Lung (2014) 192:915–920 DOI 10.1007/s00408-014-9621-6
Palliative Interventional Pulmonology Procedures in the Incarcerated Population with Cancer: A Case Series S. Shojaee • J. Dawson • R. W. Shepherd H. J. Lee
•
Received: 7 February 2014 / Accepted: 22 June 2014 / Published online: 12 July 2014 Ó Springer Science+Business Media New York 2014
Abstract Rationale Cancer is the second most common cause of death in incarcerated population and lung cancer is the most common cause of cancer death in this group. Inmates are excluded from most published surveys and research, thus the effectiveness of lung cancer palliation in this population is not known. Objective To report the feasibility and safety of palliative interventional pulmonary procedures in inmates with cancer. Study Design Retrospective review of registry data from a single center. Materials and Methods Inmate data on prospectively enrolled data registry (2009–2012) from the interventional pulmonology procedural registry at Virginia Commonwealth University was extracted and analyzed for safety and efficacy. Inmates with lung cancer and advanced malignancies with pleural or airway metastasis requiring airway debulking (mechanical/thermal), airway stenting,
and tunneled pleural catheter (TPC) placement were included in the analysis. Results A total of 16 procedures were performed in 12 incarcerated patients. These included six TPC placements in six patients. Ten procedures were performed in seven patients with airway obstruction. These procedures included rigid and flexible bronchoscopy with mechanical (rigid and balloon dilation) and thermal (laser, argon plasma coagulation, and cautery) tumor debulking and dilation, airway stenting, and tracheostomy in one case. All six TPC patients had immediate symptomatic relief and improved lung aeration on chest radiograph. Three of six patients had successful auto-pleurodesis. In the seven patients with airway obstruction, three patients reported symptomatic relief and one had resolution of post-obstructive pneumonia. No immediate- or long-term procedure-related complications were reported. Conclusion Incarcerated patients with advanced malignancy may benefit from interventional pulmonology procedures with low complications. Palliative interventional pulmonology procedures in inmates should not be withheld solely on their incarceration status.
S. Shojaee (&) J. Dawson R. W. Shepherd Interventional Pulmonology, Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, PO Box 980050, Richmond, VA 23298, USA e-mail: [email protected]
Keywords Cancer Palliative Interventional pulmonology Lung cancer Incarcerated
J. Dawson e-mail: [email protected]
Introduction
R. W. Shepherd e-mail: [email protected] H. J. Lee Interventional Pulmonology, Pulmonary Disease and Critical Care Medicine, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA e-mail: [email protected]
Lung cancer alone accounts for 8 % of all state prisoner deaths and lung cancer accounts for 1 in 3 cancer deaths in State prisons [1]. Despite growing inmate populations in the United States, inmates are excluded from most national health surveys and thus little is known about the safety and effectiveness of cancer palliation in this patient population.
123
916
In addition, the number of older inmates in US correctional facilities is increasing which may result in an increasing need for quality palliative care. Cancer in this group carries higher morbidity and mortality than the general population. This is thought to be in part secondary to the higher prevalence of lethal cancers in the incarcerated such as lung cancer, hepatic carcinomas, and non-Hodgkin lymphomas, due to higher prevalence of cancer risk factors in prison population [2–4]. Federal, state, and local inmate populations across the United States are growing larger and older, primarily due to longer sentences and ‘‘three strikes’’ sentencing laws [5]. The role of palliative procedures in patients with lung cancer is long established. Some palliative airway procedures such as airway stenting and tumor debulking can re-establish patency of the airway and relieve mechanical obstruction which may improve dyspnea, chest pain, and post-obstructive pneumonia. TPC in malignant pleural effusion (MPE) results in significant symptom relief. The catheter is tunneled under the skin with a cuff to reduce the risk of infection and allows for drainage several days/week through a one-way valve catheter into a negatively pressurized container. The drainage process was designed for lay and non-medical personnel to offer drainage of the catheter at home setting. In addition, up to 50 % of patients benefit from successful auto-pleurodesis followed by catheter removal without recurrence of the MPE. This method offers a similar benefit to chemical pleurodesis with agents such as talc without hospitalization and the risk of acute respiratory distress syndrome [6]. To our knowledge, there are no peer-reviewed publications on the challenges and barriers that correctional and consulting physicians face while providing palliative care with interventional pulmonology procedures [7]. We report a single-center experience in managing inmates with interventional pulmonology airway and pleural palliative procedures.
Study Design, Materials and Methods The study was approved by the Institutional Review Board at Virginia Commonwealth University (VCU). This was a retrospective review of prospectively collected data from the VCU medical center interventional pulmonology procedure registry (Jan 2009 through December 2012), which is a tertiary care academic and referral center for the Virginia Department of Criminal Justice.
Lung (2014) 192:915–920
therapeutic interventional pulmonology procedures for palliation which included airway lesion debulking (mechanical/ thermal), airway stenting, and TPC placement for palliative measures. Inmates who had diagnostic bronchoscopy without any therapeutic procedures or pleural procedure (thoracentesis) for diagnostic purposes only were excluded from the study. The primary endpoints were safety and efficacy. Airway procedures were evaluated specifically for lung re-expansion, symptomatic relief, stent migration, and direct procedural complications. Date of TPC insertion, correctional facility records of drainage, immediate- and long-term symptomatic relief, and auto-pleurodesis were recorded. Rate of infection post TPC placement and complications such as TPC occlusion, damage, and accidental removal were also analyzed.
Results Eleven male and one female patients (age range 43–65 years) were included in the study. A total of 16 procedures were performed in 12 patients. Four patients were diagnosed with squamous cell carcinoma of the lung, four had lung primary adenocarcinoma, and one had small cell lung cancer. In addition, one patient had metastatic thymoma, one had metastatic granular carcinoma, and one had a poorly differentiated carcinoma. Chief complaint for most patients was new or progressive worsening dyspnea resulting in decreased physical activity. Other presenting signs and symptoms included hemoptysis, chest pain, and post-obstructive pneumonia (Table 1). Six patients had TPC placed. All patients reported immediate relief of shortness of breath after TPC placement and had improved aeration of their lungs on the side of TPC placement on chest radiography. Three patients had successful auto-pleurodesis followed by catheter removal and no return of MPE (Figs. 1, 2). Table 1 Demographics Number of patients Age
12
Sex
43–65
Type of malignancy
11 male, 1 female 8 NSCLC (4 SCC, 4 adenocarcinoma of the lung) 1 SCLC 3 others (thymoma, metastatic granular carcinoma, and poorly diff. carcinoma)
Inclusion Criteria Included Inmates older than 18 years of age with lung cancer and other advanced malignancies involving the airways or lung,
123
Presenting signs and symptoms
Progressive SOB (10), hemoptysis, stridor, fever, increased sputum production, chest pain, facial swelling, and weight loss
Lung (2014) 192:915–920
Fig. 1 Tunneled pleural catheter just inserted in right pleural space
The timeframe from TPC insertion to catheter removal in the three patients who had successful auto-pleurodesis was between 1 and 2 months. The earliest death in a patient with TPC was 3 weeks after TPC placement, due to massive pericardial effusion. The longest survival after TPC insertion was 12 months in a patient who had successful auto-pleurodesis 1 month post TPC placement and is currently alive and receiving chemotherapy. Six patients underwent rigid bronchoscopy and tumor debulking (mechanical/thermal) (Figs. 3, 4). Four patients received airway stents of which three were covered metal stents. One patient with metastatic granular carcinoma and a very proximal tracheal tumor had a tracheal metal stent placed. The patient returned with tracheoesophageal fistula and tumor growth above the stent. The fistula was covered with a silicone stent through which a tracheostomy tube was inserted by percutaneous tracheostomy technique.
917
Patient had immediate symptomatic relief and was able to breathe comfortably with minimal O2 requirement, up to 4 weeks following the second procedure. One patient with post-obstructive pneumonia, who was not a chemotherapy candidate due to severe pneumonia, underwent airway stent placement followed by pneumonia resolution. The patient lived 2 years and 6 months past stent placement which allowed for the initiation of chemotherapy. The immediate post procedure benefits varied from resolution of atelectasis, stridor, and progressive dyspnea to resolution of post-obstructive pneumonia. One patient diagnosed with very advanced disease had complete occlusion of his left main stem not amenable to recanalization. Tumor debulking of the right main stem with argon plasma coagulation improved luminal diameter but was unable to extubate after the procedure and expired from bilateral pulmonary emboli. Given the small number of airway interventions and their variability, no statistical analysis can be applied to evaluate safety; however, our data showed that palliative airway interventions are feasible in prisoners. In patients with TPC placement, while the point estimate of 50 % for auto-pleurodesis in our case series was similar to reports for the general population, a 95 % confidence interval for estimate (9–90 %) reflects the large variability in this estimate due to the small sample size. Thus, no meaningful comparison to the general population can or should be drawn from this case series.
Discussion There are numerous challenges in caring for incarcerated patients with advanced malignancy. These challenges will continue to grow as the inmate population with cancer
Fig. 2 a Right-sided MPE, b status post right-sided TPC placement, c near-complete resolution of right-sided pleural effusion and successful auto-pleurodesis, 2 months post TPC placement (CXR obtained prior to TPC removal)
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Lung (2014) 192:915–920
Fig. 3 a Endotracheal near-complete stenosis by tumor on axial chest CT scan imaging, b endotracheal tumor visualized under rigid bronchoscopy, c post tumor debulking and airway stenting
Fig. 4 a Left lung collapse with partial aeration of the Upper lobe due to left main stem (LMS) tumor, b Endotracheal view of the main carina with tumor in LMS, c LMS tumor debulking and restoration of LMS and left upper lobe bronchus patency
continues to rise [8]. Different facilities have varying capabilities and relocation of inmates is common, making continuity of care difficult. To our knowledge, there is no study available on the safety and feasibility of long-term TPC and airway stents in the incarcerated patients, as most published studies exclude this population. We provide a case series that focuses on the feasibility and safety of interventional pulmonology procedures in particular: tunneled pleural catheters, airway tumor debulking, and airway stents for the palliation of advanced malignancy. MPE carries significant morbidity and TPCs are shown to be remarkably useful in the palliation of patients with severe dyspnea and discomfort as a result of MPE. In
123
patients with a non-expandable lung, TPC is the only realistic option for palliation. Patients with TPC require regular catheter drainage to achieve the maximum palliative benefit and attention to aseptic techniques, and education is required to drain and manage the TPC in order to reduce risk of infection or catheter dislodgement. The concern regarding drainage of the catheter in prison may pose challenges; however, the TPC was designed for lay people to drain and maintain the catheter. While there are different capabilities in different correctional facilities, a nurse or non-medical personnel can potentially drain the catheter for the patient without requirements for an infirmary or off-site physician visits. Our results with TPC were
Lung (2014) 192:915–920
similar to prior reported studies [9]. There were no infectious complications reported in our series and the rate of TPC removal due to the cessation of drainage (auto-pleurodesis) of the TPC was 50 %. All of our patients had their initial post procedure drainage in an infirmary connected to the hospital which may not be available in some institutions. However, after procedural discharge, inmates were transferred to their prison and the prison staffs were the primary caregivers and assisted in regular TPC catheter drainage. Our experience with TPC for this population did not differ significantly from the published literature [10, 11]. While 50 % of patients achieved auto-pleurodesis and there were no reported complications, the result of this small case series cannot be extrapolated to a larger inmate population due to a small sample size. This case series, however, shows that the use of TPC for MPE in inmates is feasible. Larger studies would be required to truly assess the safety of this palliative method in the incarcerated population. Airway stents for palliation can migrate or can become obstructed with mucus and granulation tissue requiring timely specialist consultation availability. In this study, there were no complications requiring urgent re-consultation. We recognize that this may not always be the situation; however, this may also occur in the general population. There is clearly an immediate beneficial palliation with airway tumor debulking and stenting that should not be overlooked. Alternatively, the use of opioids to relieve dyspnea is a common practice in palliative care medicine. While effective in the general population, in the incarcerated population it may be less effective due to prior or ongoing narcotic abuse and inability to titrate high doses of opioids [12]. Patients who receive airway stents may often use daily albuterol or saline nebulizer therapy to decrease mucus drying and ease clearance [13]. Nebulizer therapy is normally accessible for inmates with asthma/ COPD in prisons (Table 2). While there are limitations to this retrospective evaluation, our study collected data via a registry which allows prospective collection of data. The more obvious limitation is the small sample size in each of these cohorts. These data were collected over 3 years in a tertiary care center with small number of subjects making definitive conclusions difficult. Given the increasing cancer prevalence in inmates, the incarcerated population may not be receiving comparable palliative care as the general population. This will need to be further studied prospectively and is beyond the scope of this investigation. We recommend larger studies as more data become available with increasing awareness of safety and efficacy of palliative procedures in the incarcerated population. With the incarcerated population in the US at its greatest numbers and the increasing length of prison stay, the problems of palliative
919 Table 2 Palliative procedure results Palliative procedure
Results
TPC for MPE Number of patients
6
Symptomatic improvement
Immediate relief in all patients
Frequency of TPC drainage
Three times per week by infirmary nursing staff
Pleurodesis and TPC removal
3 (50 %)
Time from insertion to TPC removal
1–2 months
Survival post TPC insertion
3 weeks to 12 months (average of 2 months)
Complications (infection and TPC dislodgement)
None
Airway tumor debulking/airway stenting Number of patients
6 (tumor debulking in 6, airway stenting in 4)
Rigid bronchoscopy/tumor debulking
6
Airway stenting
4 (3 Aero metal stents and 1 silicone stent)
Symptomatic improvement
Resolution of lobar atelectasis (2), resolution of post-obstructive pneumonia (2), and resolution of stridor and restoration of tracheal patency (1)
Survival post procedure
5 days to 30 months
Complications (Stent migration or fracture Pneumothorax, death, etc.)
0
interventional pulmonology care are unlikely to diminish in the near future. Conclusion Incarcerated patients with advanced malignancy may benefit from interventional pulmonology procedures with low complications. Palliative interventional pulmonology procedures in inmates should not be withheld solely on their incarceration status. Conflict of interest
None.
References 1. Hospice and Palliative Care in Prisons (1998) Special issues in corrections. US Dept of Justice, National Institute of Corrections Information Center, Longmont 2. Mao L, Oh Y (1998) Does marijuana or crack cocaine cause cancer? J Natl Cancer Inst 90:1182–1184 3. Reindollar RW (1999) Hepatitis C and the correctional population. Am J Med 107:100S–103S
123
920 4. Dean-Gaitor HD, Fleming PL (1999) Epidemiology of AIDS in incarcerated persons in the United States, 1994–1996. AIDS 13:2429–2435 5. Bureau of Justice Statistics Data Brief, Medical Causes of Death in State Prisons, 2001–2004, January 2007, NCJ 216340 6. Davies HE, Mishra EK, Kahan BC et al (2012) Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA 307(22):2383–2389 7. Linder JF, Meyers FJ (2007) Palliative care for prison inmates: ‘‘don’t let me die in prison’’. JAMA 298(8):894–901 8. Mathew P, Elting L, Cooksley C, Owen S, Lin J (2005) Cancer in an incarcerated population. Cancer 104(10):2197–2204 9. Tremblay A, Mason C, Michaud G (2007) Use of tunnelled catheters for malignant pleural effusions in patients fit for pleurodesis. Eur Respir J 30(4):759–762
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Lung (2014) 192:915–920 10. Tremblay A, Michaud G (2006) Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest 129(2):362–368 11. Shojaee S, Voelkel N, Farkas L, De Wit M, Lee H (2013) Transforming growth factor b1 rise in pleural fluid following tunneled pleural catheter placement. J Bronchol Interv Pulmonol 20(4):304–308 12. Mumola C, Karberg J (2004) Drug use and dependence, state and federal prisoners. NCJ 213530:1–12 13. Hoag JB, Sherman M, Lund ME (2010) Practice patterns for maintaining airway stents deployed for malignant central airway obstruction. J Bronchol Interv Pulmonol 17(2):131–135
Palliative Interventional Pulmonology Procedures in the Incarcerated Population with Cancer: A Case Series S. Shojaee • J. Dawson • R. W. Shepherd H. J. Lee
•
Received: 7 February 2014 / Accepted: 22 June 2014 / Published online: 12 July 2014 Ó Springer Science+Business Media New York 2014
Abstract Rationale Cancer is the second most common cause of death in incarcerated population and lung cancer is the most common cause of cancer death in this group. Inmates are excluded from most published surveys and research, thus the effectiveness of lung cancer palliation in this population is not known. Objective To report the feasibility and safety of palliative interventional pulmonary procedures in inmates with cancer. Study Design Retrospective review of registry data from a single center. Materials and Methods Inmate data on prospectively enrolled data registry (2009–2012) from the interventional pulmonology procedural registry at Virginia Commonwealth University was extracted and analyzed for safety and efficacy. Inmates with lung cancer and advanced malignancies with pleural or airway metastasis requiring airway debulking (mechanical/thermal), airway stenting,
and tunneled pleural catheter (TPC) placement were included in the analysis. Results A total of 16 procedures were performed in 12 incarcerated patients. These included six TPC placements in six patients. Ten procedures were performed in seven patients with airway obstruction. These procedures included rigid and flexible bronchoscopy with mechanical (rigid and balloon dilation) and thermal (laser, argon plasma coagulation, and cautery) tumor debulking and dilation, airway stenting, and tracheostomy in one case. All six TPC patients had immediate symptomatic relief and improved lung aeration on chest radiograph. Three of six patients had successful auto-pleurodesis. In the seven patients with airway obstruction, three patients reported symptomatic relief and one had resolution of post-obstructive pneumonia. No immediate- or long-term procedure-related complications were reported. Conclusion Incarcerated patients with advanced malignancy may benefit from interventional pulmonology procedures with low complications. Palliative interventional pulmonology procedures in inmates should not be withheld solely on their incarceration status.
S. Shojaee (&) J. Dawson R. W. Shepherd Interventional Pulmonology, Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, PO Box 980050, Richmond, VA 23298, USA e-mail: [email protected]
Keywords Cancer Palliative Interventional pulmonology Lung cancer Incarcerated
J. Dawson e-mail: [email protected]
Introduction
R. W. Shepherd e-mail: [email protected] H. J. Lee Interventional Pulmonology, Pulmonary Disease and Critical Care Medicine, The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD 21287, USA e-mail: [email protected]
Lung cancer alone accounts for 8 % of all state prisoner deaths and lung cancer accounts for 1 in 3 cancer deaths in State prisons [1]. Despite growing inmate populations in the United States, inmates are excluded from most national health surveys and thus little is known about the safety and effectiveness of cancer palliation in this patient population.
123
916
In addition, the number of older inmates in US correctional facilities is increasing which may result in an increasing need for quality palliative care. Cancer in this group carries higher morbidity and mortality than the general population. This is thought to be in part secondary to the higher prevalence of lethal cancers in the incarcerated such as lung cancer, hepatic carcinomas, and non-Hodgkin lymphomas, due to higher prevalence of cancer risk factors in prison population [2–4]. Federal, state, and local inmate populations across the United States are growing larger and older, primarily due to longer sentences and ‘‘three strikes’’ sentencing laws [5]. The role of palliative procedures in patients with lung cancer is long established. Some palliative airway procedures such as airway stenting and tumor debulking can re-establish patency of the airway and relieve mechanical obstruction which may improve dyspnea, chest pain, and post-obstructive pneumonia. TPC in malignant pleural effusion (MPE) results in significant symptom relief. The catheter is tunneled under the skin with a cuff to reduce the risk of infection and allows for drainage several days/week through a one-way valve catheter into a negatively pressurized container. The drainage process was designed for lay and non-medical personnel to offer drainage of the catheter at home setting. In addition, up to 50 % of patients benefit from successful auto-pleurodesis followed by catheter removal without recurrence of the MPE. This method offers a similar benefit to chemical pleurodesis with agents such as talc without hospitalization and the risk of acute respiratory distress syndrome [6]. To our knowledge, there are no peer-reviewed publications on the challenges and barriers that correctional and consulting physicians face while providing palliative care with interventional pulmonology procedures [7]. We report a single-center experience in managing inmates with interventional pulmonology airway and pleural palliative procedures.
Study Design, Materials and Methods The study was approved by the Institutional Review Board at Virginia Commonwealth University (VCU). This was a retrospective review of prospectively collected data from the VCU medical center interventional pulmonology procedure registry (Jan 2009 through December 2012), which is a tertiary care academic and referral center for the Virginia Department of Criminal Justice.
Lung (2014) 192:915–920
therapeutic interventional pulmonology procedures for palliation which included airway lesion debulking (mechanical/ thermal), airway stenting, and TPC placement for palliative measures. Inmates who had diagnostic bronchoscopy without any therapeutic procedures or pleural procedure (thoracentesis) for diagnostic purposes only were excluded from the study. The primary endpoints were safety and efficacy. Airway procedures were evaluated specifically for lung re-expansion, symptomatic relief, stent migration, and direct procedural complications. Date of TPC insertion, correctional facility records of drainage, immediate- and long-term symptomatic relief, and auto-pleurodesis were recorded. Rate of infection post TPC placement and complications such as TPC occlusion, damage, and accidental removal were also analyzed.
Results Eleven male and one female patients (age range 43–65 years) were included in the study. A total of 16 procedures were performed in 12 patients. Four patients were diagnosed with squamous cell carcinoma of the lung, four had lung primary adenocarcinoma, and one had small cell lung cancer. In addition, one patient had metastatic thymoma, one had metastatic granular carcinoma, and one had a poorly differentiated carcinoma. Chief complaint for most patients was new or progressive worsening dyspnea resulting in decreased physical activity. Other presenting signs and symptoms included hemoptysis, chest pain, and post-obstructive pneumonia (Table 1). Six patients had TPC placed. All patients reported immediate relief of shortness of breath after TPC placement and had improved aeration of their lungs on the side of TPC placement on chest radiography. Three patients had successful auto-pleurodesis followed by catheter removal and no return of MPE (Figs. 1, 2). Table 1 Demographics Number of patients Age
12
Sex
43–65
Type of malignancy
11 male, 1 female 8 NSCLC (4 SCC, 4 adenocarcinoma of the lung) 1 SCLC 3 others (thymoma, metastatic granular carcinoma, and poorly diff. carcinoma)
Inclusion Criteria Included Inmates older than 18 years of age with lung cancer and other advanced malignancies involving the airways or lung,
123
Presenting signs and symptoms
Progressive SOB (10), hemoptysis, stridor, fever, increased sputum production, chest pain, facial swelling, and weight loss
Lung (2014) 192:915–920
Fig. 1 Tunneled pleural catheter just inserted in right pleural space
The timeframe from TPC insertion to catheter removal in the three patients who had successful auto-pleurodesis was between 1 and 2 months. The earliest death in a patient with TPC was 3 weeks after TPC placement, due to massive pericardial effusion. The longest survival after TPC insertion was 12 months in a patient who had successful auto-pleurodesis 1 month post TPC placement and is currently alive and receiving chemotherapy. Six patients underwent rigid bronchoscopy and tumor debulking (mechanical/thermal) (Figs. 3, 4). Four patients received airway stents of which three were covered metal stents. One patient with metastatic granular carcinoma and a very proximal tracheal tumor had a tracheal metal stent placed. The patient returned with tracheoesophageal fistula and tumor growth above the stent. The fistula was covered with a silicone stent through which a tracheostomy tube was inserted by percutaneous tracheostomy technique.
917
Patient had immediate symptomatic relief and was able to breathe comfortably with minimal O2 requirement, up to 4 weeks following the second procedure. One patient with post-obstructive pneumonia, who was not a chemotherapy candidate due to severe pneumonia, underwent airway stent placement followed by pneumonia resolution. The patient lived 2 years and 6 months past stent placement which allowed for the initiation of chemotherapy. The immediate post procedure benefits varied from resolution of atelectasis, stridor, and progressive dyspnea to resolution of post-obstructive pneumonia. One patient diagnosed with very advanced disease had complete occlusion of his left main stem not amenable to recanalization. Tumor debulking of the right main stem with argon plasma coagulation improved luminal diameter but was unable to extubate after the procedure and expired from bilateral pulmonary emboli. Given the small number of airway interventions and their variability, no statistical analysis can be applied to evaluate safety; however, our data showed that palliative airway interventions are feasible in prisoners. In patients with TPC placement, while the point estimate of 50 % for auto-pleurodesis in our case series was similar to reports for the general population, a 95 % confidence interval for estimate (9–90 %) reflects the large variability in this estimate due to the small sample size. Thus, no meaningful comparison to the general population can or should be drawn from this case series.
Discussion There are numerous challenges in caring for incarcerated patients with advanced malignancy. These challenges will continue to grow as the inmate population with cancer
Fig. 2 a Right-sided MPE, b status post right-sided TPC placement, c near-complete resolution of right-sided pleural effusion and successful auto-pleurodesis, 2 months post TPC placement (CXR obtained prior to TPC removal)
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Fig. 3 a Endotracheal near-complete stenosis by tumor on axial chest CT scan imaging, b endotracheal tumor visualized under rigid bronchoscopy, c post tumor debulking and airway stenting
Fig. 4 a Left lung collapse with partial aeration of the Upper lobe due to left main stem (LMS) tumor, b Endotracheal view of the main carina with tumor in LMS, c LMS tumor debulking and restoration of LMS and left upper lobe bronchus patency
continues to rise [8]. Different facilities have varying capabilities and relocation of inmates is common, making continuity of care difficult. To our knowledge, there is no study available on the safety and feasibility of long-term TPC and airway stents in the incarcerated patients, as most published studies exclude this population. We provide a case series that focuses on the feasibility and safety of interventional pulmonology procedures in particular: tunneled pleural catheters, airway tumor debulking, and airway stents for the palliation of advanced malignancy. MPE carries significant morbidity and TPCs are shown to be remarkably useful in the palliation of patients with severe dyspnea and discomfort as a result of MPE. In
123
patients with a non-expandable lung, TPC is the only realistic option for palliation. Patients with TPC require regular catheter drainage to achieve the maximum palliative benefit and attention to aseptic techniques, and education is required to drain and manage the TPC in order to reduce risk of infection or catheter dislodgement. The concern regarding drainage of the catheter in prison may pose challenges; however, the TPC was designed for lay people to drain and maintain the catheter. While there are different capabilities in different correctional facilities, a nurse or non-medical personnel can potentially drain the catheter for the patient without requirements for an infirmary or off-site physician visits. Our results with TPC were
Lung (2014) 192:915–920
similar to prior reported studies [9]. There were no infectious complications reported in our series and the rate of TPC removal due to the cessation of drainage (auto-pleurodesis) of the TPC was 50 %. All of our patients had their initial post procedure drainage in an infirmary connected to the hospital which may not be available in some institutions. However, after procedural discharge, inmates were transferred to their prison and the prison staffs were the primary caregivers and assisted in regular TPC catheter drainage. Our experience with TPC for this population did not differ significantly from the published literature [10, 11]. While 50 % of patients achieved auto-pleurodesis and there were no reported complications, the result of this small case series cannot be extrapolated to a larger inmate population due to a small sample size. This case series, however, shows that the use of TPC for MPE in inmates is feasible. Larger studies would be required to truly assess the safety of this palliative method in the incarcerated population. Airway stents for palliation can migrate or can become obstructed with mucus and granulation tissue requiring timely specialist consultation availability. In this study, there were no complications requiring urgent re-consultation. We recognize that this may not always be the situation; however, this may also occur in the general population. There is clearly an immediate beneficial palliation with airway tumor debulking and stenting that should not be overlooked. Alternatively, the use of opioids to relieve dyspnea is a common practice in palliative care medicine. While effective in the general population, in the incarcerated population it may be less effective due to prior or ongoing narcotic abuse and inability to titrate high doses of opioids [12]. Patients who receive airway stents may often use daily albuterol or saline nebulizer therapy to decrease mucus drying and ease clearance [13]. Nebulizer therapy is normally accessible for inmates with asthma/ COPD in prisons (Table 2). While there are limitations to this retrospective evaluation, our study collected data via a registry which allows prospective collection of data. The more obvious limitation is the small sample size in each of these cohorts. These data were collected over 3 years in a tertiary care center with small number of subjects making definitive conclusions difficult. Given the increasing cancer prevalence in inmates, the incarcerated population may not be receiving comparable palliative care as the general population. This will need to be further studied prospectively and is beyond the scope of this investigation. We recommend larger studies as more data become available with increasing awareness of safety and efficacy of palliative procedures in the incarcerated population. With the incarcerated population in the US at its greatest numbers and the increasing length of prison stay, the problems of palliative
919 Table 2 Palliative procedure results Palliative procedure
Results
TPC for MPE Number of patients
6
Symptomatic improvement
Immediate relief in all patients
Frequency of TPC drainage
Three times per week by infirmary nursing staff
Pleurodesis and TPC removal
3 (50 %)
Time from insertion to TPC removal
1–2 months
Survival post TPC insertion
3 weeks to 12 months (average of 2 months)
Complications (infection and TPC dislodgement)
None
Airway tumor debulking/airway stenting Number of patients
6 (tumor debulking in 6, airway stenting in 4)
Rigid bronchoscopy/tumor debulking
6
Airway stenting
4 (3 Aero metal stents and 1 silicone stent)
Symptomatic improvement
Resolution of lobar atelectasis (2), resolution of post-obstructive pneumonia (2), and resolution of stridor and restoration of tracheal patency (1)
Survival post procedure
5 days to 30 months
Complications (Stent migration or fracture Pneumothorax, death, etc.)
0
interventional pulmonology care are unlikely to diminish in the near future. Conclusion Incarcerated patients with advanced malignancy may benefit from interventional pulmonology procedures with low complications. Palliative interventional pulmonology procedures in inmates should not be withheld solely on their incarceration status. Conflict of interest
None.
References 1. Hospice and Palliative Care in Prisons (1998) Special issues in corrections. US Dept of Justice, National Institute of Corrections Information Center, Longmont 2. Mao L, Oh Y (1998) Does marijuana or crack cocaine cause cancer? J Natl Cancer Inst 90:1182–1184 3. Reindollar RW (1999) Hepatitis C and the correctional population. Am J Med 107:100S–103S
123
920 4. Dean-Gaitor HD, Fleming PL (1999) Epidemiology of AIDS in incarcerated persons in the United States, 1994–1996. AIDS 13:2429–2435 5. Bureau of Justice Statistics Data Brief, Medical Causes of Death in State Prisons, 2001–2004, January 2007, NCJ 216340 6. Davies HE, Mishra EK, Kahan BC et al (2012) Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA 307(22):2383–2389 7. Linder JF, Meyers FJ (2007) Palliative care for prison inmates: ‘‘don’t let me die in prison’’. JAMA 298(8):894–901 8. Mathew P, Elting L, Cooksley C, Owen S, Lin J (2005) Cancer in an incarcerated population. Cancer 104(10):2197–2204 9. Tremblay A, Mason C, Michaud G (2007) Use of tunnelled catheters for malignant pleural effusions in patients fit for pleurodesis. Eur Respir J 30(4):759–762
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