番茄社区

A joint educational guideline from the European Society for Medical Oncology (ESMO) and ASCO got a refresh in the latter part of 2023. The overarching goal of the updated ESMO/ASCO Global Curriculum (GC) is "promoting GC as a contemporary and comprehensive document applicable all over the world, particularly due to its capacity to harmonize education in medical oncology and, in so doing, help to reduce global disparities in cancer care," according to the GC Working Group.

On a more granular level, the new version, published in offers a "new chapter dedicated to cancer control principles, aiming to ensure that medical oncologists are able to identify and implement sustainable and equitable cancer care, tailored to local needs and resources," explained Tanja Cufer, MD, of ESMO in Lugano, Switzerland, and other members of the working group.

One of the principles focuses on delirium in cancer patients, especially at the end of life. After completing the GC, the user should have the appropriate skill set to "assess effectively, prevent, and manage the common symptoms experienced during the dying process," which includes delirium, the authors stated.

A 2023 pointed out the high prevalence of delirium in older adult patients with advanced lung cancer. Takeshi Tanigawa, MD, PhD, of Juntendo University in Tokyo, and colleagues reported a higher risk for delirium in their longitudinal research among men with lung cancer. That may have been because men are more likely to be diagnosed with squamous cell carcinoma versus adenocarcinoma. Squamous cell cancer is "more challenging to treat and is often more severe," the authors wrote. "The inflammatory response from tissue invasion may increase the risk of delirium in men."

Per Cufer's group, appropriate management of delirium requires referring patients to palliative care and counseling sooner rather than later; applying "the concept of refractory symptoms and the judicious use of palliative sedation to manage them at the end of life;" and performing "end-of-life care in a variety of settings including the patient's home."

In a related study in 2023, Pilar Pèrez-Ros, RN, PhD, of Universitat de València in Spain, and colleagues noted that delirium is most common in older patients with lung cancer (mean age 71.6) as "they showed a higher mean number of active drug treatments, a higher prevalence of treatment with anticholinergics and neuroleptics, and a higher number of ED [emergency department] visits."

The clinical presentation of delirium varies, the researchers noted, but "it has an acute onset and fluctuating symptomatology, and it generally produces changes in attention, memory, orientation, and increased vulnerability to environmental stimuli."

The following Q&A discusses the delirium assessment tools from Pèrez-Ros and colleagues, as well as guidance on cancer-related delirium management from a online presentation by Jaroslava Salman, MD, of City of Hope in Duarte, California.

What was the impetus for your delirium assessment study in older cancer patients?

Pèrez-Ros, et al: Delirium is a serious public health problem, associated with high morbidity and mortality, prolonged hospital stay, elevated healthcare costs, and reduced quality of life for patients and their caregivers. It is therefore important that healthcare professionals are trained to identify and manage delirium appropriately. The highest risk of delirium occurs in older people due to the increased confluence of different risk factors.

These risk factors are further intensified by those related to drug toxicity, the use of harsh treatments and diagnostic tests, the presence of possible brain metastases, and cognitive dysfunction related to chemotherapy.

In this exploratory, cross-sectional study, the diagnostic accuracy of CAM [Confusion Assessment Method] and MDAS [Memorial Delirium Assessment Scale] was analyzed against the gold standard medical diagnosis based on DSM-5 criteria by two medical oncologists.

What were some of the main findings?

Pèrez-Ros, et al: Among the 75 included patients, the prevalence of delirium was 62.7%. The most prevalent types of cancer in patients with delirium were hematological and lung cancer [23.4% for both; n=47 patients]. The scale with the highest diagnostic accuracy was the CAM, with a sensitivity of 100% and specificity of 86%, followed by the MDAS, with a sensitivity of 88% and specificity of 30%. The presence of cognitive impairment hindered the detection of delirium.

What is the take-home message?

Pèrez-Ros, et al: Knowing the cognitive status of older patients could help health professionals decide on the most appropriate procedure for detecting delirium, since screening is known to be useful for managing delirium in oncological surgical units.

One choice that clinicians face is the most appropriate screening tool for the population being served. There is currently no assessment tool validated exclusively in the older oncology population. The CAM scale shows higher diagnostic accuracy than the MDAS in this exploratory study.

When is the optimal time to begin delirium management in cancer care?

Salman: Ideally, we would maximize our preventive efforts to minimize any patient's risk for developing delirium. About 50% of delirium episodes in patients with advanced cancer can still be reversible.

We want to distinguish between cases where the delirium is part of the terminal stage, where the goal is to control symptoms -- for example, pain or shortness of breath. In those cases, the delirium may not actually be reversible and may be part of the course of dying.

However, if we have a patient who is not in the process of dying, then certainly it makes sense to search for possible causes and reverse the etiology of a delirium if we can, because the first-line intervention and treatment is to identify and treat reversible precipitants, so those causes that led to the development of delirium.

What are some nonpharmacological tools for delirium management?

Salman: Nonpharmacological intervention is very, very important in preventing and managing delirium, such as making sure that the patient has appropriate oxygen delivery, that they're hydrated, that we correct the electrolytes, that their bowel and bladder function is appropriately attended to, also involving physical therapy and occupational therapy to mobilize the patient.

What about pharmacological interventions?

Salman: As far as pharmacological treatment, there are no FDA-approved medications specifically for treatment of delirium, but we quite often use antipsychotic medications. The goal of using the medications is to help the patients be awake, alert, calm, comfortable, and still be able to communicate with family and staff. One of the most commonly used antipsychotic is haloperidol, which has fewer anticholinergic effects, and does not have active metabolite.

In our cancer patient population it is pretty common to use haloperidol via IV, in which case you want to make sure that you're monitoring the patient's cardiac function, because there is a risk of QTc prolongation.

What about the connection between drugs that are commonly used in cancer patients and delirium?

Salman: Our pharmacy colleagues can help us identify and eliminate any drugs that could be contributing to delirium -- for example, opioids, benzodiazepines, anticholinergic agents, or some other drugs that may be the culprit. Patients can be individually sensitive to some of these drugs.

Benzodiazepines should be reserved for management of terminal delirium, where antipsychotic agents are not sufficient for symptom control.

Read the full "ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology" here.