Frequency of unsafe storage, use, and disposal practices of opioids among cancer patients presenting to the emergency department

2016 ◽  
Vol 15 (6) ◽  
pp. 638-643 ◽  
Author(s):  
Julio Silvestre ◽  
Akhila Reddy ◽  
Maxine de la Cruz ◽  
Jimin Wu ◽  
Diane Liu ◽  
...  
Keyword(s):  
Emergency Department ◽  
Patient Education ◽  
Cancer Patients ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Pain Medications ◽  
The Impact ◽  
At Home

AbstractObjective:Approximately 75% of prescription opioid abusers obtain the drug from an acquaintance, which may be a consequence of improper opioid storage, use, disposal, and lack of patient education. We aimed to determine the opioid storage, use, and disposal patterns in patients presenting to the emergency department (ED) of a comprehensive cancer center.Method:We surveyed 113 patients receiving opioids for at least 2 months upon presenting to the ED and collected information regarding opioid use, storage, and disposal. Unsafe storage was defined as storing opioids in plain sight, and unsafe use was defined as sharing or losing opioids.Results:The median age was 53 years, 55% were female, 64% were white, and 86% had advanced cancer. Of those surveyed, 36% stored opioids in plain sight, 53% kept them hidden but unlocked, and only 15% locked their opioids. However, 73% agreed that they would use a lockbox if given one. Patients who reported that others had asked them for their pain medications (p = 0.004) and those who would use a lockbox if given one (p = 0.019) were more likely to keep them locked. Some 13 patients (12%) used opioids unsafely by either sharing (5%) or losing (8%) them. Patients who reported being prescribed more pain pills than required (p = 0.032) were more likely to practice unsafe use. Most (78%) were unaware of proper opioid disposal methods, 6% believed they were prescribed more medication than required, and 67% had unused opioids at home. Only 13% previously received education about safe disposal of opioids. Overall, 77% (87) of patients reported unsafe storage, unsafe use, or possessed unused opioids at home.Significance of Results:Many cancer patients presenting to the ED improperly and unsafely store, use, or dispose of opioids, thus highlighting a need to investigate the impact of patient education on such practices.

Patterns of storage, use, and disposal of opioids among cancer patients presenting to the emergency center.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 184-184
Author(s):  
Akhila Sunkepally Reddy ◽  
Julio Silvestre ◽  
Maxine Grace De la Cruz ◽  
Jimin Wu ◽  
Diane D Liu ◽  
...  
Keyword(s):  
Patient Education ◽  
Cancer Patients ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Emergency Center ◽  
Pain Medications ◽  
History Of ◽  
At Home

184 Background: Approximately 75% of prescription opioid abusers obtain the drug from an acquaintance. Improper opioid storage, use, and disposal along with lack of patient education may lead to increased availability of the drug for abuse by others. Our aim was to determine the opioid storage, use, and disposal patterns in patients presenting to the emergency center (EC) of a comprehensive cancer center. Methods: We surveyed 113 cancer patients receiving opioids for at least 2 months and collected information regarding opioid use, storage, and disposal. Unsafe storage was defined as storing the opioids in plain sight and sharing or losing their opioids was defined as unsafe use. Results: The median age was 53 years, 55% were female, and 64% were white and 86% had advanced cancer. 19% of the patients had history of illicit drug use and 24% reported that drug abuse is prevalent in their neighborhood. 59% obtained the opioid from their oncologist and 6% believed they were prescribed more medication than required. Of the 113 respondents, 36% stored opioids in plain sight, 53% kept them hidden but unlocked, and only 15% locked their opioids. 73% agreed that they would use a lockbox to store their opioids if given one, 78% were unaware of proper opioid disposal methods, and 67% had unused opioids at home. Only 13% previously received education about safe disposal of opioids. Patients who reported that others have asked them for their pain medications (P = .004) and those who would use a lockbox if given one (P = .019) were more likely to keep them locked. 13 patients (12%) used opioids unsafely by either sharing (5%) or losing (8%) them. Patients who reported to being prescribed more pain pills than required (P = .032), others having asked them for their pain pills (P = .06), being unemployed (P = .07), and those who were unaware of drug take-back programs (P = .06) were more likely to participate in unsafe use. Overall, 77% (87) of the patients reported unsafe storage, unsafe use, or possessed unused opioids at home. Conclusions: A large number of cancer patients improperly and unsafely store, use, or dispose of opioids. More research is needed to determine whether patient education has an effect on minimizing prescription opioid abuse.

scholarly journals DEVELOPMENT OF AN OPIOID EDUCATION RESOURCE FOR OLDER CANCER PATIENTS

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S665-S666
Author(s):  
Ruth Manna ◽  
Natalie Moryl ◽  
Natalie Gangai ◽  
Vivek Malhotra ◽  
Jennifer Wang ◽  
...  
Keyword(s):  
Patient Education ◽  
Cancer Patients ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Opioid Epidemic ◽  
Opioid Use ◽  
Additional Information ◽  
Open Questions ◽  
Older Cancer Patients ◽  
Education Resource

Abstract Pain is a common problem in older cancer patients, estimated to affect 70% of those with advanced disease. As older adults live longer after diagnosis, the use and misuse of opioids will continue to rise. Gaps in available age-friendly opioid resources for patients were identified at a Comprehensive Cancer Center. An interprofessional team worked to develop a resource to educate older cancer patients and their caregivers regarding safe opioid use. Expert clinical opinions from Supportive Care, Anesthesia Pain, Nursing, and Geriatrics Services as well as patient observations informed drafts of the resource. A total of 22 older patients in three geriatric clinics were approached for a short interview (8 open questions) surrounding opioid understanding and concerns. The most stated concerns were fear of addiction, concern about the opioid epidemic, and potential unwanted side effects. There was an evident lack of awareness of what an opioid was or which one of the medications in their list was an opioid. The interviews underscored the need for the education resource to include names of opioids, address concerns about the opioid epidemic and signs of addiction. Language was added to describe safe use, storage and disposal of opioids. Special considerations in the older adult were emphasized. Links to additional information were provided. Finally, patient education experts reviewed the draft to adapt the language to be patient-friendly. Opioids are often effectively used in cancer pain management and older cancer patients warrant proper education. Patient perspectives are critical in the development of relevant patient education resources.

Increasing non-opioid pain management in the cancer patient presenting to the emergency department.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 237-237
Author(s):  
Adriana Wechsler ◽  
Ngoc Vu
Keyword(s):  
Emergency Department ◽  
Pain Management ◽  
Cancer Patients ◽  
Patient Preference ◽  
Comfort Level ◽  
Easy Access ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Opioid Analgesia ◽  
Opioid Use

237 Background: The opioid epidemic is claiming more than 115 lives daily in the US (1). Pain is commonly the chief complaint of cancer patients presenting to the emergency department (ED) and aggressively managed with opioids. A recent study of cancer patients presenting to the ED showed they were also at high risk for opioid misuse (2). Non-opioid analgesia is often avoided from concerns of masking fevers, intolerance due to nausea/vomiting, or bleeding risk in thrombocytopenia. Our aim was to identify opportunities to reduce opioid use while safely alleviating pain in patients presenting to the Emergency Department of a comprehensive cancer center. Methods: Following the PDSA model, baseline data on current opioid use was obtained and perceived barriers to non-opioid analgesia were identified through questionnaires. Comfort level with non-opioid analgesia in cancer patients and current pain management practice was also queried. Patients eligible for non-opioid analgesia (solid tumors, no fever, pain score < 7) were then identified through retrospective chart review and the prevalence of contraindications for non-opioid (renal/liver failure, thrombocytopenia, oral intolerance) and patient preference for opioids was calculated. This data and opportunities to use non-opioid analgesia was shared with providers in education sessions. Medication order panels were modified to provide easy access to oral and intravenous acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDs). After two months the change in opioid prescribing was calculated. Results: Providers self-reported barriers to prescribing opioids as: low platelets, patient preference, and poor oral intake. Of 237 patients presenting to the MDA Emergency Department with complaints of pain between January 2018 and May 2018, 76 (32%) were eligible for non-opioid analgesia. Only 3 patients had absolute contraindications to both APAP or NSAIDs. After provider education, order entry simplification and prescribing guidance, the use of non-opioid analgesia rose from 3.9% to 9.4%. Patient satisfaction with pain control rose from 57.4 to 60.4 % following the intervention based on Press Ganey results. Conclusions: There is opportunity for non-opioid acute pain management in the solid tumor patients. Contraindications to non-opioid analgesia are uncommon. In the emergency department, safe pain relief can be provided by non-opioids such as NSAIDs and APAP.

Effect of a supportive medicine program for cancer patients on patient connectivity to care and health care utilization.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. 2034-2034
Author(s):  
Brooke Worster ◽  
Gregory D. Garber ◽  
Rebecca Cammy ◽  
Liana Yocavitch ◽  
Ayako Shimada ◽  
...  
Keyword(s):  
Emergency Department ◽  
Cancer Patients ◽  
Hospital Admissions ◽  
Cost Of Care ◽  
Emergency Department Visits ◽  
Comprehensive Cancer Center ◽  
Categorical Variables ◽  
Cancer Center ◽  
Ed Visits ◽  
The Impact

2034 Background: The benefits of supportive medicine (SM) for cancer patients include improved quality of life, increased patient satisfaction, improved symptom management, increased cost savings and improved survival rates. At one NCI-designated cancer center, all patients were screened for distress; those who screened positive or were directly referred by a provider were enrolled into our multi-disciplinary SM program. Here, we document the impact of the supportive medicine program on outcomes of emergency department (ED) visits, hospital readmission, and non-billable touchpoints associated with patient navigation and resource referrals. Methods: The program systematically screened for biopsychosocial distress utilizing the National Comprehensive Cancer Center Distress Thermometer (DT) and the Problem Checklist (PC) to identify practical, emotional, spiritual and physical issues. Patients were categorized into three types: screened and enrolled in the SM program, and screened and not enrolled in the SM program, or provider referral into the SM program. Data included patient’s age, number of hospital admissions, emergency department visits, and non-billable touchpoints at 90 and 180 days after the distress screening or referral. Descriptive data were analyzed with counts and percentages for categorical variables and summarized with mean and standard deviation for numerical variables. For investigation of the effects of time and patient type on the change in utilization rate, generalized estimation equations for Poisson regression were conducted for each outcome. Results: In all, 2,738 patients were included in the analysis. Patients who were referred from a provider tended to be younger (p < .01) and more likely to die within 90 days (p < .001). At 180 days, ED visits decreased 18% for patients referred to the SM program and 42% for patients screened into the SM program, compared to a 3% decrease in ED visits among those not enrolled in the SM program (p < .01). Similarly, hospital admissions decreased 34% for patients referred to and 39% screened into the SM program, compared to a 4% increase for patients not enrolled in the SM program (p < .01). Non-billable touchpoints increased among all types of patients. Conclusions: An SM program reduces hospital admissions and ED visits, therefore improving outcomes and potentially reducing the cost of care for cancer patients. Future research should link this data to claims data to definitely evaluate the impact of SM programs on cost.

Routine HIV Screening in Cancer Patients in the Emergency Department

2018 ◽  
Vol 17 (2) ◽  
pp. 91-95
Author(s):  
Terry W Rice ◽  
◽  
Patricia A. Brock ◽  
Carmen Gonzalez ◽  
Kelly W Merriman ◽  
...  
Keyword(s):  
Emergency Department ◽  
Hiv Testing ◽  
Cancer Patients ◽  
Linkage To Care ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Hiv Screening ◽  
Immunodeficiency Virus ◽  
Routine Hiv Screening ◽  
Incident Cases

Treatment of human immunodeficiency virus(HIV) in cancer patients improves outcomes and reduces transmission of this oncogenic virus. HIV testing rates of cancer patients are similar to the general population (15-40%), despite the association with cancer. Our aim was to increase HIV screening in the Emergency Department(ED) of a comprehensive cancer center through a quality initiative. Testing increased significantly during the intervention (p<0.001; 0.15/day to 2.69/day). Seropositive HIV rate was 1.4% (12/852), with incidence of 0.3%. All patients were linked to care. Incident cases were between 36 and 55 years of age. Barriers encountered included confusion regarding the need for written consent for HIV testing, failure to consider ordering the test, and concerns regarding linkage to care.

Patient attitudes toward oncofertility care in male cancer patients receiving targeted and immune therapies.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e21593-e21593
Author(s):  
Katy K. Tsai ◽  
Puneet Kamal ◽  
Joris Ramstein ◽  
Alain Patrick Algazi ◽  
Adil Daud ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Checkpoint Inhibitors ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Patient Attitudes ◽  
Durable Response ◽  
Care Plans ◽  
Future Fertility ◽  
Long Term Treatment ◽  
The Impact

e21593 Background: Tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICI) have resulted in durable response for many cancer patients. The impact of these agents on future fertility are not well described, and patients are often committed to long-term treatment without adequate oncofertility counseling. We sought to better characterize patient attitudes toward oncofertility and challenges faced by male cancer patients undergoing treatment with TKI or ICI. Methods: Men receiving TKI/ICI at the UCSF Helen Diller Family Comprehensive Cancer Center were retrospectively identified. Eligible men had received at least one dose of TKI/ICI. Detailed questionnaires addressing cancer history, possible effects of treatment on fertility, and obstacles to fertility preservation were completed. Results: Between January 2013 to September 2016, 51 men with a mean age of 46 years (SD 12, range 21-72), 65% white, completed questionnaires. Most (61%) were CML patients, with 12% RCC, 10% GIST, 6% melanoma, and NET, oligodendroglioma, and HCC comprising remaining histologies. 96% were treated with TKI, and 4% with ICI. At the time of diagnosis, 35% of patients indicated a desire to father future children, and 53% believed that cancer treatment might affect their fertility. Despite this, 45% were not asked whether having children was important to them, and 47% did not receive information from any provider on their oncology care team about the possible risks of TKI/ICI to future fertility. The majority of patients felt there was inadequate discussion of how treatment might affect testosterone levels (73%) and their ability to father a child (53%), yet only 14% recalled adequate referrals to a fertility specialist. Conclusions: These data demonstrate that male cancer patients perceive treatment-related infertility risks as important, yet have few opportunities to discuss these concerns with providers. Care plans to address oncofertility needs, especially as TKI/ICI are increasingly used in multiple cancer types, are needed as part of the diagnosis, treatment, and follow up of these patients. Larger retrospective and prospective studies are ongoing to further characterize this patient cohort.

Evaluation of pharmacist interventions in a head and neck medical oncology clinic

2020 ◽  
Vol 26 (6) ◽  
pp. 1390-1396
Author(s):  
Kimberly M Lau ◽  
Ila M Saunders ◽  
Assuntina G Sacco ◽  
Linda C Barnachea
Keyword(s):  
Patient Education ◽  
Head And Neck ◽  
Vital Role ◽  
Primary Objective ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Care Continuum ◽  
Medication Therapy ◽  
Pharmacist Interventions ◽  
The Impact

Introduction Head and neck cancers (HNC) are a complex and heterogeneous group of cancers, often necessitating a multidisciplinary approach across the care continuum. Oncology pharmacists are uniquely qualified to play a vital role on a multidisciplinary team and provide specialized care to optimize medication therapy. Methods This was a retrospective chart review evaluating the role of a board-certified oncology pharmacist in the head and neck oncology clinic at an academic, comprehensive cancer center from April 2017 through March 2018. The primary objective of the study was to describe the types of interventions made by the oncology pharmacists. Secondary objectives included quantifying time spent on patient education and number of prescriptions sent to pharmacies. Results The pharmacist had 873 encounters with 151 patients, resulting in 2080 interventions. Approximately 57% of the interventions were performed in the clinic. Patient education (58%), facilitation of new prescriptions or refill requests (49.9%), and supportive care management (32.6%) were the most frequent interventions. The oncology pharmacist spent 154.1 h on patient education and sent 811 prescriptions to pharmacies, with 63.6% of prescriptions sent to the institution’s cancer center pharmacy. Conclusion The incorporation of an oncology pharmacist in the HNC team optimized patient care through comprehensive and timely interventions across the care continuum. Our study is the first to highlight the vital role oncology pharmacists have in improving the overall quality of care of HNC patients. Future directions include exploring the impact of oncology pharmacist interventions on select Quality Oncology Practice Initiative measures by the American Society of Clinical Oncology.

EPR19-069: Opioid Use Among Cancer Patients Undergoing Surgery and Their Associated Risk of Re-admissions and Emergency Department Visits in the 1-Year Postsurgical Period

2019 ◽  
Vol 17 (3.5) ◽  
pp. EPR19-069 ◽  
Author(s):  
Siyana Kurteva ◽  
Robyn Tamblyn ◽  
Ari Meguerditchian
Keyword(s):  
Emergency Department ◽  
Cancer Patients ◽  
Healthcare System ◽  
Emergency Department Visits ◽  
Administrative Claims ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Ed Visits ◽  
Opioid Users ◽  
The Impact

Background: Prescription opioid use and overdose has steadily increased over the past years, resulting in a dramatic increase in opioid-related emergency department (ED) visits and hospitalizations. Methods: This study used a prospective cohort of cancer patients having undergone surgery in Montreal (Quebec) to describe their post-discharge opioid use and identify potential patterns of unplanned health service use (ED visits, hospitalizations). Provincial health administrative claims were used to measure opioid dispensation as well as hospital re-admissions and ED visits. The hospital warehouse, patient chart and patient interview will be used to further describe patient’s medical profile. Marginal structural models will be used to model the association between use of opioids and risk of ED visits and hospitalizations. Inverse probability of treatment and censoring weights will be constructed to properly adjust for confounders that may be unbalanced between the opioid and non–opioid users as well as to account for competing risk due to mortality. Reasons for the re-admissions will also be presented as part of the analyses. Covariates will include patient comorbidities, medication history, and healthcare system characteristics such as nurse-to-patient and attending physician-to-patient ratios. Results (interim): A total of 821 were included in the study; of these, 73% (n=597) were admitted for a cancer procedure. At postoperative discharge, 605 (74%) of patients had at least one opioid dispensation, of which the majority (67%) were oxycodone with hydromorphone being the second most prescribed (28%). Among those who filled a prescription, mean age was 66 (13.4), 68% had no previous history of opioid use, and 10% have had 3 or more dispensing pharmacies in the year prior to admission, compared to less than 1% for the non–opioid users. Overall, 343 people refilled their opioid prescription at least once and 128 at least twice during the 1-year postoperative period. Among cancer patients who were opioid users, 214 ED visits occurred in the 1 year after surgery compared to only 40 for the non-cancer opioid users. Conclusion: This study will help to identify the risk profile of cancer patients who are most likely to continue using opioids for prolonged periods following surgical procedures as well as quantify the impact of opioid use and its associated burden on the healthcare system in order to identify areas for possible interventions.

Practice of venous thromboembolism (VTE) prophylaxis in hospitalized cancer patients at a comprehensive cancer center.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 149-149
Author(s):  
M.Alma Rodriguez ◽  
Alma Yvette DeJesus ◽  
Lee Cheng ◽  
Michael Kroll
Keyword(s):  
Risk Assessment ◽  
Cancer Patients ◽  
Comprehensive Cancer Center ◽  
Categorical Variables ◽  
Cancer Center ◽  
Moderate Risk ◽  
Pharmacological Prophylaxis ◽  
Vte Prophylaxis ◽  
National Quality ◽  
The Impact

149 Background: VTE prophylaxis measures are endorsed by the National Quality Forum in alignment with quality indicators from the Centers for Medicare & Medicaid Services. Accordingly, documentation of VTE risk, prophylaxis measures, and contraindications are recommended for hospitalized patients. To standardize practice we embedded a VTE risk assessment and prophylaxis module into admission and post-surgical order sets (OS), starting August 15, 2011. Methods: A retrospective study of 9,065 cancer patients (≥18 years) admitted to The University of Texas MD Anderson Cancer Center between June 01, 2013 through September 30, 2013. Pharmacological prophylaxis was executed with low-molecular-weight heparin or unfractionated heparin. Mechanical prophylaxis was executed with graduated compression stockings and/or sequential compression devices. Chi-square testing was used to determine the association between categorical variables. All statistically significant levels were determined with P values < 0.05. Results: 7,366 (81%) of all hospital admissions had documented VTE risk assessment and prophylaxis through the standardized VTE module. Before implementation of the new OS, only 40% of eligible patients received an order for VTE prophylaxis. The majority of patients were designated high or moderate risk (91.1%). Patients with high risk were more likely to receive pharmacological prophylaxis than those with moderate risk (74.1% vs. 38.2%, P<0.01). The most frequent contraindications to pharmacological prophylaxis were major surgery with risk of bleeding and thrombocytopenia (Table). Conclusions: Most patients received VTE prophylaxis based on VTE risk levels presented in a standardized OS. There is is limited information in the clinical literature about the impact of VTE prophylaxis on outcomes among cancer patients, we plan to assess anticoagulation-related outcomes in this cohort of patients. [Table: see text]

The development of a nomogram to determine the risk for inappropriate opioid use in cancer patients.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11602-11602
Author(s):  
Sriram J. Yennu ◽  
Rony Dev ◽  
Tonya Edwards ◽  
Joseph Anthony Arthur ◽  
Zhanni Lu ◽  
...  
Keyword(s):  
Supportive Care ◽  
Cancer Patients ◽  
Financial Distress ◽  
Comprehensive Cancer Center ◽  
Multivariate Logistic Regression Model ◽  
Cancer Center ◽  
Opioid Use ◽  
Care Clinic ◽  
Validated Questionnaire ◽  
Edmonton Symptom Assessment Scale

11602 Background: Non-Medical opioid use is a growing crisis. Cancer patients at risk of harmful use of prescribed opioids are frequently underdiagnosed. The aim was to develop a nomogram to predict the probability of occurrence of Inappropriate opioid use that is, presence of SOAPP ≥ 7) among patients receiving outpatient supportive care consultation at a comprehensive cancer center. Methods: 3588 consecutive cancer patients referred to a supportive care clinic from March 1, 2016 to July 15, 2018 were reviewed. Patients were eligible if they had diagnosis of cancer, and were on opioids for pain for at least a week. All patients were assessed using Edmonton Symptom Assessment Scale with spiritual pain and financial distress (ESAS-FS), MEDD (morphine equivalent daily dose), SOAPP-14 (validated questionnaire for assessment of risk of inappropriate opioid use, and CAGE-AID (screening questionnaire for alcoholism/substance use disorder). Patients at with SOAPP+ were defined by SOAPP score ≥7. A nomogram was devised based on the risk factors determined in the multivariate logistic regression model and it can be used to estimate the probability of inappropriate opioid use. Results: Median age was 62yrs. Median ESAS pain item score on consultation was 5, Median ECOG was 2.20.4% were SOAPP+ and 10.1% were CAGE-AID+. SOAPP+ was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD and CAGE score. The C-index is 0.8(CI 0.78, 0.82). A nomogram was developed. For example, for a male Hispanic patient, who is married, never smoked, with the following ESAS scores: (depression = 3, anxiety = 3, financial distress = 8), CAGE score of 0, and MEDD of 20, the total score is 9+9+0+0+6+10+26+0+1 = 61. In the nomogram a score of 58 indicates the probability of inappropriate opioid use being 0.1 and a score of 88 indicates the probability of 0.2. Based on the patient’s total score of 61, the probability of his aberrant behavior is between 10% to 20% (close to 10%). Conclusions: A nomogram can predict the risk of inappropriate opioid use in cancer patients.

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