Positive Health Online

Positive Care For The Dying

How we die is, of course, a matter for all of us. Partly because of a renewed call for dignity at death and the advocacy of assisted suicide as a rational choice, it is increasingly recognised that 'officious striving to keep alive' has limits.

The Liverpool Care Pathway is becoming widely adopted for death within medical management. Appealingly named, as though the path led somewhere, it talks rather grandly about well-being near death. The published Guidelines for Healthcare Professionals are essentially administrative and defensive, though referring to “medical, physical, emotional, social and spiritual” factors. The leaflet for relatives is generous with photos of hand holding and emphasizes religious needs as though these are the norm and are an adequate substitute for practicalities.

It is a wise restraint not to inflict pointless tests and treatments at this stage, though some would accept positively anything that might lead to beneficial knowledge. But it seems to me, as a counsellor and a humanist, helpful to try to itemize positive provisions. Appropriate research would inquire into the wishes of those approaching death and into defects that occur. To begin consideration, eight general suggestions follow:

1. The question “Am I dying?” should (extraordinary circumstances apart) be answered truthfully;
2. The environment should be pleasant and calm (with resources for distraction available);
3. Those with urgent practical requirements (e.g. family or legal matters) should have assistance (the roles in 3, 6, 7, and 8 may combine) with arrangements;
4. The relief of pain on request should be unlimited (subject to advice that it may bring unconsciousness or hasten death);
5. Physical hygiene should be maintained as though the patient were not dying (unless the discomfort involved outweighs the benefits); similarly nutrition (unless rejected);
6. A trained 'companion' should attend (unless rejected), able to liaise with family and medical staff and to call for counselling if appropriate;
7. For those religious, an officiant of their faith should be available, for those not religious a competent person with a secular/ humanist world view;
8. The aim should be to accompany conscious deaths (unless rejected).

Silence on positive requirements almost invites the dying to be put into a situation conveniently marked 'unattended'. Although care may often be good, the essence of a protocol is to ensure minimum standards as the general case. Each dying is a unique instance of a universal event, and our brief final periods deserve the best possible support from the living.

Dr Edwin Salter  kl.humanfactors@virgin.net

Moderately Expressed Protein is Adverse Prognostic Factor for Breast Cancer

Prognosis for breast cancer after surgery is adverse even when a key protein is expressed moderately and without an amplification of its associated oncogene, a new study published in The Oncologist has found, suggesting that protein-inhibitor treatment would be beneficial for a larger group of patients than previously thought.

The study, led by Dr Filippo Montemurro MD from the Unit of Investigative Clinical Oncology and Division of Medical Oncology at the Institute for Cancer Research and Treatment in Torino, Italy, examined how varying levels of overexpression of HER-2 (human epidermal growth factor receptor) might predict breast cancer outcomes, and found that more moderate expressions of HER-2 serve as adverse prognostic factors for patients with operable breast cancer.

“These findings suggest rethinking HER-2 status with respect to prediction of trastuzumab [trade name Herceptin, a monoclonal antibody that interferes with the HER2/neu receptor] -related benefit in patients with early breast cancer and also, in our opinion, prognostic terms,” Dr. Montemurro said.

Biologically, the expression of HER-2 - a type of protein found in more aggressive types of breast cancer – falls on a continuous spectrum, but current tests like HercepTest™ use algorithms and categories to match treatments to the patients who would benefit most from them. Breast cancer treatments such as adjuvant trastuzumab, specifically target HER-2 to inhibit its growth.

While HER-2 testing in patients with operable breast cancer is aimed at identifying candidates for treatment, Dr. Montemurro’s study focused on whether the expression of variable levels of HER-2 also influenced prognosis. Using HercepTest™ and fluorescence in situ hybridization (FISH) when needed, researchers determined the HER-2 status of 1,150 women undergoing surgery for early breast cancer at the Institute. Dr. Montemurro and his colleagues studied the impact of HER-2 status on disease-free survival (DFS) time and other pathological features.

They found that patients whose tumours had lower levels of overexpression, and no amplification, had a distinct adverse prognosis. In particular, patients with HercepTest scores of +2, and with no associated amplification of the HER-2/neu oncogene, have adverse prognosis that is slightly better than patients with the most overexpression (+3 and HER-2/neu amplification) during the first 4 to 5 years after surgery; but that worsens in later years.

“Dr. Montemurro’s observations are provocative and point out how complex the HER-2 field is,” said Dr. Gabriel N. Hortobágyi, MD, Senior Editor of The Oncologist. “Added to the observations by Soon Paik about potential benefit from trastuzumab in patients with 1+ and 2+ HER-2 overexpression, these data emphasize the need for additional, careful research to fully understand the implications of the full spectrum of HER-2 overexpression and amplification.”

Dr. Montemurro and his colleagues recommended that further testing be done to build on their findings and to confirm whether patients with more moderate HER-2 levels would, in fact, benefit from treatments similar to those received by patients with higher levels of HER-2 and HER-2/neu amplification.

The full article, titled Moderate Immunohistochemical Expression of HER-2 (2+) Without HER-2 Gene Amplification Is a Negative Prognostic Factor in Early Breast Cancer, can be accessed at www.TheOncologist.com  or contact Sharon Lee at sharonlee@alphamedpress.com . 

About The Oncologist

Established by oncologists to help physicians better manage their practices in an ever-changing environment, The Oncologist® is the official journal of the Society for Translational Oncology (STO). Now in its 17th year, this internationally peer-reviewed journal focuses on clear and concise interpretation addressing the multimodality diagnosis, treatment, and quality of life of the cancer patient. Each issue is meant to impact the practice of oncology and to facilitate significant communication in the introduction of new medical treatments and technologies. For more information, visit www.TheOncologist.com.

About AlphaMed Press

Established in 1983, AlphaMed Press with offices in Durham, NC, San Francisco, CA, and Belfast, Northern Ireland, publishes three internationally renowned peer-reviewed journals with globally recognized editorial boards dedicated to advancing knowledge and education in their focused disciplines. STEM CELLS® (www.StemCells.com), celebrating its 30th anniversary in 2012, is the world's first journal devoted to this fast paced field of research. The Oncologist® (www.TheOncologist.com), entering its 18th year, is devoted to community and hospital-based oncologists and physicians entrusted with cancer patient care. STEM CELLS TRANSLATIONAL MEDICINE® (www.StemCellsTM.com), in its inaugural year, is dedicated to significantly advancing the clinical utilization of stem cell molecular and cellular biology. By bridging stem cell research and clinical trials, SCTM will help move applications of these critical investigations closer to accepted best practices.