Alsirafy SA, Nagy R, Hassan AD, et al. "Caregiver burden among family caregivers of incurable cancer patients in two eastern Mediterranean countries." BMC Palliat Care. 2021;20(1):163. Abstract

BACKGROUND: Although family caregivers (FCs) play an important role in the care provided to incurable cancer patients in our region, little is known about the burden they experience. This study was conducted to determine the prevalence of caregiver burden (CB) among FCs of incurable cancer patients in two Eastern Mediterranean countries and to identify factors that may be associated with significant CB.

METHODS: The study included 218 FCs, 165 from Egypt and 53 from Saudi Arabia. The 22-item Zarit Burden Interview (ZBI-22) was used to assess caregiver burden CB. Significant CB was defined as a ZBI-22 score ≥ 21. The assistance with basic ADLs was classified into 3 levels according to FCs' assistance with early/middle/late-loss basic ADLs. The relationship between CB and the assistance with ADLs and other factors was studied.

RESULTS: The mean (SD) ZBI-22 score among FCs was 23.4 (9.3) and the majority (128/218, 59%) had significant CB. Eighty-nine percent of FCs assisted with at least one basic ADL. Assistance with late-loss basic ADLs, best supportive care treatment plan and poorer performance status were associated with higher CB (p < 0.0001, =0.018 and = 0.005). However, in logistic regression analysis, only assistance with late-loss ADLs was independently associated with significant CB (OR = 3.4 [95%CI:1.2-9.7], p = 0.024).

CONCLUSION: A substantial proportion of FCs of incurable cancer patients in our region experience significant CB. Family caregivers assisting with late-loss basic ADLs are at risk of significant CB and should be routinely screened for CB.

Abdel-Hafeez A, Abdel-Aziz HI, Hassan A, et al. "Diagnosis Disclosure Preferences of Cancer Patients in Egypt: A Multi-Institutional Cross-Sectional Study." American Journal of Hospice and Palliative Medicine®. 2021. AbstractWebsite

Background:Although diagnosis disclosure to cancer patients has important roles in cancer care, it is not a routine practice in countries like Egypt. Respecting patients’ autonomy and responding to their preferences are among the factors that should guide the practice of cancer diagnosis disclosure.Objectives:To assess the preferences of Egyptian cancer patients regarding the disclosure of cancer diagnosis and to determine factors that may affect their preferences.Methods:The study included 295 patients aware of their cancer diagnosis from 3 cancer care facilities in Egypt. Patients were asked if they would have preferred to be informed of the diagnosis or not, whom they would have preferred to receive the diagnosis information from, and if they would have preferred to tell their families or not.Results:The vast majority (91%) of the included patients preferred to be informed about their diagnosis, 59% preferred to disclose the diagnosis to their families and 66% preferred to receive the diagnosis information from a physician. In univariate analysis, male gender, higher education level and employment were significantly associated with the preference for disclosure. None of the studied variables associated significantly with the preferences in multivariate analysis.Conclusion:The majority of Egyptian cancer patients in our study preferred to be informed about their diagnosis, which should be respected. The results may help in changing the diagnosis disclosure practice of health care professionals and refuting the misconception of family caregivers about cancer diagnosis disclosure in Egypt and countries with similar culture.

Abdelhafeez AAM, Makady NF, Hafez O, Atallah CN, Alsirafy SA. "Reliability and validity of the Arabic translation of the palliative performance scale." Palliative & Supportive Care. 2020;18(5):575-579. AbstractWebsite

OBJECTIVE: The aim of this study was to translate the Palliative Performance Scale (PPSv2) into Arabic and to test the reliability and validity of the PPS Arabic translation (PPS-Arabic).

METHOD: The PPSv2 was translated into Modern Standard Arabic using a forward-backward method. Inter-rater and intra-rater reliabilities were tested in a pilot study that included 20 patients. The validation study included 150 cancer patients. Patients were divided according to their treatment plan into three groups (in-remission, palliative chemotherapy, and best supportive care) to perform hypothesis-testing construct validity. Validity was further evaluated by correlating PPS-Arabic with the Karnofsky Performance Scale (KPS), the Eastern Cooperative Oncology Group (ECOG) scale, and Physical Functioning (PF2) and Role Functioning (RF2) scales of the European Organization for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ-C30).

RESULTS: The intraclass correlation coefficients for the intra-rater and inter-rater reliability were 0.935 (95% CI: 0.88-0.965; p < 0.001) and 0.965 (95% CI: 0.934-0.981; p < 0.001), respectively. The PPS-Arabic internal consistency Cronbach's alpha was 0.986. The average PPS-Arabic score differed significantly (p < 0.001) between the three groups of patients being 89 for in-remission, 58 for palliative chemotherapy, and 38 for best supportive care. The PPS-Arabic score correlated significantly (p < 0.001) with the KPS, ECOG performance scale, and the EORTC QLQ-C30 PF2 and RF2 scales.

CONCLUSION: The PPS-Arabic is a reliable and valid tool for the assessment of performance status of cancer patients.

Hunter CN, Abd El-Aal HH, Elsherief WA, Farag DE, Riad NM, Alsirafy SA. "Mirtazapine in cancer-associated anorexia and cachexia: A double-blind placebo-controlled randomized trial." Journal of Pain and Symptom Management. 2021. AbstractWebsite

CONTEXT: Few pharmacological interventions are available for cancer-associated anorexia and cachexia. Mirtazapine has been suggested for use in cancer-associated anorexia and cachexia.

OBJECTIVES: This study was conducted to assess the efficacy and tolerability of mirtazapine in cancer-associated anorexia and cachexia.

METHODS: A double-blind placebo-controlled randomized trial. The study included 120 incurable solid tumour patients with anorexia (appetite loss ≥4 on 0-10 scale, 10= maximum appetite loss), cachexia (>5% body weight loss over 6 months or >2% plus body mass index <20) and depression score ≤3 on 0-6 scale (6= extreme feelings of depression). Patients were 1:1 randomized to receive mirtazapine 15mg daily at night for 8 weeks or placebo. The primary endpoint was change in appetite from baseline to day 28. Other outcomes included changes in quality-of-life, fatigue, depressive symptoms, body weight, lean body mass, handgrip strength, inflammatory markers, adverse events and survival.

RESULTS: 48 (80%) patients in the mirtazapine arm and 52 (87%) in the placebo were assessable for the 1ry endpoint. Appetite score increased significantly with mirtazapine as well as with placebo (p<0.0001 each). The increase in appetite score did not differ significantly between the two arms in the per-protocol and intention-to-treat analysis (p=0.472 and 0.462, respectively). Mirtazapine was associated with significantly less increase in depressive symptoms and higher prevalence of somnolence. The change in other outcomes did not differ significantly between mirtazapine and placebo.

CONCLUSION: Mirtazapine 15mg at night for 28 days is no better than placebo in improving the appetite of incurable solid tumor patients with cancer-associated anorexia and cachexia.

Saleh MA, Kassem L, Atteya H, Mousa M, Alsirafy S. "Changes in Perceived Social Support after Starting Treatment in Egyptian Patients with Operable Breast Cancer: A Longitudinal Observational Study." Tumori Journal. 2020;106:28. AbstractWebsite

Background:Social support (SS) has been proven to be associated with improved outcome of early breast cancer. Little is known about the magnitude of social support available for Egyptian breast cancer patient and much less is known about the changes that occur in such support after the diagnosis of breast cancer and starting treatment.

Methods:We designed a longitudinal questionnaire based prospective cohort study using the six item form of the Medical Outcomes Study- Social Support Survey (MOS-SSS) questionnaire and included patients with pathologically proven non-metastatic breast cancer 18-70 years of age. Patients completed the self administered questionnaire at 2 time points: at first diagnosis of breast cancer and after 3-6 months of starting treatment. Comparison of the pre and post treatment questionnaires was done using paired sample T test.

Results:A total of 48 patients completed the 2 questionnaires. Median age was 48 years (range: 24-65 years). Seventy percent of our patients were married, 67% had more than 2 children and 77.8% were housewives. Around half of the patients (45.2%) had monthly income below 1200 EGP. Patients who had higher education level (p=0.002) and those who were living in Cairo (p=0.033) reported higher SS at baseline. Mean MOS-SSS score at baseline was 64.4 (±24.8) while after treatment was 76.4 (±22.3); p<0.001. The increase in SS was consistent in most of the patient subgroups but was more prominent in illiterate patients compared to educated (p=0.033), those who work a handy job compared to housewife (p=0.04), and those who lived in Upper Egypt compared to Cairo residents (p=0.029).

Conclusion:The majority of Egyptian breast cancer patients had a supportive environment after the diagnosis of breast cancer. A special attention should be paid to the at-risk groups with no sufficient SS during that period.

Zawam H, rasha salama, Alsirafy SA, Bishr MK. "Treatment Outcome of Acute Myeloid Leukemia in Egypt: A Developing Country Perspective." International Journal of Cancer and Treatment. 2018;1(1):53-59.
Hunter CN, Faheem DEED, El-Sherief WA, Abdel Aal HH, Alsirafy S. "{LBA86Mirtazapine in cancer-associated anorexia cachexia: A randomised, double-blind, placebo-controlled trial}." Annals of Oncology. 2019;30(Suppl 5):v923. AbstractWebsite

{The available options to manage cancer-associated anorexia-cachexia syndrome (CACS) are limited. At standard doses, the tetracyclic antidepressant mirtazapine causes appetite stimulation and weight gain. Based on limited evidence, it is used in cancer-associated anorexia. This trial was conducted to assess the efficacy and safety of mirtazapine in patients with CACS.A double-blind randomized placebo-controlled trial. Included patients were adults with advanced solid tumors, weight loss ≥5\%, appetite loss score ≥ 4 on 0 to 10 scale (10 = maximum appetite loss), and depression ≤3 on 0 to 6 scale (6 = extreme feelings of depression). Patients were randomized to receive mirtazapine 15 mg /day or placebo. The primary end-point was the change in appetite on a 0 to 10 appetite scale (where 10 is the best appetite possible) at week 4. Other assessed outcomes included changes in body weight, lean body mass, handgrip strength, depression (measured by the Hospital Anxiety and Depression Scale [HADS]), and quality of life (measured by Functional Assessment of Anorexia/Cachexia Therapy [FAACT] questionnaire).From 120 allocated patients, 100 completed 4 weeks treatment (48 in the mirtazapine arm and 52 in the placebo). After 4 weeks of treatment there was no significant difference between the two arms in the change from baseline in appetite or other outcome measures (Table 1). The change in the HADS depression score differed significantly in favour of mirtazapine. Sleepiness was significantly more prevalent in the mirtazapine arm (p = 0.01) and only one patient discontinued treatment due to excess sleepiness. Table: LBA86Change in outcome measures from baseline to day 28MirtazapinePlacebopMedian (Interquartile range)Appetite score2 (0-2)2 (0-2)0.401Body weight (kg)-0.8 (-1.5 – 0.9)-0.6 (-1.4 – 0.2)0.94Lean body mass (kg)-0.16 (-1.1 – 1.1)-0.37 (-1 – 0.4)0.411Handgrip strength (kg)-0.76 (-1.5 – 0.8)0 (-1 – 0.8)0.376FAACT Anorexia-cachexia scale4 (1 – 5.8)4 (0 – 6)0.997HADS Depression score1 (0.3 – 2)2 (1 – 2)0.022Compared to placebo, mirtazapine 15mg at night did not improve appetite, body weight, hand-grip strength or quality of life in advanced cancer patients with anorexia cachexia.NCT03254173.The authors.Cairo University.All authors have declared no conflicts of interest.}

Tawfik E, Abou El Kheir S, Alhassanin S, Gohar S, Harhash D, Alsirafy S. "The relation between the symptom burden of hospitalized patients with incurable cancer and the quality-of-life of their family caregivers." Annals of Oncology. 2019;30(Suppl 5):v661. AbstractWebsite

Background: Family caregivers (FCs) play important roles in the care provided to patients with incurable cancer. These patients experience a wide range of distressing symptoms. This symptom burden may add to the burden of FCs and consequently may have a negative impact on their quality of life (QoL).
Methods: This study was conducted to determine the relationship between the symptom burden in a cohort of patients with incurable cancer and the QoL of their FCs.The study included 94 dyads of hospitalized incurable cancer patients and one of their FCs. The symptom burden among patients was assessed using the revised Edmonton Symptom Assessment System (ESAS-r) and the QoL of their FCs was measured using the Medical Outcomes Study 36-Item Short-Form (MOS SF-36) questionnaire.
Results: Nausea was the most common symptom to associate with poorer QoL scores. There was a significant negative correlation between nausea and the following MOS SF-36 scales: physical functioning (r=-0.219, p = 0.034), role limitations due to physical health (r =-0.0228, p = 0.027), pain (r=-0.404, p \< 0.001), general health (r =-0.222, p = 0.031) and health change (r=-0.317, p = 0.002). Other symptoms that correlated significantly with at least one of the MOS SF-36 scales were weakness, drowsiness, lack of appetite, shortness of breath, depression and wellbeing. The total ESAS-r score correlated significantly with poorer scores on the pain (r=-0.248, p = 0.016) and health change (r=-0.311, p = 0.002) scales of MOS SF-36. In addition; older FCs age, hours of care per day, total period of care, FCs employment and inadequate income correlated significantly with poorer scores of at least one of the MOS SF-36 scales.
Conclusion: The high symptom burden experienced by patients with incurable cancer may have a negative impact on the QoL of their FCs, especially the physical aspect.

Alsirafy SA, Alabdullateef SH, Elyamany AM, Hassan AD, Almashiakhi M. "Transdermal fentanyl to parenteral morphine route switch and drug rotation in refractory cancer cachexia." BMJ supportive & palliative care. 2019. Abstract

It is recommended not to use transdermal fentanyl (Fe) patches (TFP) in cancer cachexia but TFP may be the only available option for pain. Limited evidence suggests lower Fe absorption from TFP in cachexia. We describe a case of metastatic breast cancer with refractory cachexia. Her pain was uncontrolled on TFP and was route switched and drug rotated to intravenous morphine (M). We were conservative and did not use the 1:100 TFP to oral M conversion ratio. Assuming opioid needs were similar before and after switch/rotation, the suitable conversion ratio in this case was about 1:25. Absent clear guidelines on converting from TFP in cachexia, it is better to avoid TFP. When essential to use TFP in cachexia, caution should be taken when switching from TFP to avoid overdose.

ElBatrawi MA, May Gaber, Mekheimar SI, Alsirafy SA. "Pattern of referral to a consultation-liaison psychiatry service in an Egyptian cancer center." Egyptian Journal of Psychiatry. 2019;40(2):123-126.
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