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OBJECTIVE To report the clinical and demographic characteristics of patients with advanced cervical cancer referred to the palliative care service (PC) at a major cancer center in Mexico. METHODS This is a retrospective cohort study of patients with advanced cervical cancer referred to the PC of INCan, between January 2011 and December 2015. Demographic and clinical characteristics at the time of admission to the INCan, time to referral to PC, initial Edmonton Symptom Assessment System evaluation, and follow up were recorded. RESULTS In all, 359 patients were included, median age 51 years, predominantly poor with low education. Most patients 322 (90%) received tumor-specific treatment; presence of nephrostomies and other tumor-related complication was frequent. Median time to referral was 335 days, more than 180 (50%) had five or more symptoms, pain and fatigue were the most prevalent. CONCLUSION Women with advanced cervical cancer have a high burden of symptoms; PC is only considered at the end of life. Efforts for an early referral to PC should be made.

Background: Opioids are used for pain management in cancer patients. Morphine is considered the best option. For some patients with pain of difficult control management and adverse effects, an opioid rotation should be considered. Oral methadone is an opioid to which patients can be rotated safely and effectively and inexpensive for Mexico and Latin America. Our study describes the 9-year experience of opioid rotation to methadone, the population profile, efficacy of methadone in cancer patients of the palliative care service. Methods: Retrospective study of cancer patients rotated to oral methadone for pain control. Tables of frequencies, median and interquartile ranges were made, as well as overall survival. Results: 311 patients were rotated to methadone, predominantly males (58.5%), median age of 54 years with oncological diagnoses in cervix (10.3%), germinal tumors (8.4%), breast (8.0%), prostate (7.4%) and rectal (5.5%). These patients experienced visceral (17.6%) or other types of pain (68.6%), and a combination of different types of pain, the most prevalent pain was neuropathic (88.7%) and 50% received morphine, 21% buprenorphine or fentanyl 19% previously, with a median dose of 60 mg (30-120). The main reason for rotation was difficult pain control (54%), obtaining an efficacy of 70.0%. Conclusion: In this cohort at advanced disease stage, 54% suffered from difficult pain control, thus rotation became necessary, reducing pain and manageable adverse events, without major changes of the initial and final dose. Should be promoted more widely in the management of pain of difficult control by cancer in first position prescription.

ObjectiveMajor depressive disorder (MDD) is common in patients diagnosed with advanced cancer (AC), with a prevalence of 16.5%. It is associated with great disability and worsened quality of life, increased number and intensity of physical symptoms, and lower survival. It is the main factor for the presence of suicidal ideation. Antidepressants show modest efficacy, and response requires several weeks. Ketamine has demonstrated a fast and robust antidepressant effect in subanesthetic doses. This effect may prove useful in patients with AC, MDD, and suicidal risk.MethodWe report a case of a patient with advanced cervical cancer who presented with uncontrollable pain, MDD, and a suicide attempt.ResultA 39-year-old woman diagnosed with cervical cancer stage IVB presented to the Emergency Department after a suicide attempt by hanging. Upon evaluation by the palliative care psychiatrist, she reported intense pain, unresponsive to analgesics, and had a history of persistent suicidal ideation. Antidepressant treatment was started (sertraline 50mg/d) after a single dose of ketamine hydrochloride IV (0.5 mg/kg) was administered. Treatment response was measured using the Brief Edinburgh Depression Scale before and after the intervention. The depressive symptoms decreased by 17% on day 1, 39% on day 3, and 72% on day 17.Significance of resultsThis case report shows ketamine's efficacy as an augmentation agent alongside conventional antidepressant treatment in patients with AC. Moreover, it shows rapid response in suicidal ideation that has not been achieved with treatment as usual. More clinical trials are needed to support the potential benefit and safety of ketamine in patients with AC, MDD, and persisting suicidal ideation.

The use of aggressive treatments in patients with advanced cervical cancer at the end of life is frequent. Different studies have suggested no appreciable difference in survival between patients treated aggressively versus those that received palliative care, the term is frequently misconstrued as synonymous with end-of-life. Palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient’s illness. A provisional clinical opinion released by the American Society of Clinical Oncology recommends the use of palliative care alongside standard oncologic therapy for patients newly diagnosed with metastatic cancer, according with the patients’ needs. The purpose of the chapter is to highlight the importance of palliative care (PC) as an integral part of the care of CaCu patients. A better understanding of PC would help the oncologist to identify potentially eligible patients for PC; researchers to standardize the design for future trials and administrators promote the implementation of PC programs and allocate proper resources.