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ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 1  |  Page : 44-50

Disease characteristics and treatment attributes of patients admitted to the oncology ward of a tertiary care government hospital


1 Department of Radiation Oncology, Army Hospital (R and R), New Delhi, India
2 Department of Pathology, Army Hospital (R and R), New Delhi, India
3 Command Hospital (SC), Pune, Maharashtra, India

Date of Web Publication16-May-2017

Correspondence Address:
Virender Suhag
Department of Radiation Oncology, Army Hospital (R and R), Delhi Cantt., New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1283_16

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 > Abstract 

Background: The burden of oncology patients in the most developing countries including India has witnessed a steady, progressive, and significant upward trend attributed mainly to increased life span, availability of better imaging modalities, increased awareness, and lifestyle and environmental changes. The management of such patients in government setup often presents lots of challenges such as advanced stage of presentation, existence of medical comorbid conditions, scarcity of beds, and long multimodal treatment often complicated with therapy-induced toxicities.
Materials and Methods: A prospective study was undertaken in a Radiation Oncology ward catering to male patients over 6-month duration in a superspecialty hospital of defense services. The clinical, pathological, and treatment-related attributes were recorded. Wherever possible, the clinical course of stay, complications during admission, and the response to primary management were studied.
Results: A total of 570 patients were admitted for 6-month duration. Of these patients, 240 were transferred in from other peripheral service hospitals while the remaining were admitted directly from this hospital or transferred from various wards of this hospital. The mean age of the patients was 46.5 years. Most common histology was squamous cell carcinoma. The most common site of primary was head and neck, followed closely by central nervous system tumors and gastrointestinal tract. A total of 185 patients were fresh cases admitted for workup and complete duration of definitive management (of which 82 received concurrent chemoradiation), 280 patients were for follow-up, 70 patients were admitted briefly for supportive care during a while on chemoradiation, and 15 patients were admitted for administrative reasons. Fifty-eight patients developed Grade II and onward therapy-induced hematological, gastrointestinal, cutaneous complications, and 14 patients suffered from febrile neutropenia. Thirty patients developed other significant complications warranting cross-referrals to other specialists. One hundred and thirty patients underwent more than one imaging modalities (contrast-enhanced computed tomography, magnetic resonance imaging, bone scan, and positron emission tomography-computed tomography). The duration of stay varied from 3 to 64 days, with an average duration of 38 days. There were 18 deaths during the study period.
Conclusion: The course of hospitalization for oncology cases is often prolonged and complicated by significant complications, warranting aggressive supportive care by various concerned specialists. These patients often require multiple imaging for primary and metastatic workup. There is a need for judicious selection of patients meriting admission for optimum utilization of existing resources.

Keywords: Admission, cancer, chemotherapy, radiation, supportive care, workup


How to cite this article:
Suhag V, Sunita B S, Vats P, Sarin A, Singh A K, Jain M. Disease characteristics and treatment attributes of patients admitted to the oncology ward of a tertiary care government hospital. J Can Res Ther 2017;13:44-50

How to cite this URL:
Suhag V, Sunita B S, Vats P, Sarin A, Singh A K, Jain M. Disease characteristics and treatment attributes of patients admitted to the oncology ward of a tertiary care government hospital. J Can Res Ther [serial online] 2017 [cited 2021 Jul 28];13:44-50. Available from: https://www.cancerjournal.net/text.asp?2017/13/1/44/206236


 > Introduction Top


The burden of cancer cases has witnessed a progressive rise over the past few decades and is expected to rise further. It is estimated that 0.44 million died due to cancer during the year 2011, while 0.51 million and 0.60 million persons are likely to die from cancer in 2016 and by 2021 in India, respectively. The estimated cancer mortality would increase to 0.70 million by the year 2026 as a result of change in size and composition of population.[1],[2] The main factors contributing to high burden of cancer over the years are increase in the population size as well as increase in proportion of elderly population, urbanization, and globalization.[2] About two-thirds of these cases present in locoregionally advanced stage and need to be treated aggressively by multimodal approach consisting of surgery, radiotherapy (RT), chemotherapy, and immunotherapy to increase the chances of cure. Such aggressive approach is though not without complications and toxicities warranting supportive care in some cases. Since cancer is considered to be a disease of old age, some of these cases are suffering from medical comorbid conditions, which may impact the line of management. About 60% of cancer patients will require RT during their disease, either with radical intent or with palliation of their distressing symptoms.[3]

A cancer patient may require admission for a plethora of reasons, some of which are for initial workup, for histopathological confirmation by biopsy, for invasive procedures for disease mapping, for special investigations, for definitive oncological management, for management of toxicities and complications, for supportive palliative care, and for investigations during follow-up. Since there is often a paucity of beds in public health sector in most resource-constrained developing countries, judicious selection of cases meriting hospitalization is of paramount importance. Management of such patients in the oncology ward is at times challenging and may require joint decisions with multiple specialists, nutritionists, emotional counselor, speech therapist, oncology-trained nurses, and intensivists.[4],[5]

Hence, we conducted an observational study in a tertiary care multispecialty hospital with a dedicated high-volume oncocenter to study various heterogeneous clinicomorphologic attributes of cancer patients admitted to the oncology ward and to study the various treatment characteristics.


 > Materials and Methods Top


A prospective, observational study was envisaged in a radiation oncology male ward of a tertiary care academic hospital with research interests, catering to defense clientele. Patients with suspected or histopathologically proven malignancies were admitted in the ward for various reasons. The personal attributes, clinical findings, staging workup, imaging films, and histopathological reports of these patients were perused. A note was made of the existing medical comorbid conditions. Patients were observed during their hospitalization for pain, weight loss, nutritional status, any therapy-induced toxicity, any other complication, response to primary oncological management, and response to symptomatic supportive care. The final outcome at discharge was noted. The hospital stay duration was also observed.


 > Observations And Results Top


A total of 570 patients were admitted over 6-month duration. Two hundred and forty of these patients were transferred in from other peripheral service hospitals while the remaining were admitted directly from this hospital or transferred from various wards of this hospital. The main sites of primary site are given in [Table 1].
Table 1: Primary site of origin of malignancy

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Head and neck was the most common site, followed closely by central nervous system (CNS). Overall, the most common histopathology was squamous cell carcinoma seen in a total of 180 cases of various sites. The average duration of symptoms before attending oncology outpatient department was 3 months. The most common symptoms in various sites are given in [Table 2].
Table 2: Common symptoms and average duration

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Majority of the patients presented in fourth and fifth decades, while the average age of patients was 48.3 years. The age-wise distribution is given in [Table 3].
Table 3: Age-wise distribution

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Out of 570 patients, 280 patients were fresh cases admitted for workup and definitive management, 60 patients were admitted for supportive care and to manage therapy-induced complications, while on active oncological management, 10 patients were admitted for supportive care for delayed toxicities, 10 patients were admitted for palliative treatment, and 2 patients were admitted for end-of-life care in view of progressive metastatic disease, while remaining 210 patients were admitted for review and follow-up.

Out of 280 patients who were admitted for definitive management, 210 patients were treated with radical intent while the rest received palliative RT or re-irradiation or supportive care. Out of these 210 patients who received definitive RT, 30 received neoadjuvant concurrent chemoradiotherapy (CCRT), 110 received CCRT, 40 received adjuvant CCRT, and 24 received adjuvant RT alone. Out of the remaining 70 patients, 25 patients received palliative RT, 10 patients received re-irradiation, and remaining patients were admitted briefly for supportive or terminal care. Out of 25 patients who received palliative RT, painful bony metastases were the most common site followed by brain metastases, superior vena cava obstruction, and cord compression. The most common dosage for palliative RT was 30 Gy/10 fractions.

Out of the 60 patients admitted for supportive care during active management, 20 were managed by nutritional support in the form of intravenous (IV) fluids, nasogastric (NG) feeds, percutaneous endoscopy gastrostomy (PEG) and feeding jejunostomy (FJ)/feeding gastrostomy; 6 underwent emergency tracheostomy; 12 were admitted with febrile neutropenia (FN); 3 patients developed herpes zoster; 7 had deep venous thrombosis (DVT); and 2 were admitted with features of raised intracranial tension.

Two hundred and thirty patients developed Grade II, the more toxicities, most common of which were hematological and mucocutaneous toxicities. The site-specific toxicities are given in [Table 4].
Table 4: Site-specific toxicities

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During the study period, sixty patients of recent onset malignancy underwent contrast-enhanced computed tomography/magnetic resonance imaging (CECT/MRI) of representative primary site and positron emission tomography-CT (PET-CT) for metastatic workup. Thirty patients underwent CECT/MRI for response assessment on the first follow-up and 70 patients who were admitted for review underwent imaging to rule out recurrence/residual disease. PET-CT was done in thirty review patients to rule out disease recurrence (in case of complete response) or disease progression (in case of stable residual disease). MRI brain was the most common investigation, done in 110 cases, followed by CECT of the face and neck, done in thirty cases. WBBS was done in 12 cases. Twelve patients underwent specialized investigations such as functional MRI, single-photon emission CT, magnetic resonance spectroscopy, and methionine-based PET-CT, whenever there is discord between clinical and imaging findings. Ten cases underwent electroencephalogram and three patients underwent urodynamic studies.

The duration of stay varied from 3 to 64 days, with an average duration of 38 days. Twelve patients stayed for more than 60 days primarily because they were on active chemoradiation. The details on length of stay of duration are given in [Table 5]. The common cause of delay in discharge was patients awaiting special investigations. There were 18 deaths during the study period, 10 in metastatic disease, and 8 in patients due to therapy-induced complications.
Table 5: Length of stay

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Pain, as an initial complaint or later in the course of disease, was noted in 210 patients. Pain was seen in 80 patients on onset, 33 patients while on chemoradiation, 13 patients in metastatic setting, and 12 patients while on follow-up during hospitalization. Sixty-five patients were admitted directly from the emergency department with some acute complication. The acute complications warranting admission and emergency admission are tabulated in [Table 6].
Table 6: Emergency admission indications

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 > Discussion Top


Oncology patients may present with a wide spectrum of clinical findings, with a great diversity on imaging and histopathology, and may pose a diagnostic and therapeutic dilemma. These patients are often seen by medical oncologist, radiation oncologist, surgical oncologist, oncopathologist, head and neck surgical oncologists, onco-radiologist, etc., before being started on multimodal management. Increased awareness among patients, emergence of a newer anatomical and functional imaging modalities, and the current standard recommendations on workup for primary and metastatic disease make it mandatory for the oncologists to subject the patient to a plethora of diagnostic tests, sometimes leading to delay in start of management and causing discomfort to patient and their families.[6],[7]

During the study period, sixty patients of recent onset malignancy underwent CECT/MRI of representative primary site and PET-CT for metastatic workup. Multiple imaging techniques are increasingly recommended during primary and metastatic workup as well as during review. Imaging by newer techniques is able to furnish morphological, structural, metabolic, and functional information, which along with other diagnostic tools assists in clinical decision-making.[8] However, one should be judicious in recommending this imaging as per individually tailored requirement, rather than blindly following the international guidelines, especially in resource-constrained countries with huge oncology overload. This judicious approach will decrease the workload on Radiology Department and will expedite the workup of such cases, thereby decreasing duration of stay in case of indoor patients. In this study, MRI brain was the most common imaging requested for CNS tumors admitted for review. The development of new MRI techniques has enabled the functional assessment of the structures to obtain information on the different physiological processes of the tumor microenvironment, such as oxygenation levels, cellularity, and vascularity.[9]

In our study, 24 out of 80 patients had suboptimal pain relief despite palliative RT and opioid analgesics. Pain in cancer patients is a major debilitating issue with overall prevalence rate of about 50% for all cancer types.[10] In advanced disease stages, 70%–80% of cancer patients suffer from uncontrolled pain of moderate-to-severe intensity.[11] The persistent pain causes a negative physical and psychosocial impact on patient's lives. In terminally ill patients, pain relief and other palliative care should be recognized as the primary goal of treatment. Generally, pain management for cancer patients requires critical pain assessment and thorough patient evaluation including psychological assessment. Depending on the etiology of pain, the approach to pain management can be customized for the patient. In about 85%–90% of the patients, the pain can be controlled by oral analgesics given according to the World Health Organization analgesic ladder, while in others, interventions may be required. Inadequate assessment of pain, opioid access and regulations, and stigmas associated with opioid use are significant barriers to optimal pain management.[12],[13]

In our study, 26 patients were admitted from accident and emergency department as an emergency patient. Hospitalizations among patients with cancer are common and, if unplanned, may interrupt oncologic treatment. The reported data indicate that clinical oncology, one of the most common indications for admission, is for symptomatic management of advanced cancer patients. It has been observed that that admissions are frequently unscheduled, are repeated, are quite long, and may result in patients' death or palliative care referral in more than one-third of cases.[14] Literature reveals that some of the common reasons for emergency department visits by cancer patients are pain, fever, shortness of breath, fluid and electrolyte disorders, intestinal obstruction, and pneumonia; the majority of the patients are admitted to hospitals; and about 13% of the admitted patients die during hospitalization.[15],[16] Some of the top reasons for unplanned hospitalization are potentially preventable, suggesting that comorbidity management and close coordination among involved health-care providers should be promoted.

In our study, 15 patients were found to have anemia, most of which were receiving concurrent chemotherapy. The most common type of picture on peripheral smear was microcytic, hypochromic type. Anemia is a frequent finding in cancer patients, occurring in >40% of cases.[17] In patients treated with chemotherapy, the incidence of anemia may rise to 90%.[18] Causes of anemia in cancer patients are multifaceted and include such factors as nutritional deficiency anemia, anemia of malignancy, and treatment-related anemia. Anemia results in decrease of functional capacity, lower performance status, poor compliance, and adverse prognosis.[19] Blood transfusions, iron supplementation (in absolute or functionally iron-deficient anemias), and erythropoiesis-stimulating agents are among the treatment options for anemia, selected based on the best benefit-to-risk ratio for each individual patient.[20]

In our study, 18 patients developed DVT and 2 had pulmonary thromboembolism (PTE). They were managed by low molecular weight heparin and Acitrom. The close relationship between malignancy and venous thromboembolism (VTE) is well established as these patients are in a hypercoagulable state. Thrombotic events are the second leading cause of death in cancer patients after death from cancer itself. In fact, the presence of malignancy increases the risk of VTE by a factor of 4–6, and large population-based studies show that the incidence of VTE is on the rise.[21] Overall, cancer patients constitute 15%–20% of the patients diagnosed with VTE, and depending on the type of tumor, extent of malignancy, type of cancer treatment, and presence of other risk factors, 1%–25% of patients with malignancy will develop thrombosis. Furthermore, cancer-associated thrombosis is linked with poor prognosis, and it is the second leading cause of death in cancer patients. In one study of a population registry, the 1-year survival of cancer patients diagnosed with VTE was one-third that of cancer patients without VTE (12% vs. 36%) matched for sex, age, tumor type, and duration of cancer. In another population-based study, the in-hospital mortality for cancer patients who developed VTE while in the hospital was double that for patients who did not develop the complication.[22],[23]

In our study, 14 patients were admitted with FN, out of which 10 were on CCRT and 4 were on RT alone. All patients received intravenous antibiotics and injection granulocyte-colony stimulating factor (GCSF). With the advent of multimodal aggressive treatment in these immunocompromised patients, FN constitutes a significant cause of hospitalization which leads to increased duration of hospital stay, may cause interruption in definitive oncological management, can compromise final oncological outcome, and leads to increased cost of treatment. Kim et al. assessed the incidence of FN in breast cancer patients who received neoadjuvant or adjuvant chemotherapy with doxorubicin/cyclophosphamide followed by docetaxel chemotherapy (AC-D).[24] Among the 254 patients reported to the registry, the FN incidence after AC-D chemotherapy was 29.5% (75/254). Patients with FN events frequently experienced dose reduction/delays, which eventually led to a decreased relative dose intensity. Jolis et al. included 734 patients with breast cancer and 291 with lymphoma.[25] Over the first four chemotherapy cycles, patients had an incidence of 11.0% grade 3–4 neutropenia and 4.3% FN in the breast cancer cohort and 40.5% and 14.8% in the lymphoma cohort. Hospitalization due to FN was required in 2.0% and 12.0% of breast cancer and lymphoma patients, respectively.

Injection GCSF was used in 56 patients in this study mainly when they either were admitted with neutropenia or were showing persistent significant downward trend in total leukocyte count counts. Injection GCSF is increasingly being used in prophylactic and therapeutic setting these days to manage neutropenia. It is expected to delay the onset and severity of neutropenia, help complete the definitive oncological management in time, and decrease duration of stay. Gerlier et al., in an expert survey on risk of FN in breast cancer and non-Hodgkin's lymphoma, observed that without GCSF primary prophylaxis (PP), FN occurred in 31% of breast cancer patients, and 13% had prolonged severe neutropenia (PSN). After GCSF secondary prophylaxis (SP), 4% experienced further FN events.[26] In 10 NHL patients receiving PP, 2 (20%) developed FN, whereas 13 (45%) of the 29 patients without PP developed FN and 3 (10%) PSN. Based on oncologist expert opinion, hospitalization rates for FN (average length of stay) without and with PP were, respectively, 48% (4.2 days) and 19% (1.5 days).

Four patients were shifted to Intensive Care Unit (ICU), the indications being tumor bleed, aspiration pneumonitis, status epilepticus, and PTE. There was a justified reluctance on the part of intensivists to accept oncology patients, mainly due to shortage of beds and institutional policy for judicious selection of patients with salvageable underlying conditions.[27] Three to five days of ICU triage may be warranted before making a final decision regarding the management of critically ill cancer patients. Nowadays, taking into account only the diagnosis of cancer to consider ICU admission of patients who need full-supporting management is no longer justified. The number and severity of organ failures are still the most important determinants for in-hospital mortality of critically ill cancer patients. Although the initial reports showed dismal prognosis, recent data suggest that an increased number of patients with solid and hematological malignancies benefit from intensive care support, with dramatically decreased mortality rates, primarily attributed to advances in the management of the underlying malignancies and support of organ dysfunctions.[28]

In our study, 85 patients developed dysphagia during or after chemoradiation, of which x, y, and z patients developed Grade II, II, and IV dysphagia. Twelve patients underwent PEG, 5 underwent FJ, and rest was managed by NG tube placement either blindly or under the guidance of UGIE. Dysphagia is a common, debilitating, and potentially life-threatening squeal of concurrent chemoradiation for head and neck malignancy. Nguyen et al. assessed the prevalence, severity, and morbidity of dysphagia following concurrent chemoradiation for head and neck cancer.[29] Fifty-five patients with locally advanced head and neck cancer underwent concurrent chemotherapy and radiation. At a median follow-up of 17 months, 25 patients (45%) developed severe dysphagia requiring prolonged tube feedings for more than 3 months or repeated dilatations. Most patients had severe weight loss (0–21 kg) during treatment, likely due in part to mucositis in the orodigestive tube. Prophylactic PEG-feeding tube placement in locally advanced squamous cell carcinoma of the head and neck patients can reduce the incidence of severe toxicities, including mucositis and weight loss, and avoid RT interruption.

In this study, five patients were admitted for management of aspiration pneumonitis, all of them were elderly patients who received CCRT for head and neck cancers. Aspiration pneumonia, secondary to inhalation of food particles, saliva, or other foreign substances, represents an underreported complication of chemoradiotherapy in head and neck cancer.[29],[30] Aspiration pneumonia after radiation is likely due to a combination of contributing factors including acute and chronic radiation-induced mucosal changes, radiation-induced altered swallow, muscle fibrosis, and xerostomia.[30],[31] These factors lead to swallowing dysfunction which in turn increases the risk of both aspiration and aspiration pneumonia. Xu et al. evaluated the incidence, risk factors, and mortality of aspiration pneumonia in a large cohort of head and neck cancer patients treated with CCRT.[32] Of 3513 head and neck cancer patients, 801 patients developed aspiration pneumonia at a median time of 5 months after initiating treatment. The 1- and 5-year cumulative incidence of aspiration pneumonia was 15.8% and 23.8% for head and neck cancer patients.

There were 12 deaths during the study period in the ward; common causes included progressive metastatic disease, FN, tumor bleed, and PTE. Death in oncology ward can have negative impact on other patients, so there is a tendency on the part of treating clinicians to convince the attendants to take the patient home to allow him to die peacefully in familiar environment. Referring the patient to a hospice and arranging a health-care provider at home are alternative options. Any death in oncology ward merits dignity and bereavement services to family.


 > Conclusions Top


This study has confirmed that the common causes for admission to a radiation oncology ward are for definitive management of the malignancy, for supportive care while on chemoradiation, and for management of acute and delayed toxicities. Another common indication for admission during this study was for review and recategorization of cases as per the standard guidelines, which is an organization requirement also. One preventable cause of prolonged hospital stay is delay in multiple imagings, which can be avoided by judicious recommendation of investigations, by working up these cases on outdoor basis, and by better coordination with concerned allied departments.

Management of oncology cases can be challenging at times and requires high index of clinical suspicion for diagnosing any emergency promptly and team effort between various specialties of oncology. These patients should be considered for admission wherever the hospitalization can help continuation of definitive management, thereby improving oncological outcome. Admission to tertiary care hospital mainly for palliative or terminal care should be best avoided.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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