Úlceras cutáneas en pacientes oncológicos con cuidados paliativos de soporte domiciliario

Abstract

INTRODUCTION. The goal of palliative care is to improve the quality of life of patients who have a serious or life-threatening disease, such as cancer, and their families, during the terminal phase of the illness, combining physical, psychological and spiritual aspects in order to manage the symptoms so that patients may live as actively as possible until death. Cutaneous ulcerations (UC) are a health problem which affects patients who need home support. It may aggravate their prognosis and increase the care load, both for the palliative care specialists and the patient´s families. OBJECTIVE. The objective of this study is to find out the incidence and prevalence rate of cutaneous ulcerations in terminal cancer patients being supported at home by a palliative care team, and the factors which influence their appearance. As well as estimating the survival time of those patients, and the possible prognostic factors. METHODS. A three year retrospective cohort study in patients diagnosed with cancer in treatment by an urban Palliative Home Care Team (ESAD) was carried out between the years 2010 and 2012. Different variables were analyzed such us presence of UC (degree of altered skin integrity, etiology of UC), Palliative Performance Scale (PPS), Norton Scale, the tool for Controlling Nutritional Status (CONUT) and several other variables that may cause skin deterioration, such as previous history of: Diabetes Mellitus, Cerebrovascular Accident, Chronic Venous Insufficiency, sepsis and previous treatment with cytostatic drugs. Qualitative variables were described using absolute and relative frequencies and quantitative variables using the mean and standard deviation or median and interquartile range depending on the density function of the frequency distribution. To compare different groups multiple bivariate analysis using chi-square, Fisher exact test, Student t test or Mann Whitney were performed. The odds ratio of the variables related to the prevalence, and Hazard Ratio of variables related to the incidence and survival, along with confidence intervals of 95% were estimated. Various multivariate models (logistic regression and Cox regression) were performed to adjust for potential confounders. RESULTS. A total of 510 patients were included in the study, of which 57% were male and the average age was 72. The median follow-up was 24 days. 20% of the patients died within a week of being referred to palliative care, and almost 90% of them presented a PPS equal to or less than 50. There was a prevalence of cutaneous ulcerations in 37.6% of cases 95% CI [34,1% – 41,9%]. Most of the cutaneous ulcerations were superficial, and about 85% of the patients presented pressure ulcers. The following factors were linked to the presence of skin ulcers: cancer patients (p= 0,002), of whom the patients affected by skin tumors presented skin ulcers more frequently, and the Norton Scale (p< 0,001), where the lower the score, the greater the development of skin ulcers. The incidence was 24,3%, 95% CI [20,1 – 28,4%] and was associated during the follow-up time with the presence of previous history of sepsis HR de 2,9, IC 95% [1,1 – 8,03], (p= 0,01), the PPS scale HR de 3,2, IC 95% [1,3 - 8,01], (p= 0,01) and the CONUT scale, where higher punctuation, increased risk of skin ulceration, HR 2,4, IC 95% [1,2 – 4,9], (p=0,02). Those patients who presented skin ulcers upon admission to the Palliative Home Care Team had a short survival time. Long follow-up periods increase the incidence of skin ulcers. However, from the moment they appear, the survival time of the patients decreases greatly (p< 0,001). The other factors related to survival time were: cancer patients, of whom those patients affected by skin tumors presented a shorter survival time during the period of home care, and brain tumors, whose patients had a longer survival time; the Norton Scale (p< 0,001), where the higher the risk of skin ulcers, as established by such Scale, the shorter the survival time; and the CONUT scale, which showed that patients with a higher risk of malnutrition presented a shorter survival time. CONCLUSIONS. The patients referred to the ESAD show similar characteristics with regard to cancerous diseases, gender and age as the rest of the population in general, but patients are included too late in palliative care. The prevalence of UC is very high, appearing most of them during admission in the ESAD and causing premature mortality after their appearance. The presence of UC was associated with the type of cancer pathology and the Norton scale. The appearance of UC during follow the ESAD was associated with: a history of sepsis episode, the PPS, CONUT scale and Norton scale. The type of cancer disease, the Norton scale and risk of malnutrition (CONUT scale) were associated with survival period during follow-up time.