Gastro-Intestinal Symptoms in Palliative Care Patients

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Author

Despite not bringing new information, reading your review was a pleasure.

The major strength of your review is the approach in the same paper to all the significant gastrointestinal symptoms. The review is good.

However, I suggest adding the method used to find and select the papers you referred to in your paper.

Kind regards

Author Response

Dear reviewer,

Thank you for taking the time to read and comment this review article. My intention was not to produce a systematic review of the literature for each symptom. Therefore, using PubMed, I looked at each symptom in palliative care/ palliation, in English in the last 5 years as of November 2023. Sometimes earlier literature was also presented, and if pertinent and felt to bring additional substantial recommendations, it was included. 

I have included in the introductory paragraph the method by which I obtained the referenced articles.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Redactors,

Thank you very much for the opportunity to revise the article „Gastro-Intestinal Symptoms in Palliative Care Patients”. The article is interesting and well-written.

I recommend decribing in more details valuable sources of fibre in palliative care patients.

I also think that information about recommended suplementation should be described.

Thanks

Author Response

Dear reviewer,

Thank you for taking the time to read this review article and making suggestions. 

With respect to your suggestion regarding valuable sources of fibre in palliative care patients and after another round of reviewing further articles, I believe that there is so much to say about so many different forms of fibre that the reader could be confused regarding the addition of fibre to a seriously-ill patient's diet, and the research and fibre has not been done in palliative patients to allow for  any recommendations in this particular population.  I have made an adjustment to the non-pharmacological approach of constipation as follows:

Fibre can be increased in patients who ingest inadequate amounts but  not necessarily up to the usual recommended 30 grams/day in this terminal population, as there is a risk of fecaloma or obstruction in those with abdominal malignancy and other comorbid factors³. In fact, some would recommend a low-residue diet to improve laxation⁴. The use of mineral oil per os and psyllium supplements are not recommended in this population. On the one hand, mineral oil will prevent lipid soluble vitamins from being absorbed, and psyllium requires great quantities of fluids to be ingested to bulk up the stool enough to get a reflex peristatic movement. As a result, psyllium has been used for the treatment of diarrhea and fecal incontinence⁵. 

Your suggestion to include information about supplementation is an interesting one. However, as the purpose of the study was regarding assessment and treatment of symptoms, I do not feel that supplementation (in case of poor nutritional status?) is necessary here. 

best regards

Reviewer 3 Report

Comments and Suggestions for Authors

First of all, thank you for the opportunity to review the article “Gastro-Intestinal Symptoms in Palliative Care Patients”.

The title indicates the content of the article, that is, the different gastrointestinal symptoms that appear in palliative patients. The abstract already indicates that it is not an exhaustive review and will focus on the most frequent symptoms and the basic aspects for their control.

The content of the article is not new since it is a topic that has been previously discussed in different publications and clinical practice guides internationally. It is not indicated whether a literature search has been carried out following a research question and what the final objective of the research is.

The origin of the sources of the tables is not referenced. Only table 3 indicates what the source is.

Regarding the conclusions, they are very generic and do not respond to the basic aspects of the review.

The references are correct, although some are prior to 2010. However, a review of different published clinical practice guidelines such as “Hisanaga T, et al. Clinical Guidelines for Management of Gastrointestinal Symptoms in Cancer Patients: The Japanese Society of Palliative Medicine Recommendations. J Palliat Med. 2019 Aug;22(8):986-997. doi: 10.1089/jpm.2018.0595. Epub 2019 Apr 2. PMID: 30939064.” O “Kumar M. Management of gastrointestinal symptoms in palliative care. InnovAiT. 2020;13(5):273-279. doi:10.1177/1755738020906182” that already address similar topics to that of the review article.

Author Response

Dear reviewer,

I am grateful for your review of this article.

In answer to your first question, was there a research question and a final objective, no there was not. I was asked to author an expert author review article by one of the members of the Canadian Association of General Practitioners in Oncology. I agree that there are other overall palliative care reviews and practice guidelines for symptom management in terminally-ill patients. Interestingly, my literature search had not revealed the two articles that you mentioned, probably because I did a search for the individual symptoms rather than an overall search for palliative care best practices. Thank you for bringing those articles to my attention.

In my first paragraph I now have added the description of my literature search, which again, was not systematic by any means:

PubMed was used for capturing of the last 5 years of English literature on various subjects such as constipation in palliative care or palliation, nausea and vomiting, bowel obstruction, GI bleeds and ascites. Earlier articles were retained if these seemed to contribute to pertinent substantial recommendations. To note as well that though this article focuses on symptomatic cancer patients, family physicians and primary care nurse practitioners will also be addressing the palliative needs of patients with non-malignant terminal illnesses; some of the following recommendations may apply to that population as well.

I have added the sources for tables 1 and 2.

And I have tried to give a succinct but more detailed conclusion:

In conclusion, patients with serious illness are often prone to GI symptoms with a significant effect on their QOL. Nurses, nurse practitioners, oncologists and family physicians who care for these patients should regularly assess this population for the presence of these symptoms.  A cornerstone to their management is obtaining a good history, physical exam, investigations as warranted by the symptom, and always making sure that the patient’s goals of care remain at the center of the management. Constipation can be managed with non-pharmacological approaches and with medications as tolerated by the patient. Nausea and vomiting can be addressed simultaneously with anti-emetics and by fixing the underlying cause where possible. Ascites can be acted upon early to prevent burdensome symptoms from developing through use of diuretics, but eventually may require more interventional techniques if and when the ascites becomes resistant. GI bleeds can in some cases come without warning and be catastrophic; other bleeds may come on gradually, allowing for medical treatment or interventions to control them. The patient and family need to be aware of all options especially in the case of a GI obstruction, where the rate of complications and secondary burden can be high for some treatment options. Therefore, it is paramount that the patient understands and appreciates not just the underlying cause of their symptom(s), but also their prognosis. Regardless of the decision the team (doctors, nurse practitioner, surgeons, patient and family) may make, good palliation can provide comfort and QOL. It is now widely recognized that early palliative care involvement is helpful for the patients’ QOL by alleviating spiritual, social, psychological distress and to prevent physical symptoms or address them early on as in the cases of constipation, ascites, and nausea, as well as to explore goals of care. A multi-disciplinary approach will benefit the patient and their family in obtaining good symptom management and treatments that respect the patient’s values.

I hope that this answers your questions and that the modifications improve the manuscript.

Best regards.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors

You accepted all my improvement suggestions and included them in the review.

I think the requirements for publishing are achieved.

Congratulations.

Best wishes

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript has been sufficiently improved to warrant publication in Current Oncology.

Reviewer 3 Report

Comments and Suggestions for Authors

I thank you again for the opportunity to have been able to review the new version of the article. I understand that the article wants to present a global vision of the state of the art regarding Gastro-Intestinal Symptoms in Palliative Care Patients. It is appreciated that you have taken into account the considerations that I previously indicated, in that sense, taking into account that it is indicated that a bibliographic search and the search strategy have been carried out, as well as that the conclusion has been synthesized.