Depression is up to three times more frequent in patients in PC than in the general population.
Depression is not a normal state in the end-of-life phase, but an illness that complicates already existing illnesses and which is not diagnosed or treated as it should be (197). This can contribute, among other causes, to the fact that many physicians do not detect the depression of their patients, so the patient’s emotional state must be monitored on a regular basis (204). It is important in these patients to differentiate the genuine depressive disorder of normal bereavement from the adaptative disorder with depressed mood (197). A) Presence, during a 2-week period, of five or more of the following symptoms7, which represent a change from previous functioning; at least one of the symptoms must be depressed mood or loss of interest or pleasure. C) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning of the individual.
Treatments: corticosteroids, chemotherapy (vincristine, vinblastine, asparaginase, intrathecal methotrexate, interferon, interleukins), amphotericin B, total brain radiation.
Research about depression in the end-of-life phase has been mainly carried out on patients with cancer, HIV-AIDS and older people. Different systematic reviews have studied the pharmacological and non-pharmacological treatments in patients with cancer (203; 207).
With respect to non-pharmacological therapy, the review of the AHRQ is based on three previous SRs; some of them include patients with cancer, but without a depression diagnosis (the appearance of this is one of the result variables assessed). The interventions are based on psychological counselling and support by different professionals, social support, relaxation and group therapy. The Rodin review (207) was based on four individual studies that included patients with depression diagnosis. There are no controlled studies about the efficiency of supplementary or alternative therapies in the treatment of depression in cancer patients (203).
Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TAD) are efficient in the treatment of depression of cancer patients. The AHRQ review (89) included nine studies (five shared with the Rodin review) and provides data about the efficiency of corticosteroids (methylprednisolone) and of desimipramine. The authors of the reviews recommend SSRIs as first choice due to their better profile of side effects (207). Pharmacological treatment of depression requires a meticulous assessment of the treatments the patient receives due to the risk of interactions and increase of side effects. Although there are no controlled studies, most experts recommend a strategy that combines support psychotherapy, education of the patient and family and the administration of antidepressants (197; 209).
The risk of suicide in patients with cancer is up to 10 times greater than in the general population (210). Suicide thoughts are very frequent in patients with cancer in advanced phases (up to 45% of them present them), but they are usually fleeting and are associated with feelings of loss of control and anxiety about the future (197). It is important to identify the cause of despair, which are frequently badly controlled symptoms (pain) and feelings of abandonment (189).
Establishing a therapeutic relationship is the basis for working with patients with a suicide risk. Non-pharmacological therapies are efficient in slight to moderate depression of patients in PC (203; 207).


Tricyclic antidepressants and SSRIs are efficient in the treatment of depression in patients in PC (203; 207). Psychostimulants, such as methylphenidate, improve depressive symptoms in cancer patients and they have a quicker response than antidepressants (208). The initial assessment of depressed patients in PC includes: identifying and addressing potentially treatable causes, evaluation of adverse effects and interactions of previous pharmacological treatments and estimation of the possible risk of suicide. The initial therapy of depressed patients in PC includes psychosocial structured interventions, including psychotherapy by the personnel of the care team, and, if necessary, by specialised personnel within a structured programme. If necessary, antidepressant drugs can be used (SSRI or tricyclic), bearing in mind their pharmacological properties, other drugs the patient receives and his or her symptom profile at each given time.
Psychostimulants, such as methylfenidate, can be used as an alternative to tricyclic antidepressants and SSRI, above all when a rapid start of the antidepressant effect is required or in cases with very short life expectancy.
7 The symptoms clearly due to medical illness are not included, or delirious ideas or hallucinations that are not congruent with the mood. This improves the diagnostic specificity of total PSA, allowing about 20% of men to avoid having a biopsy.
Severe and moderate symptoms are defined according to the International Prostatic Symptom Score (IPSS)1. Within the context of higher risk is included a family history (first degree relative) of prostate cancer or men of African ancestry. They were developed by an expert panel representing laboratory medicine, oncology, urology, family medicine, radiology, and consumers. The condition is called Cushing’s disease when it is caused by a tumor of the pituitary gland, which causes the body to produce excess cortisol.
In many Cushing’s cases, tumors that require surgery can be removed with minimally-invasive techniques such as laparoscopic adrenalectomy. Events like Venture Atlanta, the Flashpoint at Georgia Tech accelerator program, and TAG Business Launch aren’t simply vehicles that bring entrepreneurs and investors together, they’re also avenues to connect with industry experts, or to find a mentor. Bos says that she has a “personal board of directors who I know will pick up my call if I tell them it’s urgent.” She also knows that mentoring is not a one-way street. Whether it’s eating more whole grains or figuring out how to eat more non-starchy vegetables, the best way to start eating healthier is to focus on one change at a time.
Focus on making small changes to your eating habits rather than completely remodeling your diet. For more information on what Sargent Choice is and what options are available, be sure to explore the Sargent Choice website!
Lets start include natural organic food in our daily menu, and you will see the benefit for your health. The recommendations included should be considered with caution taking into account that it is pending evaluate its validity.
Symptom Control" and with the aim to improve the navigation, a navigation menu has been included to allow direct access to each one of the subsections. It can be present in up to 90% of patients in the last days of life (184) and its appearance is associated with a worse prognosis (34).
Does the abnormal behaviour fluctuate during the day, that is, tend to come and go or increase and decrease in severity?
This may be one of the reasons for the lack of randomised studies on the assessment of any treatment for delirium in PC. Apart from this indication there is little evidence about its efficiency in the treatment of delirium in general (184).
Clinical evaluation is necessary as well as close attention to the repercussions of the unease on the patients and their family to avoid premature sedation (185). It is necessary to resort to non-experimental studies or to expert opinions and extrapolate the data from other populations to prepare recommendations on the treatment of insomnia. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. Due to the heterogeneity in the results, the publications present results without meta-analysis. The antidepressant treatment must be started at gradual doses in patients who receive drugs with sedative effects such as opioids; the association of SSRI with tramadol fosters the risk of convulsions. Suicide risk factors include: non-controlled pain, advanced illness, male gender, depression, despair, delirium, previous psychopathology and abuse of substances, family or personal history of suicide attempts, advanced age (189) or social isolation. Casarett DJ, Inouye SK, for the American College of Physicians-American Society of Internal Medicine End-of-Life Care Consensus Panel*. The information should assist men between the ages of 50 to 75 who have a life expectancy of greater than 10 years in making an informed decision as to whether to have this test performed.
Serum may be stored refrigerated for 24 - 48 hours (loss of activity occurs at a rate of about 2 - 4% per day). He says, “My role was to put them in front of the right people who could give them great advice and great support.
Mentoring is about building a relationship, helping someone grow and develop and helping to bring other resources to bear. One of my friends is an avid pasta eater, and while he loves food and works out a lot, his diet isn’t the most balanced. One way to do this: Pick a goal each month such as replacing your lunch sandwich white bread with wheat bread or have a serving of fruit at breakfast. Another great resource for BU students is FREE nutritional counseling from registered dietitians at the Sargent Choice Nutrition Center, located on the 6th floor of Sargent College. The lateral menu on the left, helps to navigate through each and every one of the subsections. So, to reduce the suicide risk it is essential to identify the major depression, such as despair, which is an even stronger predictor than depression (189).
Survival prediction in terminal cancer patients: A systematic review of the medical literature.
A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. Evaluating CAM treatment at the end of life: a review of clinical trials for massage and meditation. American Psychiatric Association diagnostic and statistical manual of mentaldisorders 4 th edition (DSM-IV). Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: meta-analyses.
Can oncologists detect distress in their out-patients and how satisfied are they with their performance during bad news consultations? The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. He asked me for one way to start eating healthier, so last semester I gave him the goal of at least two fruits a day. The repercussion of the patient’s insomnia on family members and carers is important. An information package also been developed for physicians to facilitate counselling for the public on the appropriate use of the PSA test. Now that he’s gotten into the routine of eating fruit every day, he is ready for this semester’s goal: choose lean meats like chicken and pork and eat a full serving of non-starchy vegetables at least once a week.
They are normally administered by oral route, but in a dying patient the administration of diazepam by rectal route or midazolam by subcutaneous route may be useful (202).
While some people are able to make big changes to their diets overnight, many are more like my friend who are more willing to stick with something with gradual changes.



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