Antineoplastic therapy use in patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center: a simultaneous care model

A month of diagnostic imaging studies in an acute supportive/palliative care unit

AIM

The aim was to assess the characteristics of patients who required imaging studies during admission to an acute supportive palliative care unit (ASPCU).

METHODS

A consecutive number of patients who performed imaging studies during ASPCU admission in a month period were assessed. Epidemiological data, ongoing anticancer treatment, cancer diagnosis, reasons for admission, referral, and type of imaging study were recorded. Indications, findings, consequent actions for treatment, prognosis, and discharge were also collected.

RESULTS

Twenty-one of 56 patients admitted to ASPCU in the period taken into consideration were assessed. Pain and deterioration of the general condition were the most frequent indications for admission. Computed tomography (CT) was the most frequent imaging study performed. Indications for performing imaging studies depended on individual clinical needs. Findings suggested different clinical decisions, after a comprehensive oncological and palliative care assessment and family conference, the most frequent of which was to withdraw oncological treatments. The majority of patients underwent transition to palliative care and were discharged home or to hospice.

CONCLUSION

Imaging studies were of paramount importance for clinical treatment and decision-making process in an intensive ASPCU. There is the need to explore the need and the possible outcomes of imaging studies, as well cost-effectiveness in any ASPCU.

Hematologic Malignancies Patients Face High Symptom Burden and Are Lately Referred to Palliative Consultation: Analysis of a Single Center Experience

Although hematologic neoplasms have been on the vanguard of cancer therapies that led to notable advances in therapeutic efficacy, many patients face significant symptom burden, which make them eligible for early palliative care (PC) integration. However, previous reports demonstrated that hematological malignancies receive more aggressive care at the end-of-life and are less likely to receive care from specialist palliative services compared to solid tumors. Our aim was to characterize symptom burden, performance status and clinical characteristics of a cohort of hematologic malignancies patients referred to PC outpatient consultation, according to their diagnosis. Fifty-nine hematological malignancies patients referred to PC consultation between January 2018 and September 2021 were included. Clinical and laboratory data were evaluated retrospectively by medical charts analysis. Patients exhibited high ESAS and reduced PPS scores at the time of PC referral. Acute leukemia and multiple myeloma patients had the highest symptom burden scores; in spite of this, median time from the first PC consultation until death was only 3 and 4 months, respectively. In conclusion, we identified that hematologic neoplasms patients are highly symptomatic and are frequently referred to PC in end stages of their disease.

Systemic Anti-Cancer Therapy Use in Palliative Care Outpatients With Advanced Cancer

PURPOSE

To evaluate factors associated with continuation of systemic anti-cancer therapy (SACT) after palliative care consultation, and SACT administration in the last 30 days of life, in outpatients with cancer referred to palliative care. Timing of referral was of particular interest.

METHODS

Patient, disease, and treatment-related factors associated with SACT before and after palliative care, and in the last 30 days of life, were identified using 3-level multinomial logistic regression. Referral to palliative care was categorized by time from death as early (>12 months), intermediate (6-12 months), and late (≤6 months).

RESULTS

Of the 337 patients, 240 (71.2%) received SACT for advanced cancer; of these, 126 (52.5%) received SACT only prior to palliative care while 114 (47.5%) also received SACT afterward. Only 35/337 (10.4%) received SACT in the last 30 days of life. On multivariable analysis, factors associated with continuing SACT after palliative care consultation were a cancer diagnosis for <1 year (OR 3.09, p = 0.01), breast primary (OR 11.88, p = 0.0008), and early (OR 28.8, p < 0.001) or intermediate (OR 6.67, p < 0.001) referral timing. No factors were significantly associated with receiving SACT in the last 30 days versus earlier, but the median time from palliative care referral to death in those receiving SACT in the last 30 days versus stopping SACT earlier was 1.78 versus 4.27 months.

CONCLUSION

Patients who received SACT following palliative care consultation were more likely to be referred early; however, patients receiving SACT in their last 30 days tended to be referred late.

Models of Palliative Care Delivery for Patients With Cancer

Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.

Association between palliative care and end-of-Life care for patients with hematological malignancies: A population-based study

To date, few studies have examined the end-of-life (EOL) care for patients with hematological malignancies (HMs). We evaluated the effects of palliative care on the quality of EOL care and health care costs for adult patients with HMs in the final month of life.We conducted a population-based study and analyzed data from Taiwan's Longitudinal Health Insurance Database, which contains claims information for patient medical records, health care costs, and insurance system exit dates (our proxy for death) between 2000 and 2011.A total of 724 adult patients who died of HMs were investigated. Of these patients, 43 (5.9%) had received only inpatient palliative care (i-Pal group), and 19 (2.6%) received home palliative care (h-Pal group). The mean health care costs during the final month of life were not significantly different between the non-Pal and Pal groups (p=0.315) and between the non-Pal, i-Pal, and h-Pal groups (p=0.293) either. By the multivariate regression model, the i-Pal group had lower risks of chemotherapy, ICU admission, and receipt of CPR, but higher risks of at least two hospitalizations and dying in hospital after adjustments. The h-Pal group had the similar trends as the i-Pal group but lower risk of dying in hospital after adjustments.Patients with HMs who had received palliative care could benefit from less aggressive EOL cancer care in the final month of life. However, 8.6% patients with HMs received palliative care. The related factors of more hospitalizations and dying in hospital warrant further investigation.

Intensity of Cancer Care Near the End of Life at a Tertiary Care Cancer Center in Jordan

CONTEXT

Chemotherapy use in the last month of life is an indicator of poor quality of end-of-life care.

OBJECTIVES

We assessed the frequency of chemotherapy use at the end of life at our comprehensive cancer center in Jordan and identified the factors associated with chemotherapy use.

METHODS

We conducted a retrospective chart review to examine the use of chemotherapy in the last 30 days and 14 days of life in consecutive adult patients with cancer seen at King Hussein Cancer Center (KHCC) who died between January 1, 2010, and December 31, 2012. We collected data on patient and disease characteristics, palliative care referral, and end-of-life care outcome indicators.

RESULTS

Among the 1714 decedents, 310 (18.1%) had chemotherapy use in the last 30 days and 142 (8.3%) in the last 14 days of life. Over half (910; 53.1%) had a palliative care referral. Chemotherapy use in the last 30 and 14 days of life were associated with younger age (odds ratio [OR] 0.99/yr, P = 0.01, and OR 0.99/yr, P = 0.01, respectively) and hematological malignances (OR 1.98, P < 0.001, and OR 2.85, P < 0.001, respectively). Palliative care referral was significantly associated with decreased use of chemotherapy in the last 30 (OR 0.30, P < 0.001) and 14 (OR 0.15, P < 0.001) days of life.

CONCLUSIONS

A sizable minority of patients with cancer at KHCC received chemotherapy at the end of life. Younger patients and those with hematological malignancies were more likely to receive chemotherapy, whereas those referred to palliative care were significantly less likely to receive chemotherapy at the end of life.

Clinically Significant Drug-Drug Interactions Involving Medications Used for Symptom Control in Patients With Advanced Malignant Disease: A Systematic Review

CONTEXT

Most patients with advanced malignant disease need to take several drugs to control symptoms. This treatment raises risks of serious adverse effects and drug-drug interactions (DDIs).

OBJECTIVES

To identify studies reporting clinically significant DDIs involving medications used for symptom control, other than opioids used for pain management, in adult patients with advanced malignant disease.

METHODS

Systematic review with searches in Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials, from the start of the databases (Embase from 1980) through June 21, 2018. In addition, reference lists of relevant full-text articles were hand-searched.

RESULTS

Of 9699 retrieved citations, 462 were considered potentially eligible. After full-text reading, 29 were included in the final analysis, together with 13 articles from reference lists. The 42 included publications were case reports, letters to the Editor, and one retrospective study. Drugs most often involved were antiepileptics, antidepressants, corticosteroids, and nonopioid analgesics. Clinical manifestations of identified DDIs included sedation, respiratory depression, serotonin syndrome, neuroleptic malignant syndrome, delirium, seizures, ataxia, liver and kidney failure, bleeding, cardiac arrhythmias, rhabdomyolysis, and others. The most common mechanisms eliciting DDIs were alteration of CYP450-dependent metabolism and overstimulation of serotonin receptors in the central nervous system.

CONCLUSION

Drugs used for symptom control in patients with advanced cancer may cause serious DDIs. Although there is limited evidence for the risk of clinically significant DDIs, physicians treating patients with cancer should try to limit polypharmacy, avoid drug combinations with a high risk of DDIs, and closely monitor patients for adverse drug reactions.

Combined effects of Lenvatinib and iodine-131 on cell apoptosis in nasopharyngeal carcinoma through inducing endoplasmic reticulum stress

Nasopharyngeal carcinoma (NPC) is a type of malignant tumor characterized by high invasiveness, metastatic potential and worldwide incidence among patients with head and neck cancer. It has previously been demonstrated that Lenvatinib (LEB) is an efficient anti-cancer agent by multi-targeting of tyrosine kinase inhibitors. Iodine-131 (I-131) therapy has been accepted for the treatment of thyroid cancer and other carcinomas. In the present study, the combined effects of LEB and I-131 were investigated on NPC and the potential signal pathway mediated by LEB and I-131 on NPC cells was explored. Inhibitory effects of LEB and I-131 for NPC cells growth were investigated via MTT assay. Migration and invasion of NPC cells was studied by aggression assays following incubation of LEB and I-131. Apoptosis of NPC cells and tissues were analyzed via flow cytometry and TUNEL assay, respectively. Apoptosis-related gene expression levels in NPC cells following treatment with LEB and I-131 were determined by western blotting. Endoplasmic reticulum (ER) stress in NPC cells were analyzed in NPC cells and tumor tissues. Immunohistochemistry was used to analyze the efficacy of LEB and I-131 in NPC-tumor bearing mice. The results demonstrated that combined treatment of LEB and I-131 significantly inhibited growth, apoptosis, migration and invasion of NPC cells compared with single agent therapy. Apoptosis-related gene expression levels of caspase-3 and caspase-9 were upregulated by LEB and I-131, whereas B call lymphoma-2, and P53 were downregulated in NPC cells and tumor tissues. In addition, signal mechanism analysis demonstrated that combined treatment of LEB and I-131 promoted expression levels of activating transcription factor 6, inositol-requiring protein 1 (IER1), protein kinase RNA-like endoplasmic reticulum kinase (RERK), and C/EBP homologous protein in NPC cells. Furthermore, combined treatment of LEB and I-131 markedly inhibited in vivo growth of NPC and further prolonged survival of experimental mice compared with single agent and control groups. Immunohistochemistry indicated that c-jun N-terminal kinase and Caspase-3 were increased in NPS tumor tissues in xenograft models treated with LEB and I-131. Apoptotic bodies were also increased in tumors treated by LEB and I-131. In conclusion, these findings indicate that combined treatment of LEB and I-131 may inhibit NPC growth and aggression through upregulation of ER stress, suggesting combined treatment of LEB and I-131 may be a potential therapeutic schedule for the treatment of NPC.

Can early palliative care with anticancer treatment improve overall survival and patient-related outcomes in advanced lung cancer patients? A review of the literature

Purpose

Metastatic non-small-cell lung cancer (NSCLC), the leading cause of death from cancer worldwide, is a debilitating disease that results in a high burden of symptoms and poor quality of life; the estimated prognosis after the diagnosis has been established was less than 1 year until some years ago. At the present, the new targeted therapies and immunotherapy are changing the course of the disease. However, advanced NSCLC remains an incurable disease, with a poor prognosis for the majority of the affected patients, so that quality of life and relief from symptoms are primary objectives of treatment. Some evidences suggest that early palliative care (EPC) for these patients can improve quality of life and even survival.

Design

A systematic review of the studies evaluating the impact on objective and on patient-reported outcomes of the introduction of EPC in opposition to standard care (SC), for advanced lung cancer patients, was performed. Because of the small number of studies conducted in this area, retrospective studies were also considered for the review.

Results

Five studies were included because they matched the inclusion criteria previously defined as relevant for the study. The review found that both survival and quality of life were better for patients included in EPC groups.

Conclusions

While results of the studies included in this review are not always comparable because different methods and scales have been used, there is enough evidence for clinical oncologists to implement the use of EPC in clinical practice for advanced lung cancer patients.

Metastasis-associated protein 2 promotes the metastasis of non-small cell lung carcinoma by regulating the ERK/AKT and VEGF signaling pathways

Non-small cell lung carcinoma (NSCLC) is the most common cause of cancer‑associated mortality in the world and accounts for ~85% of human lung cancers. Metastasis‑associated protein 2 (MTA2) is a component of the histone deacetylase complex and serves a role in tumor progression; however, the mechanism through which MTA2 is involved in the progression of NSCLC remains unclear. The aim of the present study was to investigate the expression and function of MTA2 and the MTA2‑mediated signaling pathway in NSCLC cells. Expression of MTA2 and its target genes was analyzed in MTA2‑overexpressing and anti‑MTA2 antibody (AbMTA2)‑treated NSCLC cells, as well as growth, migration, invasion and apoptotic‑resistance. The inhibitory effects on tumor formation were analyzed using AbMTA2‑treated NSCLC cells and in a mouse model. Histological assessment was conducted to analyze the expressions levels of extracellular signal‑regulated kinase (ERK), RAC‑α serine/threonine protein kinase (AKT) and vascular endothelial growth factor (VEGF) in experimental tumors. Results of the present study demonstrated that MTA2 was overexpressed in NSCLC cells. The growth, migration and invasion of NSCLC cells were markedly inhibited by AbMTA2. In addition, it was observed that the ERK/AKT and VEGF signaling pathways were both upregulated in MTA2‑overexpressing NSCLC cells, and downregulated following silencing of MTA2 activation. ERK and AKT phosphorylation levels were downregulated in NSCLC cells and tumors following MTA2 silencing. The in vivo study demonstrated that tumor growth was markedly inhibited following siRNA‑MTA2 treatment. In conclusion, the results of the present study suggested that MTA2 silencing may significantly inhibit the growth and aggressiveness of NSCLC cells. Results from the present study indicated that the mechanism underlying the MTA2‑mediated invasive potential of NSCLC cells involved the ERK/AKT and VEGF signaling pathways, which may be a potential therapeutic target for the treatment of NSCLC.

Reduced use of chemotherapy at the end of life in an integrated-care model of oncology and palliative care

Aims and Background

When there is little hope of a clinical benefit, too delayed a withdrawal from chemotherapy might be detrimental for a patient's quality of life. We evaluated appropriately timed cessation of chemotherapy in our Oncology Department after integration of a Supportive and Palliative Care Unit.

Methods

We carried out a review of deceased patients in our department from January 2006 to December 2009. Activities of the Supportive and Palliative Care Unit started in late 2007. We analyzed the characteristics of patients near the end of life and chemotherapy use within 30 days of death as an aggressiveness of cure index.

Results

During the considered period, 361 hospitalized patients died: 69 in 2006, 77 in 2007, 97 in 2008 and 118 in 2009; 102 never received chemotherapy. Sixty-one of the remaining 259 patients died within 30 days of the last drug administration. The percentage of patients receiving chemotherapy in their last 30 days fell from 19% in 2006 and 20% in 2007, to 16% in 2008 and 14% in 2009.

Conclusions

Supportive and Palliative Care Unit integration decreased chemotherapy use in the last 30 days of life. A careful evaluation of prognostic factors of advanced cancer patients and provision of appropriate supportive and palliative cares can reduce the use of futile anticancer chemotherapy and preserve a patient's qualify of life.

Preclinical trial of the multi-targeted lenvatinib in combination with cellular immunotherapy for treatment of renal cell carcinoma

Lenvatinib is an oral, multi-targeted tyrosine kinase inhibitor of vascular endothelial growth factor receptors 1-3, fibroblast growth factor receptors 1-4, platelet-derived growth factor receptor β, RET and KIT. Cellular immunotherapy has the potential to be a highly targeted treatment, with low toxicity to normal tissues and a high capacity to eradicate tumor tissue. The present study assessed the safety, maximum tolerated dose (MTD) and preliminary antitumor activity of lenvatinib and cellular immunotherapy in a murine model of renal cell carcinoma (RCC). The present study used a therapeutic dose of 0.12 mg lenvatinib and/or 10⁴ rat uterine cancer adenocarcinoma (RuCa)-sensitized lymphocytes administered once daily continuously in 7-day cycles. Tumor regression was observed in mice with RCC following treatment with lenvatinib and 10⁴ RuCa-sensitized lymphocytes. MTD was established as once daily administration of 0.18 mg lenvatinib and 10⁶ RuCa-sensitized lymphocytes. The most common treatment-related adverse effects observed were fatigue (40%), mucosal inflammation (30%), proteinuria, diarrhea, vomiting, hypertension and nausea (all 40%). Combination therapy using lenvatinib and cellular immunotherapy enhanced the antitumor effect induced by single treatments and prolonged the survival of mice with RCC compared with either of the single treatments. Treatment with lenvatinib (0.12 mg) combined with 10⁴ RuCa-sensitized lymphocytes was associated with manageable toxicity consistent with individual agents. Further evaluation of this combination therapy in mice with advanced RCC is required. In conclusion, cellular immunotherapy and oncolytic therapy for cancer may be improved by the synergistic effects of lenvatinib and sensitized lymphocytes. In the present study, the inherent antineoplastic and immune stimulatory properties of the two agents were enhanced when used in combination, which may provide a basis for clinical treatment of patients with RCC.

Prognostic Value of Heart Rate Variability in Patients With Cancer

INTRODUCTION

Previous studies have shown that autonomic dysfunction is associated with shorter survival in patients with advanced cancer. We examined the association between heart rate variability, a measure of autonomic function, and survival in a large cohort of patients with cancer.

METHODS

We retrospectively examined the records of 651 patients with cancer who had undergone ambulatory electrocardiogram monitoring for 20 to 24 hours. Time domain heart rate variability (SD of normal-to-normal beat interval [SDNN]) was calculated using power spectral analysis. Survival data were compared between patients with SDNN ≥ 70 milliseconds (Group 1, n = 520) and SDNN < 70 milliseconds (Group 2, n = 131).

RESULTS

Two groups were similar in most variables, except that patients in group 2 had a significantly higher percentage of male patients (P = 0.03), hematological malignancies (P = 0.04), and use of non-selective serotonin reuptake inhibitor antidepressants (P = 0.04). Patients in group 2 had a significantly shorter survival rate (25% of patients in group 2 died by 18.7 weeks vs. 78.9 weeks in group 1 patients; P < 0.0001). Multivariate analysis showed that SDNN < 70 milliseconds remained significant for survival (hazard ratio 1.9 [95% confidence interval: 1.4-2.5]) independent of age, cancer stage, and performance status.

CONCLUSION

The presence of cancer in combination with decreased heart rate variability (SDNN < 70 milliseconds) is associated with shorter survival time.

Characteristics of the case mix, organisation and delivery in cancer palliative care: a challenge for good-quality research

OBJECTIVES

Palliative care (PC) services and patients differ across countries. Data on PC delivery paired with medical and self-reported data are seldom reported. Aims were to describe (1) PC organisation and services in participating centres and (2) characteristics of patients in PC programmes.

METHODS

This was an international prospective multicentre study with a single web-based survey on PC organisation, services and academics and patients' self-reported symptoms collected at baseline and monthly thereafter, with concurrent registrations of medical data by healthcare providers. Participants were patients ≥18 enrolled in a PC programme.

RESULTS

30 centres in 12 countries participated; 24 hospitals, 4 hospices, 1 nursing home, 1 home-care service. 22 centres (73%) had PC in-house teams and inpatient and outpatient services. 20 centres (67%) had integral chemotherapy/radiotherapy services, and most (28/30) had access to general medical or oncology inpatient units. Physicians or nurses were present 24 hours/7 days in 50% and 60% of centres, respectively. 50 centres (50%) had professorships, and 12 centres (40%) had full-time/part-time research staff. Data were available on 1698 patients: 50% females; median age 66 (range 21-97); median Karnofsky score 70 (10-100); 1409 patients (83%) had metastatic/disseminated disease; tiredness and pain in the past 24 hours were most prominent. During follow-up, 1060 patients (62%) died; 450 (44%) <3 months from inclusion and 701 (68%) within 6 months. ANOVA and χ² tests showed that hospice/nursing home patients were significantly older, had poorer performance status and had shorter survival compared with hospital-patients (p<.0.001).

CONCLUSIONS

There is a wide variation in PC services and patients across Europe. Detailed characterisation is the first step in improving PC services and research.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01362816.

Trends in the Aggressiveness of End-of-Life Cancer Care in the State of Qatar

Purpose

Quality of end-of-life (EOL) care is a key component of excellence in cancer care, and monitoring indicators for quality of EOL cancer care is crucial to providing excellent care. The aim of the current study is to describe the relative aggressiveness of EOL cancer care in the state of Qatar and to compare it with international figures.

Methods

We analyzed all deaths from cancer in Qatar between January 1, 2009 and December 31, 2013. A total of 784 eligible patients were studied to assess aggressiveness of cancer care at EOL.

Results

The average number of intensive care unit admissions per person decreased from 0.44 to 0.22 (P < .001) over the period of study. In addition, patients spent fewer days in the intensive care unit (2.79 to 1.82 days; P = .006) and made fewer visits to the emergency department (1.00 to 0.52 visits; P < .001) in the last 30 days of life. Fewer patients had at least one aggressive treatment measure at EOL during the 5-year period (82.3% to 71.0%; P = .038). The mean composite score for aggressiveness of EOL care decreased from 2.24 to 1.92 (P < .01).

Conclusion

The aggressiveness of EOL cancer care has significantly decreased over time in Qatar; however, despite this decrease, the rate is still higher than that reported internationally. The integration of community palliative care services in Qatar may further decrease the aggressiveness of cancer care at EOL.

Acute symptomatic complications among patients with advanced cancer admitted to acute palliative care units: A prospective observational study

BACKGROUND

Limited information is available on the symptomatic complications that occur in the last days of life.

AIM

We documented the frequency, clinical course, and survival for 25 symptomatic complications among patients admitted to acute palliative care units.

DESIGN

Prospective longitudinal observational study.

MEASUREMENTS

Their attending physician completed a daily structured assessment of symptomatic complications from admission to discharge or death.

SETTING/PARTICIPANTS

We enrolled consecutive advanced cancer patients admitted to acute palliative care units at MD Anderson Cancer Center, USA, and Barretos Cancer Hospital, Brazil.

RESULTS

A total of 352 patients were enrolled (MD Anderson Cancer Center = 151, Barretos Cancer Hospital = 201). Delirium, pneumonia, and bowel obstruction were the most common complications, occurring in 43%, 20%, and 16% of patients on admission, and 70%, 46%, and 35% during the entire acute palliative care unit stay, respectively. Symptomatic improvement for delirium (36/246, 15%), pneumonia (52/161, 32%), and bowel obstruction (41/124, 33%) was low. Survival analysis revealed that delirium (p < 0.001), pneumonia (p = 0.003), peritonitis (p = 0.03), metabolic acidosis (p < 0.001), and upper gastrointestinal bleed (p = 0.03) were associated with worse survival. Greater number of symptomatic complications on admission was also associated with poorer survival (p < 0.001).

CONCLUSION

Symptomatic complications were common in cancer patients admitted to acute palliative care units, often do not resolve completely, and were associated with a poor prognosis despite active medical management.

Symptom Expression in the Last Seven Days of Life Among Cancer Patients Admitted to Acute Palliative Care Units

CONTEXT

The symptom burden in the last week of life of patients with advanced cancer has not been well characterized.

OBJECTIVES

To examine the frequency, intensity, and predictors for symptoms in the last seven days of life among patients who were able to communicate and died in an acute palliative care unit (APCU).

METHODS

We systematically documented the Edmonton Symptom Assessment System (ESAS) daily and 15 symptoms twice daily on consecutive advanced cancer patients admitted to APCUs at MD Anderson Cancer Center (U.S.) and Barretos Cancer Hospital (Brazil) from admission to death or discharge in 2010/2011. We examined the frequency and intensity of the symptoms from death backward.

RESULTS

A total of 203 of 357 patients died. The proportion of patients able to communicate decreased from 80% to 39% over the last seven days of life. ESAS anorexia (P = 0.001 in longitudinal analyses), drowsiness (P < 0.0001), fatigue (P < 0.0001), poor well-being (P = 0.01), and dyspnea (P < 0.0001) increased in intensity closer to death. In contrast, ESAS depression (P = 0.008) decreased over time. Dysphagia to solids (P = 0.01) and liquids (P = 0.005) as well as urinary incontinence (P = 0.0002) also were present in an increasing proportion of patients in the last few days of life. In multivariate analyses, female sex, non-Hispanic race, and lung cancer were significantly associated with higher ESAS symptom expression (odds ratio > 1).

CONCLUSION

Despite intensive management in APCUs, some cancer patients continue to experience high symptom burden as they approached death.

Differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor oncology specialists

BACKGROUND

Patients with hematologic malignancies often receive aggressive care at the end-of-life. To better understand the end-of-life decision-making process among oncology specialists, we compared the cancer treatment recommendations, and attitudes and beliefs toward palliative care between hematologic and solid tumor specialists.

PATIENTS AND METHODS

We randomly surveyed 120 hematologic and 120 solid tumor oncology specialists at our institution. Respondents completed a survey examining various aspects of end-of-life care, including palliative systemic therapy using standardized case vignettes and palliative care proficiency.

RESULTS

Of 240 clinicians, 182 (76%) clinicians responded. Compared with solid tumor specialists, hematologic specialists were more likely to favor prescribing systemic therapy with moderate toxicity and no survival benefit for patients with Eastern Cooperative Oncology Group (ECOG) performance status 4 and an expected survival of 1 month (median preference 4 versus 1, in which 1 = strong against treatment and 7 = strongly recommend treatment, P < 0.0001). This decision was highly polarized. Hematologic specialists felt less comfortable discussing death and dying (72% versus 88%, P = 0.007) and hospice referrals (81% versus 93%, P = 0.02), and were more likely to feel a sense of failure with disease progression (46% versus 31%, P = 0.04). On multivariate analysis, hematologic specialty [odds ratio (OR) 2.77, P = 0.002] and comfort level with prescribing treatment to ECOG 4 patients (OR 3.79, P = 0.02) were associated with the decision to treat in the last month of life.

CONCLUSIONS

We found significant differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor specialists, and identified opportunities to standardize end-of-life care.

Bedside clinical signs associated with impending death in patients with advanced cancer: preliminary findings of a prospective, longitudinal cohort study

BACKGROUND

Five highly specific physical signs associated with death within 3 days among cancer patients were recently reported that may aid in the diagnosis of impending death. In this study, the frequency and onset of another 52 bedside physical signs and their diagnostic performance for impending death were examined.

METHODS

Three hundred fifty-seven consecutive patients with advanced cancer who had been admitted to acute palliative care units at 2 tertiary care cancer centers were enrolled. Fifty-two physical signs were systematically documented every 12 hours from admission to death or discharge. The frequency and median time of onset of each sign from death backwards were examined, and the likelihood ratios (LRs) associated with death within 3 days were calculated.

RESULTS

Two hundred three of the 357 patients (57%) died at the end of the admission. Eight physical signs that were highly diagnostic of impending death were identified. These signs occurred in 5% to 78% of the patients within the last 3 days of life, had a late onset, and had a high specificity (>95%) and a high positive LR for death within 3 days. They included nonreactive pupils (positive LR, 16.7; 95% confidence interval [CI], 14.9-18.6), a decreased response to verbal stimuli (positive LR, 8.3; 95% CI, 7.7-9), a decreased response to visual stimuli (positive LR, 6.7; 95% CI, 6.3-7.1), an inability to close eyelids (positive LR, 13.6; 95% CI, 11.7-15.5), drooping of the nasolabial fold (positive LR, 8.3; 95% CI, 7.7-8.9), hyperextension of the neck (positive LR, 7.3; 95% CI, 6.7-8), grunting of vocal cords (positive LR, 11.8; 95% CI, 10.3-13.4), and upper gastrointestinal bleeding (positive LR, 10.3; 95% CI, 9.5-11.1).

CONCLUSIONS

Eight highly specific physical signs associated with death within 3 days among cancer patients were identified. These signs may inform the diagnosis of impending death.

Changes in medication profile among patients with advanced cancer admitted to an acute palliative care unit

PURPOSE

The decision-making process for medication use in the last weeks of life is complex because of patient frailty and poor prognosis. Limited literature is available on medication use in the palliative care setting, particularly in acute palliative care units (APCUs). We examined the changes in medication profile among hospitalized patients with advanced cancer before their palliative care inpatient consultation team referral, after palliative care consultation, at the time of APCU admission, and at APCU discharge or death.

METHODS

We included consecutive patients with advanced cancer who were first seen by our inpatient palliative care consultation team and subsequently admitted to the APCU. We retrieved data on all scheduled medications at the prespecified time points.

RESULTS

Among the 100 patients, the median duration of hospitalization was 10.5 days (interquartile range 8-15 days), and the median APCU stay was 5 days (interquartile range 3-7 days). The average number of medications before palliative care inpatient consultation team referral, after palliative care consultation, at APCU admission and at APCU discharge/death was 9.2 (standard deviation [SD] 4.5), 9.9 (SD 4.2), 10.3 (SD 3.8), and 10.1 (SD 3.8), respectively (P = 0.03). An increasing proportion of patients received medications for symptom control over their course of hospitalization, including systemic corticosteroids, laxatives, neuroleptics, and antiulcer agents (P < 0.05). In contrast, the frequency of several classes of medications such as antihypertensives, antilipemics, and anticonvulsants decreased over time (P < 0.05).

CONCLUSIONS

Palliative care involvement was associated with an increase in symptom control medications and decrease in medications for comorbid conditions over time.

[Use of a standard format to describe the activity of hospital-based palliative care team: a lever for improving end of life care]

INTRODUCTION

Early integrated palliative care is recommended in patients with incurable disease. Despite their development, hospital-based palliative care teams (PCT) are introduced late in the course of standard oncology care. The objective of this study is to describe the activity of an academic hospital-based PCT, using a standard format, which integrates indicators of early introduction and quality of end of life care, thus allowing a systematic analysis of its practice.

METHODS

The annual activity of the PCT is described from 2007 to 2012. Data are collected for each patient prospectively by the team: reasons for referral and activities of PCT, performance status and chemotherapy at the time of first referral, visit to emergency and admission to ICU.

RESULTS

The number of patients referred to the PCT increased from 337 patients in 2007 to 539 in 2012, among whom 90% were cancer patients, 84% at metastatic stage. Relief of symptoms was the most frequent reason for referral. In 2012, 280 (64%) patients were receiving chemotherapy and 41% had a PS≤2 at the time of first referral. Half patients died each year (270 in 2012); 17% of these received chemotherapy in their last 14 days of life, 3% visited emergency room twice and 13% were admitted in ICU, once during their last month of life, 48% died in hospice or at home.

CONCLUSION

The use of a standard format to describe the activity of hospital-based PCTs, the timing of their introduction and the quality of care is feasible. The generalization of this format for monitoring to assess the curative medicine interface/palliative could be a lever for improving the integration of palliative care.

Quality of end-of-life care in patients with hematologic malignancies: a retrospective cohort study

BACKGROUND

To the authors' knowledge, only limited data are available regarding the quality of end-of-life care for patients with hematologic malignancies. In this retrospective cohort study, the quality of end-of-life care was compared between patients with hematologic malignancies and those with solid tumors.

METHODS

All adult patients who died of advanced cancer between September 1, 2009 and February 28, 2010 while under the care of the study institution were included. The authors collected baseline demographics and end-of-life care indicators, including emergency room visits, hospitalization, intensive care unit admissions, and systemic cancer therapy use within the last 30 days of life.

RESULTS

Of a total of 816 decedents, 113 (14%) had hematologic malignancies. In the last 30 days of life, patients with hematologic malignancies were more likely to have emergency room visits (54% vs 43%; P = .03), hospital admissions (81% vs 47%; P < .001), ≥ 2 hospital admissions (23% vs 10%; P < .001), > 14 days of hospitalization (38% vs 8%; P < .001), intensive care unit admissions (39% vs 8%; P < .001) and death (33% vs 4%; P < .001), chemotherapy use (43% vs 14%; P < .001), and targeted therapy use (34% vs 11%; P < .001) compared with patients with solid tumors. Patients with hematologic malignancies were also less likely to have palliative care unit admissions (8% vs 17%; P = .02). The composite score for aggressiveness of care (with 0 indicating the best and 6 indicating the worst) was significantly higher among patients with hematologic malignancies compared with those with solid tumors (median, 2 vs 0; P < .001). On multivariate analysis, hematologic malignancy was found to be a significant factor associated with aggressive end-of-life care (odds ratio, 6.6; 95% confidence interval, 4.1-10.7 [P < .001]).

CONCLUSIONS

The results of the current study indicate that patients with hematologic malignancies received more aggressive care at the end of life.

Targeted agent use in cancer patients at the end of life

CONTEXT

The use of targeted therapy at the end of life has not been well characterized.

OBJECTIVES

To determine the frequency and predictors of targeted therapy use in the last days of life.

METHODS

All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had contact with our institution within the last three months of life were included. We collected baseline demographics and data on chemotherapy and targeted agents.

RESULTS

Eight hundred sixteen patients were included: average age 62 years (range 21-97), female 48% and white 61%. The median interval between the last treatment and death was 47 (interquartile range [IQR] 21-97) days for targeted agents and 57 (IQR 26-118) days for chemotherapeutic agents. Within the last 30 days of life, 116 (14%) patients received targeted agents and 147 (18%) received chemotherapy. Regimens given in the last 30 days of life included a median of one (IQR 1-2) chemotherapeutic or targeted agent and 43 (5%) patients receiving targeted agents had concurrent chemotherapy. The most common targeted agents in the last 30 days of life were erlotinib (n = 25), bevacizumab (n = 20), rituximab (n = 11), gemtuzumab (n = 8), and temsirolimus (n = 8). On multivariate analysis, younger age (odds ratio [OR] 0.98 per year, P = 0.01), hematologic malignancy (OR = 6.1, P < 0.001), and lung malignancy (OR = 2.6, P = 0.05) were associated with increased targeted agent use in the last 30 days of life.

CONCLUSION

Targeted agents were used as often as chemotherapy at the end of life, particularly among younger patients and those with hematologic malignancies. Guidelines on targeted therapy use at the end of life are needed.

Higher complication risk of totally implantable venous access port systems in patients with advanced cancer - a single institution retrospective analysis

BACKGROUND

Totally implantable port systems are generally recommended for prolonged central venous access in diverse settings, but their risk of complications remains unclear for patients with advanced cancer.

AIM

The aim of this study was to assess the risk of port system failure in patients with advanced cancer.

DESIGN

We conducted a retrospective cohort study in a comprehensive cancer centre.

SETTING/PARTICIPANTS

A detailed chart review was conducted among 566 patients with 573 ports inserted during January-June, 2009 (average 345.3 catheter-days). Cox regression analysis was applied to evaluate factors during insertion and early maintenance that could lead to premature removal of the port systems due to infection or occlusion.

RESULTS

Port system-related infection was significantly associated with receiving palliative care immediately after implantation (hazard ratio, HR = 7.3, 95% confidence interval, 95% CI = 1.2-46.0), after adjusting for probable confounders. Primary cancer site also impacted the occurrence of device-related infection. Receiving oncologic/palliative care (HR = 3.0, P = 0.064), advanced cancer stage (HR = 6.5, P = 0.077) and body surface area above 1.71 m(2) (HR = 3.4, P = 0.029) increased the risk of port system occlusion.

CONCLUSIONS

Our study indicates that totally implantable port systems yield a higher risk of complications in terminally ill patients. Further investigation should be carefully conducted to compare outcomes of various central venous access devices in patients with advanced cancer and to develop preventive strategies against catheter failure.

Access to palliative care among patients treated at a comprehensive cancer center

BACKGROUND

Palliative care (PC) is a critical component of comprehensive cancer care. Previous studies on PC access have mostly examined the timing of PC referral. The proportion of patients who actually receive PC is unclear. We determined the proportion of cancer patients who received PC at our comprehensive cancer center and the predictors of PC referral.

METHODS

We reviewed the charts of consecutive patients with advanced cancer from the Houston region seen at MD Anderson Cancer Center who died between September 2009 and February 2010. We compared patients who received PC services with those who did not receive PC services before death.

RESULTS

In total, 366 of 816 (45%) decedents had a PC consultation. The median interval between PC consultation and death was 1.4 months (interquartile range, 0.5-4.2 months) and the median number of medical team encounters before PC was 20 (interquartile range, 6-45). On multivariate analysis, older age, being married, and specific cancer types (gynecologic, lung, and head and neck) were significantly associated with a PC referral. Patients with hematologic malignancies had significantly fewer PC referrals (33%), the longest interval between an advanced cancer diagnosis and PC consultation (median, 16 months), the shortest interval between PC consultation and death (median, 0.4 months), and one of the largest numbers of medical team encounters (median, 38) before PC.

CONCLUSIONS

We found that a majority of cancer patients at our cancer center did not access PC before they died. PC referral occurs late in the disease process with many missed opportunities for referral.

Development and cross-validation of the in-hospital mortality prediction in advanced cancer patients score: a preliminary study

PURPOSE

Acute palliative care units (APCUs) provide intensive symptom support and transition of care for advanced cancer patients. Better understanding of the predictors of in-hospital mortality is needed to facilitate program planning and patient care. In this prospective study, we identified predictors of APCU mortality, and developed a four-item In-hospital Mortality Prediction in Advanced Cancer Patients (IMPACT) predictive model.

METHODS

Between April and July 2010, we documented baseline demographics, the Edmonton Symptom Assessment Scale (ESAS), 80 clinical signs including known prognostic factors, and 26 acute complications on admission in consecutive APCU patients. Multivariate logistic regression analysis was used to identify factors for inclusion in a nomogram, which was cross-validated with bootstrap analysis.

RESULTS

Among 151 consecutive patients, the median age was 58, 13 (9%) had hematologic malignancies, and 52 (34%) died in the hospital. In multivariate analysis, factors associated with in-hospital mortality were advanced education (odds ration [OR]=11.8, p=0.002), hematologic malignancies (OR=8.6, p=0.02), delirium (OR=4.3, p=0.02), and high ESAS global distress score (OR=20.8, p=0.01). In a nomogram based on these four factors, total scores of 6, 10, 14, 17, and 21 corresponded to a risk of death of 10%, 25%, 50%, 75%, and 90%, respectively. The model has 92% sensitivity and 88% specificity for predicting patients at low/high risk of dying in the hospital, and a receiver-operator characteristic curve concordance index of 83%.

CONCLUSIONS

Higher education was associated with increased utilization of the interdisciplinary palliative care unit until at the end of life. Patients with higher symptom burden, delirium, and hematologic malignancies were also more likely to require APCU care until death.

Palliative care consultation service and palliative care unit: why do we need both?

BACKGROUND

Palliative care (PC) infrastructure has developed differently around the globe. Whereas some institutions consider the palliative care unit (PCU) a valuable component, others report that the sole provision of a state-of-the art palliative care consultation service (PCCS) suffices to adequately care for the severely ill and dying.

OBJECTIVE

To aid institutional planning, this study aimed at gathering patient data to distinguish assignments of a concomitantly run PCU and PCCS at a large hospital and academic medical center.

METHODS

Demographics, Eastern Cooperative Oncology Group performance status, symptom/problem burden, discharge modality, and team satisfaction with care for all 601 PCU and 851 PCCS patients treated in 2009 and 2010 were retrospectively analyzed.

RESULTS

Patients admitted to the PCU versus those consulted by the PCCS: (a) had a significantly worse performance status (odds ratio [OR], 1.48); (b) were significantly more likely to suffer from severe symptoms and psychosocial problems (OR, 2.05), in particular concerning physical suffering and complexity of care; and (c) were significantly much more likely to die during hospital stay (OR, 11.03). For patients who were dying or in other challenging clinical situations (suffering from various severe symptoms), self-rated team satisfaction was significantly higher for the PCU than the PCCS.

CONCLUSION

This study presents a direct comparison between patients in a PCU and a PCCS. Results strongly support the hypothesis that the coexistence of both institutions in one hospital contributes to the goal of ensuring optimal high-quality PC for patients in complex and challenging clinical situations.

The accuracy of probabilistic versus temporal clinician prediction of survival for patients with advanced cancer: a preliminary report

Clinicians have limited accuracy in the prediction of patient survival. We assessed the accuracy of probabilistic clinician prediction of survival (CPS) and temporal CPS for advanced cancer patients admitted to our acute palliative care unit, and identified factors associated with CPS accuracy. Eight physicians and 20 nurses provided their estimation of survival on admission by (a) the temporal approach, "What is the approximate survival for this patient (in days)?" and (b) the probabilistic approach, "What is the approximate probability that this patient will be alive (0%-100%)?" for ≥24 hours, 48 hours, 1 week, 2 weeks, 1 month, 3 months, and 6 months. We also collected patient and clinician demographics. Among 151 patients, the median age was 58 years, 95 (63%) were female, and 138 (81%) had solid tumors. The median overall survival time was 12 days. The median temporal CPS was 14 days for physicians and 20 days for nurses. Physicians were more accurate than nurses. A higher accuracy of temporal physician CPS was associated with older patient age. Probabilistic CPS was significantly more accurate than temporal CPS for both physicians and nurses, although this analysis was limited by the different criteria for determining accuracy. With the probabilistic approach, nurses were significantly more accurate at predicting survival at 24 hours and 48 hours, whereas physicians were significantly more accurate at predicting survival at 6 months. The probabilistic approach was associated with high accuracy and has practical implications.

The Frequency and Correlates of Spiritual Distress Among Patients With Advanced Cancer Admitted to an Acute Palliative Care Unit

Limited research is available on the frequency of spiritual distress and its relationship with physical and emotional distress. We reviewed patients admitted to our acute palliative care unit (APCU) and determined the association between patient characteristics, symptom severity using the Edmonton Symptom Assessment scale (ESAS), and spiritual distress as reported by a chaplain on initial visit. In all, 50 (44%) of 113 patients had spiritual distress. In univariate analysis, patients with spiritual distress were more likely to be younger (odds ratio [OR] = 0.96, P = .004), to have pain (OR = 1.2, P = .010) and depression (OR = 1.24, P = .018) compared to those without spiritual distress. Spiritual distress was associated with age (OR = 0.96, P = .012) and depression (OR = 1.27, P = .020) in multivariate analysis. Our findings support regular spiritual assessment as part of the interdisciplinary approach to optimize symptom control.

Timing of palliative care referral and symptom burden in phase 1 cancer patients: a retrospective cohort study

BACKGROUND

Phase 1 trials offer patients with advanced cancer the opportunity to pursue life-prolonging cancer treatments. In the current study, the timing of referral and symptom burden between patients referred to palliative care by phase 1 oncologists and those referred by non-phase 1 oncologists were compared.

METHODS

All 57 patients with advanced solid tumors who were referred by phase 1 oncologists to the palliative care outpatient clinic at The University of Texas M. D. Anderson Cancer Center (MDACC) between 2007 and 2008 were included. The comparison cohort was comprised of 114 non-phase 1 patients who were stratified by age, sex, and cancer diagnosis in a 1:2 ratio. Information regarding patient characteristics, Edmonton Symptom Assessment Scale (ESAS), timing of referral, and survival was retrieved.

RESULTS

Both cohorts had the following matched characteristics: average age of 57 years, with 44% of the patients being female and 47% having gastrointestinal cancers. At the time of palliative care consultation, patients referred by phase 1 oncologists were more likely than patients referred by non-phase 1 oncologists to have a better performance status (Eastern Cooperative Oncology Group 0-1: 61% vs 36% [P = .003). The ESAS was not significantly different with the exception of better well-being in the phase 1 cohort (mean, 4.5 vs 5.5; P = .03). No difference was found for the duration between registration at MDACC and palliative care consultation (13 months vs 11 months; P = .41) and overall survival from the time of palliative care consultation (5 months vs 4 months; P = .69).

CONCLUSIONS

Outpatients referred to palliative care by phase 1 oncologists were found to have a better performance status but similar symptom burden compared with patients referred by non-phase 1 oncologists. Patients with phase 1 involvement did not appear to have delayed palliative care referral compared with non-phase 1 patients. The results of the current study support the development of a simultaneous care model.