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Chandrasekar D, Tribett E, Ramchandran K. Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer. Curr Treat Options Oncol 2016; 17:23. [PMID: 27032645 PMCID: PMC4819778 DOI: 10.1007/s11864-016-0397-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.
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Affiliation(s)
- Divya Chandrasekar
- />Hospice and Palliative Medicine, Stanford University School of Medicine, 2502 Galahad Court, San Jose, CA 95122 USA
| | - Erika Tribett
- />General Medical Disciplines, Stanford University School of Medicine, Medical School Office Building, 1265 Welch Road, MC 5475, Stanford, CA 94305 USA
| | - Kavitha Ramchandran
- />Outpatient Palliative Medicine, Stanford Cancer Institute, Medical School Office Building, 1265 Welch Road MC 5475, Stanford, CA 94305 USA
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Yang S, Alibhai SMH, Kennedy ED, El-Sedfy A, Dixon M, Coburn N, Kiss A, Law CHL. Optimal management of colorectal liver metastases in older patients: a decision analysis. HPB (Oxford) 2014; 16:1031-42. [PMID: 24961482 PMCID: PMC4487755 DOI: 10.1111/hpb.12292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 04/22/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Comparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients. METHODS A Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters. RESULTS In base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age. CONCLUSIONS HR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values.
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Affiliation(s)
- Simon Yang
- Division of General Surgery, University of TorontoToronto, ON
| | - Shabbir MH Alibhai
- Department of Medicine, University Health NetworkToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON
| | - Erin D Kennedy
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Mount Sinai HospitalToronto, ON
| | - Abraham El-Sedfy
- Department of Surgery, Saint Barnabas Medical CenterLivingston, NJ
| | - Matthew Dixon
- Department of Surgery, Maimonides Medical CenterBrooklyn, NY
| | - Natalie Coburn
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Sunnybrook Health Sciences CentreToronto, ON
| | - Alex Kiss
- Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Institute for Clinical Evaluative SciencesToronto, ON
| | - Calvin HL Law
- Division of General Surgery, University of TorontoToronto, ON,Department of Health Policy Management & Evaluation, University of TorontoToronto, ON,Division of General Surgery, Sunnybrook Health Sciences CentreToronto, ON,Correspondence, Calvin H.L. Law, Division of General Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite T2-025, Toronto, Ontario, Canada M4N 3M5. Tel: +1 416 480 4825. Fax: +1 416 480 5804. E-mail:
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Clinical efficacy of adjunctive G-CSF on solid tumor and lymphoma patients with established febrile neutropenia. Support Care Cancer 2013; 22:1105-12. [DOI: 10.1007/s00520-013-2067-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 11/19/2013] [Indexed: 01/04/2023]
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O'Brien MB, Johnston GM, Gao J, Dewar R. End-of-life care for nursing home residents dying from cancer in Nova Scotia, Canada, 2000-2003. Support Care Cancer 2007; 15:1015-21. [PMID: 17277924 PMCID: PMC3747102 DOI: 10.1007/s00520-007-0218-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2006] [Accepted: 01/10/2007] [Indexed: 11/25/2022]
Abstract
INTRODUCTION With our population aging, an increasing proportion of cancer deaths will occur in nursing homes, yet little is known about their end-of-life care. This paper identifies associations between residing in a nursing home and end-of-life palliative cancer care, controlling for demographic factors. METHODS For this population-based study, a data file was created by linking individual-level data from the Nova Scotia Cancer Centre Oncology Patient Information System, Vital Statistics, and the Halifax and Cape Breton Palliative Care Programs for all persons 65 years and over dying of cancer from 2000 to 2003. Multivariate logistic regression was used to compare nursing home residents to nonresidents. RESULTS Among the 7,587 subjects, 1,008 (13.3%) were nursing home residents. Nursing home residents were more likely to be female [adjusted odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2-1.7], older (for > or = 90 vs 65-69 years OR 5.4, CI 4.1-7.0), rural (OR 1.5, CI 1.2-1.8), have only a death certificate cancer diagnosis (OR 4.2, CI 2.8-6.3), and die out of hospital (OR 8.5, CI 7.2-10.0). Nursing home residents were less likely to receive palliative radiation (OR 0.6, CI 0.4-0.7), medical oncology consultation (OR 0.2, CI 0.1-0.4), and palliative care program enrollment (Halifax OR 0.2, CI 0.2-0.3; Cape Breton OR 0.4, CI 0.3-0.7). CONCLUSION Demographic characteristics and end-of-life services differ between those residing and those not residing in nursing homes. These inequalities may or may not reflect inequities in access to quality end-of-life care.
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Affiliation(s)
- Meaghan B O'Brien
- School of Health Services Administration, Dalhousie University and Surveillance and Epidemiology Unit, Cancer Care Nova Scotia, 5599 Fenwick Street, Halifax, Nova Scotia B3H 1R2, Canada
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Harder Y, Amon M, Schramm R, Georgi M, Banic A, Erni D, Menger MD. Heat shock preconditioning reduces ischemic tissue necrosis by heat shock protein (HSP)-32-mediated improvement of the microcirculation rather than induction of ischemic tolerance. Ann Surg 2005; 242:869-78, discussion 878-9. [PMID: 16327497 PMCID: PMC1409874 DOI: 10.1097/01.sla.0000189671.06782.56] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Supraphysiologic stress induces a heat shock response, which may exert protection against ischemic necrosis. Herein we analyzed in vivo whether the induction of heat shock protein (HSP) 32 improves survival of chronically ischemic myocutaneous tissue, and whether this is based on amelioration of microvascular perfusion or induction of ischemic tolerance. METHODS The dorsal skin of mice was subjected to local heat preconditioning (n = 8) 24 hours before surgery. In additional heat-preconditioned animals (n = 8), HSP-32 was inhibited by tin-protoporphyrin-IX. Unconditioned animals served as controls (n = 8). A random-pattern myocutaneous flap was elevated in the back of the animals and fixed into a dorsal skinfold chamber. The microcirculation, edema formation, apoptotic cell death, and tissue necrosis were analyzed over a 10-day period using intravital fluorescence microscopy. RESULTS HSP-32 protein expression was observed only in heat-preconditioned but not in unconditioned flaps. Heat preconditioning induced arteriolar dilation, which was associated with a significant improvement of both arteriolar blood flow and capillary perfusion in the distal part of the flap. Further, heat shock reduced interstitial edema formation, attenuated apoptotic cell death, and almost completely abrogated the development of flap necrosis (4% +/- 1% versus controls: 53% +/- 5%; P[r] < 0.001). Most strikingly, inhibition of HSP-32 by tin-protoporphyrin-IX completely blunted the preconditioning-induced improvement of microcirculation and resulted in manifestation of 72% +/- 4% necrosis. CONCLUSION Local heat preconditioning of myocutaneous tissue markedly increases flap survival by maintaining adequate nutritive perfusion rather than inducing ischemic tolerance. The protection is caused by the increased arteriolar blood flow due to significant arteriolar dilation, which is mediated through the carbon monoxide-associated vasoactive properties of HSP-32.
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Affiliation(s)
- Yves Harder
- Institute for Clinical & Experimental Surgery, University of Saarland, D-66421 Homburg/Saar, Germany.
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Abstract
The very poor outcome of invasive fungal infections (IFI) in patients with haematological malignancies or recipients of haematopoietic stem cell transplantation is largely attributed to their compromised host defence mechanisms. The restoration or augmentation of immune responses in these patients is now considered as one of the cornerstones of effective antifungal therapy. Major advances in the field of experimental immunology have provided insight on the important regulatory role of cytokines in both innate and adaptive immunity to fungal pathogens. Preclinical studies have convincingly demonstrated that immunomodulation with cytokines can enhance the antifungal activity of neutrophils and monocytes/macrophages as well as upregulate protective T-helper type 1 adaptive immune responses. Evidence on the clinical use of cytokines in immunocompromised hosts with IFI is, however, still scant and inconclusive. The present review summarizes experimental and clinical data on the role of cytokines in the immune response to fungal pathogens and on their potential use for prevention or treatment of fungal infections. Implications for future research are also briefly discussed.
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Townsley C, Pond GR, Peloza B, Kok J, Naidoo K, Dale D, Herbert C, Holowaty E, Straus S, Siu LL. Analysis of treatment practices for elderly cancer patients in Ontario, Canada. J Clin Oncol 2005; 23:3802-10. [PMID: 15923574 DOI: 10.1200/jco.2005.06.742] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Older patients are underrepresented in many areas of cancer services utilization and in clinical trial enrollment. This study evaluates whether age, when adjusted for sex, comorbidity, stage, tumor site, geography, and time period, is predictive of cancer treatment practice. METHODS First, we used the Ontario Cancer Registry (OCR) to examine for any apparent differences in treatment practices between elderly (> or = 70 years) and younger patients in the last three decades. Second, we performed a chart review of 1,505 patients with lung, breast, and colorectal cancers seen in Ontario either at an urban center, the Princess Margaret Hospital, or at a rural center, the Northwestern Regional Cancer Centre. Patients were randomly selected from two time periods, 1977 to 1978 and 1997; and the study population was to comprise at least 50% elderly patients. RESULTS OCR data demonstrated that, in some settings, such as colorectal cancer, the proportions of elderly cancer patients who were referred to cancer centers and who received any cancer treatment were lower than their younger counterparts. The chart review data showed that increasing age was a significant negative predictor for receiving any cancer treatment (P < .001, multivariate analysis) and for having a clinical trial discussion with the treating specialist (P < .001, multivariate analysis). CONCLUSION Independent of other factors, older age is consistently a cause of disparity in cancer treatment practice and in clinical trial discussion with patients. By increasing the accrual rate of elderly cancer patients in clinical trials, a better understanding of appropriate therapies for this patient population can be obtained and may, thereby, impact on their cancer-related morbidity and mortality.
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Affiliation(s)
- Carol Townsley
- Department of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, 610 University Ave, Ste 5-210, Toronto, Ontario, M5G 2M9, Canada
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Johnson VMP, Teno JM, Bourbonniere M, Mor V. Palliative Care Needs of Cancer Patients in U.S. Nursing Homes. J Palliat Med 2005; 8:273-9. [PMID: 15890038 DOI: 10.1089/jpm.2005.8.273] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Increasingly, nursing homes are the place of care for older Americans with cancer. Yet, few studies has characterized the quality of care for this growing population. OBJECTIVE Characterize the scope and quality of cancer care in U.S. nursing homes. DESIGN Secondary analysis of the national repository of the Minimum Data Set (MDS) SETTING AND SUBJECTS: Nursing home residents noted to have cancer diagnosis on the MDS. RESULTS Of the 190,769 New Hampshire residents (8.8%) with a cancer diagnosis, 1 in 4 had weight loss (23.4%), received intravenous medications (27.7%), or used oxygen (25.4%). Overall, 45.3% had a do-not-resuscitate (DNR) order, with state variations ranging from 17.8% (New Jersey) to 70.5% (Wisconsin). More than 1 in 10 (12.0%) were defined as terminally ill, although only 29.3% of these received hospice services. Among patients with pain, half of those who survived to a second assessment had persistent, severe pain (51.3%), which also varied by state, ranging from 43.3% (Iowa) to 65.8% (Nevada). Active treatment was rare; less than 5% received chemotherapy or radiotherapy. However, 15.5% had parenteral and/or tube feedings for nutrition. Approximately, 1 in 10 New Hampshire residents had advanced cancer. CONCLUSION Our findings suggest important opportunities to improve the quality of cancer care for older adults.
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