Prognostic factors of survival in patients with advanced cancer admitted to home care

Vital Signs in Palliative Care: A Scoping Review

Vital signs are routinely measured in secondary healthcare settings and can be used to detect clinical problems, guide treatment, and monitor response to treatment. Vital signs are less frequently measured in palliative care settings. Reasons for this are unclear. This scoping review aimed to assess the generic use of vital signs in palliative care, and its role in prognostication for adult patients with cancer receiving palliative care. Medline, Embase, and CINAHL were searched for articles involving adult patients with advanced cancer receiving palliative care who had their vital signs measured. Twenty-six articles were identified in which one or a combination of vital signs, with or without other clinical parameters, was used to prognosticate for patients. An additional three articles investigated the generic use of vital signs in patients with advanced cancer. There was significant heterogeneity between identified studies, with some indication that changes in vital signs may indicate that a patient is close to death. However, other studies suggested that patients may maintain normal vital signs until the time of death. Further studies are needed to explore whether abnormal vital signs may be used as a prognostic indicator for patients with cancer receiving palliative care.

Implementation of Patient Reported Outcomes in Outpatient Palliative Care: From Paper to Computer

BACKGROUND

This quality improvement project aimed to transition completion of Edmonton Symptom Assessment System (ESAS) at our supportive care clinic from paper to electronic format.

MEASURES

Proportion of patients who completed electronic ESAS (eESAS).

INTERVENTION

Starting July 2018, patients could complete eESAS 24h before check-in (eESAS-before), eESAS after check-in (eESAS-after) or on paper (pESAS).

OUTCOMES

A total of 6631 cancer patients had 25,767 clinic visits between July 13, 2018 and November 5, 2021. The ESAS completion rate was 100%. eESAS uptake gradually increased over time, first reaching ≥75% eESAS completion in 5/2019 (eESAS-after 61.9%; eESAS-before 14.0%; pESAS 24.1%). We observed a sharp uptake in eESAS-before since adoption of telehealth during the pandemic (May 2020) and the ≥75% eESAS target was consistently achieved from November 2020 onwards (eESAS-after 0.6%; eESAS-before 76.7%; pESAS 22.7%). In an anonymous survey, we identified several modifiable barriers to implementing eESAS.

CONCLUSIONS

Transition to eESAS was a gradual process and was catalyzed by the pandemic.

Symptom Burden and Survival in Patients Receiving Outpatient and Home-Based Palliative Care

Background: Symptom burden assessment with the Edmonton Symptom Assessment System (ESAS) has been widely studied among patients in outpatient palliative care (OPC), but fewer reports in home-based palliative care (HBPC), and none has assessed the prognostic value of ESAS scores in HBPC. Methods: This retrospective cohort study compares symptom burden and its prognostic value in adult patients receiving OPC and HBPC services between January 1, 2019, and June 30, 2021. Results: Patients completed the ESAS at the first OPC consultation (n = 4086) and at admission to HBPC (n = 4087). OPC patients were younger, more likely to have cancer, less likely to have had a recent hospitalization, and had higher adjusted median ESAS scores (28.1 vs. 22.9) compared with HBPC patients (all p < 0.001). ESAS was prognostic of survival in both settings (Hazard ratio 1.18-1.64, p < 0.01). Conclusion: Symptom burden is an independent prognosticator of survival in HBPC and OPC in this community-based setting.

Machine learning models for 180-day mortality prediction of patients with advanced cancer using patient-reported symptom data

PURPOSE

The objective of the current study was to develop and test the performances of different ML algorithms which were trained using patient-reported symptom severity data to predict mortality within 180 days for patients with advanced cancer.

METHODS

We randomly selected 630 of 689 patients with advanced cancer at our institution who completed symptom PRO measures as part of routine care between 2009 and 2020. Using clinical, demographic, and PRO data, we trained and tested four ML algorithms: generalized regression with elastic net regularization (GLM), extreme gradient boosting (XGBoost) trees, support vector machines (SVM), and a single hidden layer neural network (NNET). We assessed the performance of algorithms individually as well as part of an unweighted voting ensemble on the hold-out testing sample. Performance was assessed using area under the receiver-operating characteristic curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The starting cohort of 630 patients was randomly partitioned into training (n = 504) and testing (n = 126) samples. Of the four ML models, the XGBoost algorithm demonstrated the best performance for 180-day mortality prediction in testing data (AUROC = 0.69, sensitivity = 0.68, specificity = 0.62, PPV = 0.66, NPV = 0.64). Ensemble of all algorithms performed worst (AUROC = 0.65, sensitivity = 0.65, specificity = 0.62, PPV = 0.65, NPV = 0.62). Of individual PRO symptoms, shortness of breath emerged as the variable of highest impact on the XGBoost 180-mortality prediction (1-AUROC = 0.30).

CONCLUSION

Our findings support ML models driven by patient-reported symptom severity as accurate predictors of short-term mortality in patients with advanced cancer, highlighting the opportunity to integrate these models prospectively into future studies of goal-concordant care.

Identifying the palliative care needs of frail, older, housebound patients in the community: A cross-sectional study

BACKGROUND

The early introduction of palliative care can have a positive impact on the quality of life of patients suffering from life-limiting diseases. However, the palliative care needs of older, frail, housebound patients are still mostly unknown, as is the impact of frailty on the importance of these needs.

OBJECTIVES

To identify the palliative care needs of frail, older, housebound patients in the community.

METHODS

We conducted a cross-sectional observational study. This study took place in a single primary care center and included patients who were ≥65 years old, housebound, followed by the Geriatric Community Unit of the Geneva University Hospitals.

RESULTS

Seventy-one patients completed the study. Most patients were female (56.9%), and mean age (SD) was 81.1 (±7.9). The Edmonton Symptom Assessment Scale mean (SD) score was higher in frail patients as opposed to vulnerable patients for tiredness (p = 0.016), drowsiness (p = 0.0196), loss of appetite (p = 0.0124), and impaired feeling of well-being (p = 0.0132). There was no difference in spiritual well-being, measured by the spiritual scale subgroup of the Functional Assessment of the Chronic Illness Therapy-Spiritual Well-Being scale (FACIT-sp) between frail and vulnerable participants, although scores in both groups were low. Caregivers were mainly spouses (45%) and daughters (27.5%) with a mean (SD) age of 70.7 (±13.6). The overall carer-burden measured by the Mini-Zarit was low.

SIGNIFICANCE OF RESULTS

Older, frail, housebound patients have specific needs that differ from non-frail patients and should guide future palliative care provision. How and when palliative care should be provided to this population remains to be determined.

Study on the solubilization effect of 7-ethyl-10-hydroxycamptothecin based on molecular docking and molecular dynamics simulation

CONTEXT

With the continuous improvement of anticancer drugs, the condition of patients has been controlled to a certain extent, but the problem that still needs to be urgently solved is that most anticancer drug candidates' solubility is low. On the one hand, the low solubility of anticancer drugs may lead to a decrease in the absorption rate of anticancer drugs, poor treatment effect, and even death in severe cases. On the other hand, it will also lead to a waste of medical resources. At the same time, the rapid and scientific screening of ideal anticancer drugs has become a difficult problem that researchers have to face in the research process. In this study, we found two kinds of SN38-ligand complexes that solubilize 7-ethyl-10-hydroxycamptothecin (SN38) through molecular docking and molecular dynamics simulation methods. This process not only provided valuable information on improving the solubility of SN38, but also helped to discover effective potential complexes that solubilize SN38 quickly and scientifically.

METHODS

The interaction of the SN38 with folic acid and isoproterenol hydrochloride was rapidly determined by molecular docking and molecular dynamics simulation methods. We used Discovery Studio software to perform molecular docking. And then, we used Gromacs 2019.3 software to perform molecular dynamics, analyzing and comparing the hydrogen bonds, solvent-accessible surface areas, energies, and so on between SN38 and SN38-ligand complexes. And the force field adopted the Gromos 54a7.

Effect of Deintensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents

OBJECTIVE

Guidelines advocate against tight glycemic control in older nursing home (NH) residents with advanced dementia (AD) or limited life expectancy (LLE). We evaluated the effect of deintensifying diabetes medications with regard to all-cause emergency department (ED) visits, hospitalizations, and death in NH residents with LLE/AD and tight glycemic control.

RESEARCH DESIGN AND METHODS

We conducted a national retrospective cohort study of 2,082 newly admitted nonhospice veteran NH residents with LLE/AD potentially overtreated for diabetes (HbA1c ≤7.5% and one or more diabetes medications) in fiscal years 2009-2015. Diabetes treatment deintensification (dose decrease or discontinuation of a noninsulin agent or stopping insulin sustained ≥7 days) was identified within 30 days after HbA1c measurement. To adjust for confounding, we used entropy weights to balance covariates between NH residents who deintensified versus continued medications. We used the Aalen-Johansen estimator to calculate the 60-day cumulative incidence and risk ratios (RRs) for ED or hospital visits and deaths.

RESULTS

Diabetes medications were deintensified for 27% of residents. In the subsequent 60 days, 28.5% of all residents were transferred to the ED or acute hospital setting for any cause and 3.9% died. After entropy weighting, deintensifying was not associated with 60-day all-cause ED visits or hospitalizations (RR 0.99 [95% CI 0.84, 1.18]) or 60-day mortality (1.52 [0.89, 2.81]).

CONCLUSIONS

Among NH residents with LLE/AD who may be inappropriately overtreated with tight glycemic control, deintensification of diabetes medications was not associated with increased risk of 60-day all-cause ED visits, hospitalization, or death.

Caregiver Distress in Home Palliative Care

Aim: This study aims to determine the symptom burden of caregivers who were following their loved ones at home and factors associated with this burden. Methods: From a consecutive number of patients followed at home by a specialistic palliative care team, a sample of 46 couples of patients-caregivers was screened. Epidemiological data of both patients and caregivers were collected, also including some variables, such as the level of religiousness, education, economic conditions, and financial distress. The Edmonton Symptom Assessment System (ESAS) was measured in both patients and caregivers. Caregivers were asked to provide a comment in a semi-structured interview, about "what do you think of your loved one's suffering?" They were also invited to release any further comment. Results: Caregivers' symptom burden was relevant. Sleep disturbances were even more relevant in caregivers. Caregivers with a lower level of education and financial distress experienced more global symptom burden. Caregivers manifested a deep sense of injustice and gripes regarding previous hospitalizations. Conclusion: There is an association between patient-reported severity of symptoms and caregiver symptoms. These data suggest delivering support to those caregivers who express higher levels of symptoms. There is a need for further research to explore the possible interventions to mitigate caregivers' symptom burden.

Longitudinal patient-reported outcomes and survival among early-stage non-small cell lung cancer patients receiving stereotactic body radiotherapy

BACKGROUND AND PURPOSE

The study objective was to determine whether longitudinal changes in patient-reported outcomes (PROs) were associated with survival among early-stage, non-small cell lung cancer (NSCLC) patients undergoing stereotactic body radiation therapy (SBRT).

MATERIALS AND METHODS

Data were obtained from January 2015 through March 2020. We ran a joint probability model to assess the relationship between time-to-death, and longitudinal PRO measurements. PROs were measured through the Edmonton Symptom Assessment Scale (ESAS). We controlled for other covariates likely to affect symptom burden and survival including stage, tumor diameter, comorbidities, gender, race/ethnicity, relationship status, age, and smoking status.

RESULTS

The sample included 510 early-stage NSCLC patients undergoing SBRT. The median age was 73.8 (range: 46.3-94.6). The survival component of the joint model demonstrates that longitudinal changes in ESAS scores are significantly associated with worse survival (HR: 1.04; 95% CI: 1.02-1.05). This finding suggests a one-unit increase in ESAS score increased probability of death by 4%. Other factors significantly associated with worse survival included older age (HR: 1.04; 95% CI: 1.03-1.05), larger tumor diameter (HR: 1.21; 95% CI: 1.01-1.46), male gender (HR: 1.87; 95% CI: 1.36-2.57), and current smoking status (HR: 2.39; 95% CI: 1.25-4.56).

CONCLUSION

PROs are increasingly being collected as a part of routine care delivery to improve symptom management. Healthcare systems can integrate these data with other real-world data to predict patient outcomes, such as survival. Capturing longitudinal PROs-in addition to PROs at diagnosis-may add prognostic value for estimating survival among early-stage NSCLC patients undergoing SBRT.

Symptomatic Features and Factors Associated With Do-Not-Resuscitate Consent in Advanced Cancer Patients Admitted to Palliative Care Ward

This study aimed to conduct a retrospective cross-sectional study to investigate the prevalence of symptoms and symptom clusters on sociodemographic and disease characteristics, as well as factors associated with Do-Not-Resuscitate (DNR) consent. Advanced cancer patients were enrolled between 2018 and 2020 with available data. Demographic and clinical data were obtained for analysis from Hospital Information System (HIS) in China. Symptom clusters were extracted by hierarchical cluster analysis. Chi-square test and multiple logistic regression were conducted to investigate the prevalence characteristics of symptoms and influencing factors of DNR consent, respectively. 798 advanced cancer patients were enrolled. The most prevalent symptoms were pain (93%), anorexia (36.5%), and sleep disorders (34.2%). High heart rate was associated with poor performance status and more symptoms. Three clusters were extracted: fatigue-related, respiratory-circulatory system, and digestive system symptom clusters. The incidence of symptoms was statistically significant in age, gender, education level, residence, BMI, performance status, distress score, ADL, and primary pain level. The DNR signature rate was 15.5%. Female, distant metastasis, in-ward rescue, and appearance of dyspnea were independent influencing factors of DNR signature.Chinese hospitalized cancer patients had more symptoms burden that were influenced by various demographic characteristics, especially pain and fatigue-related symptoms. Concerning the trajectory of vital signs is important among advanced cancer patients. The DNR signature rate was lower and our finding indicating an urgency to accurately assess the prognosis and give more palliative care education to enhance DNR rates and early signing in Chinese context.

Oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care: a preliminary retrospective cohort study

Background

The role of oxygen therapy in end-of-life care for patients with advanced cancer is incompletely understood. We aimed to evaluate the association between oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care.

Methods

We conducted a retrospective cohort study at a primary care practice in suburban Tokyo. Adult patients in home care with advanced cancer demonstrating first low oxygen saturation (less than 90%) detected in home visits were consecutively included in the study. Cox proportional hazards regression was used to investigate the effect of oxygen use on overall survival and survival at home, adjusted for systolic blood pressure, decreased level of consciousness, dyspnea, oral intake, performance status, and cardiopulmonary comorbidity.

Results

Of 433 identified patients with advanced cancer, we enrolled 137 patients (oxygen use, n = 35; no oxygen use, n = 102) who developed low oxygen saturation. In multivariable analysis, the adjusted hazard ratio (HR) of oxygen use was 0.68 (95% confidence interval 0.39–1.17) for death and 0.70 (0.38–1.27) for death at home. In patients with dyspnea, the HR was 0.35 (0.13–0.89) for death and 0.33 (0.11–0.96) for death at home; without dyspnea, it was 1.03 (0.49–2.17) for death and 0.84 (0.36–1.96) for death at home.

Conclusions

Oxygen use was not significantly associated with survival in patients with advanced cancer and low oxygen saturation, after adjusting for potential confounders. It may not be necessary to use oxygen for prolongation of survival in such patients, particularly in those without dyspnea.

Oncologic Emergencies: Palliative Care in the Emergency Department Setting

BACKGROUND

Palliative care is an essential component of emergency medicine, as many patients with terminal illness will present to the emergency department (ED) for symptomatic management at the end of life (EOL).

OBJECTIVE

This narrative review evaluates palliative care in the ED, with a focus on the literature behind management of EOL symptoms, especially dyspnea and cancer-related pain.

DISCUSSION

As the population ages, increasing numbers of patients present to the ED with severe EOL symptoms. An understanding of the role of palliative care in the ED is crucial to effectively communicating with these patients to determine their goals and provide medical care in line with their wishes. Beneficence, nonmaleficence, and patient autonomy are essential components of palliative care. Patients without medical decision-making capacity may have an advance directive, do not resuscitate or do not intubate order, or Portable Medical Orders for Life-Sustaining Treatment available to assist clinicians. Effective and empathetic communication with patients and families is vital to EOL care discussions. Two of the most common and distressing symptoms at the EOL are dyspnea and pain. The most effective treatment of EOL dyspnea is opioids, with literature showing little efficacy for other therapies. The most effective treatment for cancer-related pain is opioids, with expeditious pain control achievable with a rapid fentanyl titration. It is also important to address nausea, vomiting, and secretions, as these are common at the EOL.

CONCLUSIONS

Emergency clinicians play a vital role in EOL patient care. Clear, empathetic communication and treatment of EOL symptoms are essential.

Association Between Heart Rate and Reversibility of the Symptom, Refractoriness to Palliative Treatment, and Survival in Dyspneic Cancer Patients

CONTEXT

Dyspnea is one of the most distressing symptoms for terminally ill cancer patients and a predictor of poor prognosis. Identification of simple clinical signs, such as heart rate, indicating clinical course of each patient is of value.

OBJECTIVES

To explore the potential association between heart rate and reversibility of the symptom, treatment response to palliative intervention, and survival in terminally ill cancer patients with dyspnea at rest.

METHODS

This is a secondary analysis of a multicenter prospective cohort study of patients with advanced cancer to validate multiple prognostic tools. In the patients with dyspnea at rest at the baseline, we examined a potential association between heart rate and the reversibility of dyspnea and refractoriness to palliative treatment using logistic regression analysis. Survivals were compared using the Cox proportional hazards model among four groups with different levels of the heart rate (≤74, 75-84, 85-97, and ≥98).

RESULTS

A total of 2298 patients were enrolled, and 418 patients (18%) had dyspnea at rest. Reversibility of dyspnea was significantly higher in the patients with lower heart rate (P for trend = 0.008), and the refractoriness to palliative treatment tended to be higher in the patients with higher heart rate (P for trend = 0.101). The median survival for each heart rate quartile groups was significantly higher in the lower heart rate group (24 vs. 21 vs. 14 vs. 9 days; heart rate ≤74, 75-84, 85-97, and ≥98, respectively; log-rank P < 0.001).

CONCLUSION

Heart rate may help clinicians to make the prediction of the patient's clinical course more accurate.

Cachexia in Cancer Patients: Systematic Literature Review

Introduction Cachexia in cancer patients, especially in advanced stage, is recently known as an emerging problem. Cachexia occurs in about half of all patients with neoplastic disease. The diagnosis of cachexia needs comprehensive evaluation of body weight and body composition for several months. Cachexia will give negative impacts such as increased mortality, chemotoxicity, and decreased quality of life. Here, we review the current evidence describing the definition, stages, mechanisms, diagnosis and treatment of cachexia in cancer patients.

Methods We identified 75 studies and/or review articles evaluating cachexia and weight loss in cancer patients by searching PubMed and EMBASE databases.

Results Cachexia is reported across all stages and types of cancers. The most recent definition of cachexia is reported in a 2011 paper by International Consensus. The mechanism of cachexia in cancer is complex and involved many factors which elaborate together to produce cachexia. The diagnostic evaluation and cut-off measurement of cachexia, especially in cancer varied across studies. The loss of weight that happens during chemotherapy will make a poor prognosis. Cachexia can worsen chemotherapy toxicity. Combination of dietary modification and exercise with supplementation of medication that control appetite and inflammation are important in the management of cachexia in cancer patients.

Conclusion Patients with cancer are the population at risk for developing cachexia before and after chemotherapy. Cachexia diagnosis needs evaluation of body weight and body composition. Nonpharmacological treatments, such as dietary modification and physical exercise, are the best strategy to reduce cachexia in cancer patients.

Patient-reported symptoms and problems at admission to specialized palliative care improved survival prediction in 30,969 cancer patients: A nationwide register-based study

BACKGROUND

Large, nationally representative studies of the association between quality of life and survival time in cancer patients in specialized palliative care are missing.

AIM

The aim of this study was to investigate whether symptoms/problems at admission to specialized palliative care were associated with survival and if the symptoms/problems may improve prediction of death within 1 week and 1 month, respectively.

SETTING/PARTICIPANTS

All cancer patients who had filled in the EORTC QLQ-C15-PAL at admission to specialized palliative care in Denmark in 2010-2017 were included through the Danish Palliative Care Database. Cox regression was used to identify clinical variables (gender, age, type of contact (inpatient vs outpatient), and cancer site) and symptoms/problems significantly associated with survival. To test whether symptoms/problems improved survival predictions, the overall accuracy (area under the receiver operating characteristic curve) for different prediction models was compared. The validity of the prediction models was tested with data on 5,508 patients admitted to palliative care in 2018.

RESULTS

The study included 30,969 patients with an average age of 68.9 years; 50% were women. Gender, age, type of contact, cancer site, and most symptoms/problems were significantly associated with survival time. The predictive value of symptoms/problems was trivial except for physical function, which clearly improved the overall accuracy for 1-week and 1-month predictions of death when added to models including only clinical variables.

CONCLUSION

Most symptoms/problems were significantly associated with survival and mainly physical function improved predictions of death. Interestingly, the predictive value of physical function was the same as all clinical variables combined (in hospice) or even higher (in palliative care teams).

Higher Distress in Patients with Breast Cancer Is Associated with Declining Breast Reconstruction

Background:

Distress among newly diagnosed patients with breast cancer is common and may have an impact on their surgical decision-making. The revised Edmonton Symptom Assessment System (ESAS-r) is a validated instrument that provides an estimate of patients’ total distress, and no previous study has related preoperative scores to the choice to have breast reconstruction.

Methods:

Women with breast cancer treated at the Princess Margaret Cancer Centre in 2014 were reviewed, and patient and tumor characteristics were collected from local databases. Breast reconstruction status was obtained from patients’ electronic medical records until April 2017. A multivariable logistic regression model assessed for an independent association between preoperative ESAS-r total distress scores and patients’ decision to have breast reconstruction.

Results:

A total of 312 patients were analyzed. ESAS-r values had an overall median score of 10.0 and ranged from 0 to 69 (interquartile range, 17). Of these patients, 82 chose to undergo breast reconstruction surgery (26.8%). Multivariable logistic regression analysis showed that higher ESAS-r scores were associated with patients forgoing breast reconstruction surgery (lumpectomy-alone group: odds ratio estimate, 1.034 [1.004–1.064], P = 0.025; mastectomy-alone group: odds ratio estimate, 1.031 [1.004–1.059], P = 0.023).

Conclusions:

This study of patients with breast cancer found that higher distress scores as measured by the ESAS-r were associated with reduced breast reconstruction. Distress in patients with breast cancer is important to address, as it is often treatable, and its resolution may unmask a desire for breast reconstruction, which has known benefits psychosocially.

Adverse Events in Home Care: Identifying and Responding with interRAI Scales and Clinical Assessment Protocols

Outcomes of adverse events in home care are varied and multifactorial. This study tested a framework combining two health measures to identify home care recipients at higher risk of long-term care placement or death within one year. Both measures come from the Resident Assessment Instrument-Home Care (RAI-HC), a standardized comprehensive clinical assessment. Persons scoring high in the Method for Assigning Priority Levels (MAPLe) algorithm and Changes in Health, End-stage disease, Signs and Symptoms (CHESS) scale were at the greatest risk of placement or death and more than twice as likely to experience either outcome earlier than others. The target group was more likely to trigger mood, social relationship, and caregiver distress issues, suggesting mental health and psychosocial interventions might help in addition to medical care and/or personal support services. Home care agencies can use this framework to identify home care patients who may require a more intensive care coordinator approach.

Implementation of the Edmonton Symptom Assessment System for Symptom Distress Screening at a Community Cancer Center: A Pilot Program

A better understanding of how the Edmonton Symptom Assessment System (ESAS) can be used for distress screening may facilitate its use to improve patient care. In 2015, the General Medical Oncology Outpatient Clinic at Lyndon B. Johnson Hospital implemented a pilot project with ESAS for distress screening. The impact of ESAS screening on access to psychosocial care before and after program implementation is reported here.

Background.

Distress screening is mandated by the American College of Surgeons Commission on Cancer; however, there is limited literature on its impact in actual practice. We examined the impact of a pilot distress screening program on access to psychosocial care.

Methods.

Edmonton Symptom Assessment System (ESAS) screening was routinely conducted at our community‐based medical oncology program. Patients who screened positive for severe distress were sent to a social worker for triage and referred to the appropriate services if indicated. We compared the proportion of patients who had ESAS completed, the proportion of patients who screened positive, and the number of patients who had social work assessment and palliative care consultation over the preimplementation (September 2015), training (October/November 2015), and postimplementation (December 2015) periods.

Results.

A total of 379, 328, and 465 cancer patients were included in the preimplementation, training, and postimplementation periods, respectively. The proportion of patients who completed ESAS increased over time (83% vs. 91% vs. 96%). Among the patients who had completed ESAS, between 11% and 13% were positive for severe distress, which remained stable over the three periods. We observed a significant increase in social work referrals for psychosocial assessment (21% vs. 71% vs. 79%). There was also a trend towards an increased number of palliative care referrals (12% vs. 20% vs. 28%).

Conclusion.

Our community‐based cancer center implemented distress screening rapidly in a resource‐limited setting, with a notable increase in symptom documentation and psychosocial referral.

Implications for Practice.

The American College of Surgeons Commission on Cancer mandates distress screening; however, there is limited literature on how this process should be implemented and its impact on clinical practice. We used the Edmonton Symptom Assessment System for routine symptom distress screening in a community‐based medical oncology program that provides care for an underserved population. Comparing before and after program implementation, we found an increase in the number of documentations of symptom burden and an increase in psychosocial referrals. Findings from this study may inform the implementation of routine symptom distress screening in cancer patients.

Differences in Symptom Burden Among Cancer Patients With Different Stages of Cachexia

CONTEXT

Cancer patients with cachexia may suffer from significant burden of symptoms and it can severely impair patients' quality of life. However, only few studies have targeted the symptom burden in cancer cachexia patients, and whether the symptom burden differed in different cachexia stages is still unclear.

OBJECTIVES

The aims of this study were to evaluate the symptom burden in cancer cachexia patients and to compare the severity and occurrence rates of symptoms among cancer patients with non-cachexia, pre-cachexia, cachexia, and refractory cachexia.

METHODS

Advanced cancer patients (n = 306) were included in this cross-sectional study. Patients were divided into four groups, based on the cachexia stages of the international consensus. The M.D. Anderson Symptom Inventory added with eight more cachexia-specific symptoms were evaluated in our patients. Differences in symptom severity and occurrence rates among the four groups were compared using one-way ANOVA or Kruskal-Wallis test analyses.

RESULTS

Lack of appetite, disturbed sleep, fatigue, lack of energy, and distress were the symptoms with highest occurrence rates and severity scores in all four groups and were exacerbated by the severity of cachexia stages. After confounders were adjusted for, significant differences were seen in symptoms of pain, fatigue, disturbed sleep, remembering problems, lack of appetite, dry mouth, vomiting, numbness, feeling dizzy, early satiety, lack of energy, tastes/smell changes, and diarrhea.

CONCLUSION

This study identified higher symptom burden in cancer patients with cachexia and it increased with the stages of cachexia, which emphasized the importance of screening in multiple co-occurring symptoms for cachexia patients.

The Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments

CONTEXT

Routine symptom assessment represents the cornerstone of symptom management. Edmonton Symptom Assessment System (ESAS) is one of the first quantitative symptom assessment batteries that allows for simple and rapid documentation of multiple patient-reported symptoms at the same time.

OBJECTIVES

To discuss the historical development of ESAS, its current uses in different settings, and future developments.

METHODS

Narrative review.

RESULTS

Since its development in 1991, ESAS has been psychometrically validated and translated into over 20 languages. We will discuss the variations, advantages, and limitations with ESAS. From the clinical perspective, ESAS is now commonly used for symptom screening and longitudinal monitoring in patients seen by palliative care, oncology, nephrology, and other disciplines in both inpatient and outpatient settings. From the research perspective, ESAS has offered important insights into the nature of symptom trajectory, symptom clusters, and symptom modulators. Furthermore, multiple clinical studies have incorporated ESAS as a study outcome and documented the impact of various interventions on symptom burden. On the horizon, multiple groups are actively investigating further refinements to ESAS, such as incorporating it in electronic health records, using ESAS as a trigger for palliative care referral, and coupling ESAS with personalized symptom goals to optimize symptom response assessment.

CONCLUSION

ESAS has evolved over the past 25 years to become an important symptom assessment instrument in both clinical practice and research. Future efforts are needed to standardize this tool and explore its full potential to support symptom management.

Validation of the Chinese version of functional assessment of anorexia-cachexia therapy (FAACT) scale for measuring quality of life in cancer patients with cachexia

PURPOSE

The assessment of quality of life (QOL) is an important part of cachexia management for cancer patients. Functional assessment of anorexia-cachexia therapy (FAACT), a specific QOL instrument for cachexia patients, has not been validated in Chinese population. The aim of this study was to validate the FAACT scale in Chinese cancer patients for its future use.

METHODS

Eligible cancer patients were included in our study. Patients' demographic and clinical characteristics were collected from the electronic medical records. Patients were asked to complete the Chinese version of FAACT scale and the MD Anderson symptom inventory (MDASI), and then the reliability and validity were analyzed.

RESULTS

A total of 285 patients were enrolled in our study, data of 241 patients were evaluated. Coefficients of Cronbach's alpha, test-retest and split-half analyses were all greater than 0.8, which indicated an excellent reliability for FAACT scale. In item-subscale correlation analysis and factor analysis, good construct validity for FAACT scale was found. The correlation between FAACT and MDASI interference subscale showed reasonable criterion-related validity, and for further clinical validation, the FAACT scale showed excellent discriminative validity for distinguishing patients in different cachexia status and in different performance status.

CONCLUSIONS

The Chinese version of FAACT scale has good reliability and validity and is suitable for measuring QOL of cachexia patients in Chinese population.

The last days of life: symptom burden and impact on nutrition and hydration in cancer patients

PURPOSE OF REVIEW

To examine the symptom burden in cancer patients during the last days of life, its impact on nutrition and hydration, and the role of artificial nutrition and hydration in the final days.

RECENT FINDINGS

During the last days of life, cancer patients often experience progressive functional decline and worsening symptom burden. Many symptoms such as anorexia-cachexia, dysphagia, and delirium could impair oral intake. These, coupled with refractory cachexia, contribute to persistent weight loss and decreased quality of life. Furthermore, the inability to eat/drink and body image changes can result in emotional distress for patients and caregivers. Clinicians caring for these individuals need to ensure longitudinal communication about goals of care, education about the natural process of dying, optimization of symptom management, and provide appropriate emotional support for patients and caregivers. There is a lack of evidence to support that artificial nutrition and hydration can improve outcomes during the last days of life. Artificial nutrition is not recommended because of its invasive nature, whereas artificial hydration may be considered on a case-by-case basis.

SUMMARY

This review highlights the need to conduct further research on symptom burden, nutrition, and hydration during the last days of life.

Unexpected death in palliative care: what to expect when you are not expecting

PURPOSE OF REVIEW

Death is a certainty in life. Yet, the timing of death is often uncertain. When death occurs suddenly and earlier than anticipated, it is considered as an unexpected death. In this article, we shall discuss when is death expected and unexpected, and review the frequency, impact, causes, and approach to unexpected death in the palliative care setting.

RECENT FINDINGS

Even in the palliative care setting in which death is relatively common, up to 5% of deaths in hospice and 10% of deaths in palliative care units were considered to be unexpected. Unexpected death has significant impact on care, including unrealized dreams and unfinished business among patients, a sense of uneasiness and complicated bereavement among caregivers, and uncertainty in decision making among healthcare providers. Clinicians may minimize the impact of unexpected events by improving their accuracy of prognostication, communicating the uncertainty with patients and families, and helping them to expect the unexpected by actively planning ahead. Furthermore, because of the emotional impact of unexpected death on bereaved caregivers, clinicians should provide close monitoring and offer prompt treatment for complicated grief.

SUMMARY

Further research is needed to understand how we can better predict and address unexpected events.

Symptom Frequencies and Intensities in Hospitalized Patients With Advanced Cancer Having Depressive Disorder

Aim:

To explore the frequencies and intensities of depressive symptoms associated with hospitalized patients with advanced cancer.

Methods:

A total of 196 hospitalized patients with advanced cancer were surveyed with the Edmonton Symptom Assessment System and Self-Rating Depression Scale (SDS). The χ2 test and Wilcoxon rank-sum test were used to compare the frequency and intensity of symptoms between patients with and without depressive disorders. Spearman rank correlation was used to test the correlation between depression and symptoms.

Results:

Of the 196 enrolled patients, 115 (59%) were males. The median age of the patients was 58 (19-80) years. Seventy-six (39%) patients were diagnosed with depression (SDS ≥ 53). Patients with depressive disorders exhibited pain, drowsiness, and nausea along with a higher frequency and intensity of poor self-perception, appetite loss, anxiety, dyspnea, and fatigue. Depressive symptoms were positively correlated with the symptoms.

Conclusion:

Depressive disorders are very common and severe in hospitalized patients with advanced cancer. Identifying the frequencies and intensities of the symptoms enables early intervention to improve patients’ quality of life.

Shock Index and Decreased Level of Consciousness as Terminal Cancer Patients' Survival Time Predictors: A Retrospective Cohort Study

CONTEXT

Predicting prognosis using noninvasive and objective tools may facilitate end-of-life decisions for terminal cancer patients, their families, and other health care professionals.

OBJECTIVES

To investigate if the shock index (SI), along with decreased level of consciousness (DLOC), is a reliable tool for predicting short-term survival time in terminal cancer patients.

METHODS

A two-part retrospective cohort study was performed on 670 consecutive adult hospice patients. Part 1 of the study was performed to investigate the reliability of SI and DLOC on admission and to make a simple tool for predicting survival time. Part 2 of the study was to validate the tool's reproducibility and analyze the correlation between SI, DLOC, and survival time.

RESULTS

In Part 1, multivariate Cox proportional hazards analyses for all study patients revealed that SI ≥ 1.0 in patients with DLOC was a significant risk factor of death (hazard ratio 3.08; 95% CI 1.72-5.53; P = 0.000). Generalized additive models confirmed that DLOC patients with SI = 1.0 had 9.58 days of mean survival time (MST). Receiver operating characteristic curve analyses of SI in patients with DLOC revealed that a survival time of less than three days was most reliably predicted. In Part 2, an increase in SI statistically decreased survival time. The upper 95% CIs of the calculated mean survival time for DLOC patients with SI ≥ 1.0 were less than one week. Bootstrap analyses revealed that the 95% CIs of the predicted survival time were 4.54-6.18 days in DLOC patients with SI = 1.0.

CONCLUSION

An SI ≥ 1.0 along with DLOC is a highly reliable tool for predicting short-term survival time in terminal cancer patients.

Prognostication of Survival in Patients With Advanced Cancer: Predicting the Unpredictable?

BACKGROUND

Prognosis is a key driver of clinical decision-making. However, available prognostication tools have limited accuracy and variable levels of validation.

METHODS

Principles of survival prediction and literature on clinician prediction of survival, prognostic factors, and prognostic models were reviewed, with a focus on patients with advanced cancer and a survival rate of a few months or less.

RESULTS

The 4 principles of survival prediction are (a) prognostication is a process instead of an event, (b) prognostic factors may evolve over the course of the disease, (c) prognostic accuracy for a given prognostic factor/ tool varies by the definition of accuracy, the patient population, and the time frame of prediction, and (d) the exact timing of death cannot be predicted with certainty. Clinician prediction of survival is the most commonly used approach to formulate prognosis. However, clinicians often overestimate survival rates with the temporal question. Other clinician prediction of survival approaches, such as surprise and probabilistic questions, have higher rates of accuracy. Established prognostic factors in the advanced cancer setting include decreased performance status, delirium, dysphagia, cancer anorexia-cachexia, dyspnea, inflammation, and malnutrition. Novel prognostic factors, such as phase angle, may improve rates of accuracy. Many prognostic models are available, including the Palliative Prognostic Score, the Palliative Prognostic Index, and the Glasgow Prognostic Score.

CONCLUSIONS

Despite the uncertainty in survival prediction, existing prognostic tools can facilitate clinical decision-making by providing approximated time frames (months, weeks, or days). Future research should focus on clarifying and comparing the rates of accuracy for existing prognostic tools, identifying and validating novel prognostic factors, and linking prognostication to decision-making.

Objective palliative prognostic score among patients with advanced cancer

CONTEXT

The accurate prediction of survival is one of the key factors in the decision-making process for patients with advanced illnesses.

OBJECTIVES

This study aimed to develop a short-term prognostic prediction method that included such objective factors as medical history, vital signs, and blood tests for use with patients with advanced cancer.

METHODS

Medical records gathered at the admission of patients with advanced cancer to the hospice palliative care unit at a tertiary hospital in Taiwan were reviewed retrospectively. The records included demographics, history of cancer treatments, performance status, vital signs, and biological parameters, Multivariate logistic regression analyses and receiver operating characteristic curves were used for model development.

RESULTS

The Objective Palliative Prognostic Score was determined by using six objective predictors identified by multivariate logistic regression analysis. The predictors include heart rate >120/min, white blood cells >11,000/mm(3), platelets <130,000/mm(3), serum creatinine level >1.3 mg/dL, serum potassium level >5 mg/dL, and no history of chemotherapy. The area under the receiver operating characteristic curve used to predict seven-day survival was 82.0% (95% confidence interval 75.2%-88.8%). If any three predictors of the six were reached, death within seven days was predicted with 68.8% sensitivity, 86.0% specificity, 55.9% positive predictive value, and 91.4% negative predictive value.

CONCLUSION

The Objective Palliative Prognostic Score consists of six objective predictors for the estimation of seven-day survival among patients with advanced cancer and showed a relatively high accuracy, specificity, and negative predictive value. Objective signs, such as vital signs and blood test results, may help clinicians make decisions at the end of life.