Integrating palliative care into the trajectory of cancer care

Midazolam Indications and Dosing in Palliative Medicine: Results from a Multinational Survey

Despite sparse evidence and limited guidance on indications, use, and dosing, midazolam is widely used in palliative care. We aimed to describe and compare the use of midazolam in three different countries to improve clinical practice in palliative care. We performed an online survey among palliative care physicians in Norway, Denmark, and the United Kingdom (UK). The focus was indications, dosing, administration, and concomitant drugs. A web-based questionnaire was distributed to members of the respective national palliative medicine associations. The total response rate was 9.4%. Practices in the UK, Norway, and Denmark were overall similar regarding the indications of midazolam for anxiety, dyspnoea, and pain treatment in combination with opioids. However, physicians in the UK used a higher starting dose for anxiety, dyspnoea, and pain treatment compared to Norway and Denmark, as well as a higher maximum dose. Danish physicians preferred, to a higher degree, on-demand midazolam administration. Despite practice similarities in the UK, Norway, and Denmark, differences exist for midazolam dosing and administration in palliative medicine. We demonstrated a lack of consensus on how midazolam should be used in palliative care, setting the stage for future studies on the topic.

Timely integration of palliative care. the reality check. a retrospective analysis

PURPOSE

A large volume of literature suggests that timely integration of palliative care (PC) enhances the well-being, quality of life and satisfaction of patients and their families. It may also positively impact clinical outcomes and healthcare costs throughout the disease trajectory. Therefore, reviewing clinical practice to reflect real-life situations regarding timely PC integration is essential.

METHODS

This study, conducted at the Vienna General Hospital between March 2016 and August 2022, retrospectively examined PC consultation (PCC) requests. It aimed to assess the timeliness of PC integration by analysing the duration between diagnosis and the first PCC request, as well as the interval between the first PCC request and death.

RESULTS

This study included 895 PCCs. The median time from diagnosis to the first PCC was 16.6 (interquartile range (IQR): 3.9-48.4) months, while the median time from the first PCC to death was 17.2 (IQR: 6.1-50.7) days. The median time from diagnosis to first PCC was 10.4 months in females (confidence interval (CI): 6.0-14.8) compared to 10.6 months in males (CI: 8.1-13.1; p = 0.675). There were no gender disparities in the time from first PCC to death, with a median of 23.3 days (CI: 15.6-31.0) for females and 22.3 days (CI: 16.2-28.4) for males (p  = 0.93). Fifty percent of patients died between 5 and 47 days after the first PCC.

CONCLUSION

These findings highlight the discrepancy between the clinical perception of PC as end-of-life care and the existing literature, thereby emphasising the importance of timely PC integration.

Quality of life for patients with advanced gastrointestinal cancer randomised to early specialised home-based palliative care: the ALLAN trial

BACKGROUND

The primary aim of specialised palliative care (SPC) is to improve the quality of life (QoL) for patients with a high symptom burden from a life-threatening disease. This randomised study aimed to assess the QoL impact of early integration of SPC alongside tumour-specific palliative treatment in patients with gastrointestinal (GI) cancers.

METHODS

We randomly assigned ambulatory patients with advanced GI cancer to early integration of SPC and palliative tumour-specific treatment or tumour-specific treatment alone. The primary endpoint was QoL assessed at baseline and every sixth week using the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire.

RESULTS

A total of 118 patients were randomised. The difference in total FACT-G score between patients assigned to early integration with SPC and controls was 5.2 points (95% CI: -0.1 to 10.5, p = 0.216), 6.7 points (95% CI: 0.2 to 13.3, p = 0.172), and 13 points (95% CI: 5.7 to 20.2, p = 0.004) at weeks 6, 12, and 24, respectively.

CONCLUSIONS

This prospective randomised trial strengthens the argument for early integration of SPC with tumour-specific treatment in patients with advanced GI cancers. We found an improved QoL for patients with advanced GI cancer 24 weeks after randomisation to early integration of home-based SPC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (ref: NCT02246725).

Stepped Palliative Care for Patients With Advanced Lung Cancer: A Randomized Clinical Trial

Importance

Despite the evidence for early palliative care improving outcomes, it has not been widely implemented in part due to palliative care workforce limitations.

Objective

To evaluate a stepped-care model to deliver less resource-intensive and more patient-centered palliative care for patients with advanced cancer.

Design, Setting, and Participants

Randomized, nonblinded, noninferiority trial of stepped vs early palliative care conducted between February 12, 2018, and December 15, 2022, at 3 academic medical centers in Boston, Massachusetts, Philadelphia, Pennsylvania, and Durham, North Carolina, among 507 patients who had been diagnosed with advanced lung cancer within the past 12 weeks.

Intervention

Step 1 of the intervention was an initial palliative care visit within 4 weeks of enrollment and subsequent visits only at the time of a change in cancer treatment or after a hospitalization. During step 1, patients completed a measure of quality of life (QOL; Functional Assessment of Cancer Therapy-Lung [FACT-L]; range, 0-136, with higher scores indicating better QOL) every 6 weeks, and those with a 10-point or greater decrease from baseline were stepped up to meet with the palliative care clinician every 4 weeks (intervention step 2). Patients assigned to early palliative care had palliative care visits every 4 weeks after enrollment.

Main Outcomes and Measures

Noninferiority (margin = -4.5) of the effect of stepped vs early palliative care on patient-reported QOL on the FACT-L at week 24.

Results

The sample (n = 507) mostly included patients with advanced non-small cell lung cancer (78.3%; mean age, 66.5 years; 51.4% female; 84.6% White). The mean number of palliative care visits by week 24 was 2.4 for stepped palliative care and 4.7 for early palliative care (adjusted mean difference, -2.3; P < .001). FACT-L scores at week 24 for the stepped palliative care group were noninferior to scores among those receiving early palliative care (adjusted FACT-L mean score, 100.6 vs 97.8, respectively; difference, 2.9; lower 1-sided 95% confidence limit, -0.1; P < .001 for noninferiority). Although the rate of end-of-life care communication was also noninferior between groups, noninferiority was not demonstrated for days in hospice (adjusted mean, 19.5 with stepped palliative care vs 34.6 with early palliative care; P = .91).

Conclusions and Relevance

A stepped-care model, with palliative care visits occurring only at key points in patients' cancer trajectories and using a decrement in QOL to trigger more intensive palliative care exposure, resulted in fewer palliative care visits without diminishing the benefits for patients' QOL. While stepped palliative care was associated with fewer days in hospice, it is a more scalable way to deliver early palliative care to enhance patient-reported outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT03337399.

Palliative care for patients with hematologic malignancies in Germany: a nationwide survey on everyday practice and influencing factors from the perspective of treating physicians

Integrating palliative care into the treatment of patients with advanced hematological malignancies (HM) remains challenging. To explore treating physicians' perspectives on current palliative care practice and to evaluate factors influencing integration, we conducted a nationwide online survey. Based on literature and expert review, the survey addressed the importance of palliative care, communication about life-threatening conditions, challenges in establishing goals of care, and factors influencing the integration of palliative care. 207 physicians treating patients with HM in Germany participated. We used standard descriptive statistics to analyze quantitative data and a content structuring approach. Most physicians considered palliative care in HM to be very important (60.6%) and discussed life-threatening conditions with more than half of their patients (52%), especially when goals of care were changed (87.0%) or when patients raised the topic (84.0%). Disease-related factors, different professional perspectives on prognosis, and patient hopes were the main barriers to changing goals of care, but collaboration with colleagues and multidisciplinary teams provided important support. Time constraints were identified as the main barrier to integrating palliative care. The majority worked well with palliative care teams. Referral processes and conditions were perceived as minor barriers. The study highlights the need to address barriers to integrating palliative care into the management of patients with advanced HM. Future research should aim at optimizing palliative care for patients with HM.

Examining Variability in Intra-Hospital Patient Referrals to Specialized Palliative Care: A Comprehensive Analysis of Disciplines and Mortality

Background: In Austria, specialized palliative care (SPC) access is limited, with unclear referral criteria, making it challenging to identify hospitalized patients requiring SPC and determine referral timing and mortality at the palliative care unit (PCU). Methods: This retrospective cohort study analyzed patients who underwent a palliative care (PC) needs assessment between March 2016 and November 2021 and were subsequently admitted to the PCU of Austria's largest academic hospital. Demographic, clinical, and standardized referral form data were used for analysis, employing descriptive statistics and logistic regression. Results: Out of the 903 assessed patients, 19% were admitted to the PCU, primarily cancer patients (94.7%), with lung (19%) and breast cancer (13%) being most prevalent. Common referral reasons included pain (61%) and nutritional problems (46%). Despite no significant differences in referral times, most patients (78.4%) died in the PCU, with varying outcomes based on cancer type. Referral reasons like pain (OR = 2.3), nutritional problems (OR = 2.4), and end-of-life care (OR = 6.5) were significantly associated with the outcome PCU mortality. Conclusions: This study underscores Austria's SPC access imbalance and emphasizes timely PC integration across disciplines for effective advance care planning and dignified end-of-life experiences in PCUs.

Development and validation of impact of early integration of palliative care and oncology(IEI PCO) questionnaire: a survey for medical oncologists and nurses

OBJECTIVES

Many associations have recently recommended early integration of oncology and palliative care for more standard cancer care and better quality of life. We aimed to create a questionnaire to assess the opinion of medical oncologists and nurses about the clinical impact of the integrated palliative care and oncology (PCO) program.

METHODS

A novel semi-structured questionnaire called Impact of Early Integration of Palliative Care Oncology (IEI PCO) questionnaire was developed and tested for validity and reliability then distributed to the oncologists and nurses working in Kuwait Cancer Control Center.

RESULTS

After the pilot stage, testing the final questionnaire for validity and reliability was done with satisfactory results. Finally, the complete questionnaires were 170 out of 256 (response rate 66.41%). More awareness about the available palliative care services and the new available PCO services (p-value < 0.001 for all). Most of the oncologists and nurses agreed with the currently available structure of PCO, appreciated the patients' discharge plan and continuity of care of palliative medicine, admitted less work burden, a better attitude, and higher satisfaction (p-value for all < 0.001) toward palliative care. Significant improvements in symptoms were appreciated by oncologists and nurses after the integration of palliative care (p-value for all < 0.001. Oncologists and nurses valued repeated honest communication, discussion of the goals of care, dealing more effectively with ending active treatment, and higher acceptance of patients and families of PC policy of transfer, and significant progress in the care of end-of-life symptoms (p-value for all < 0.001).

CONCLUSIONS

The IEI PCO questionnaire demonstrated the psychometric criteria for content, face, and construct validity and reliability. It provides a valuable tool to assess the impact of PCO integration. The opinion of medical oncologists and nurses was significantly positive toward the early integration of PCO in Kuwait in most aspects of care. This integration led to improved symptom control, end-of-life care, communication, and planned discharge and follow-up plans. Moreover, decreases the work burden, improves attitude, higher satisfaction of the oncology staff, and continuity of care.

Introduction of Various Models of Palliative Oncology Care: A Systematic Review

BACKGROUND

The aim of this study is to synthesize the existing evidence on various palliative care (PC) models for cancer patients. This effort seeks to discern which facets of PC models are suitable for various patient cohorts, elucidate their mechanisms, and clarify the circumstances in which these models operate.

METHODS

A comprehensive search was performed using MeSH terms related to PC and cancer across various databases. The Preferred Reporting Items for Systematic Reviews and a comprehensive evidence map were also applied.

RESULTS

Thirty-three reviews were published between 2009 and 2023. The conceptual PC models can be classified broadly into time-based, provider-based, disease-based, nurse-based, issue-based, system-based, team-based, non-hospice-based, hospital-based, community-based, telehealth-based, and setting-based models. The study argues that the outcomes of PC encompass timely symptom management, longitudinal psychosocial support, enhanced communication, and decision-making. Referral methods to specialized PC services include oncologist-initiated referral based on clinical judgment alone, via referral criteria, automatic referral at the diagnosis of advanced cancer, or referral based on symptoms or other triggers.

CONCLUSION

The gold standard for selecting a PC model in the context of oncology is a model that ensures broad availability of early PC for all patients and provides well-timed, scheduled, and specialized care for patients with the greatest requirement.

Pre-Diagnosis Pain in Patients With Pancreatic Cancer Signals the Need for Aggressive Symptom Management

OBJECTIVE

This study assessed the impact of pancreatic cancer (PC) pain on associated symptoms, activities, and resource utilization from 2016 to 2020 in an online patient registry.

PATIENTS AND METHODS

Responses from PC patient volunteers (N = 1978) were analyzed from online surveys in a cross-sectional study. Comparisons were performed between PC patient groups reporting, (1) the presence vs. absence of pre-diagnosis PC pain, (2) high (4-8) vs. low (0-3) pain intensity scores on an 11-point numerical rating scale (NRS), and (3) year of PC diagnosis (2010-2020). Descriptive statistics and all bivariate analyses were performed using Chi-square or Fisher's Exact tests.

RESULTS

PC pain was the most frequently reported pre-diagnosis symptom (62%). Pre-diagnostic PC pain was reported more frequently by women, those with a younger age at diagnosis, and those with PC that spread to the liver and peritoneum. Those with pre-diagnostic PC pain vs. those without reported higher pain intensities (2.64 ± 2.54 vs.1.56 ± 2.01 NRS mean ± SD, respectively, P = .0039); increased frequencies of post-diagnosis symptoms of cramping after meals, feelings of indigestion, and weight loss (P = .02-.0001); and increased resource utilization in PC pain management: (ER visits N = 86 vs. N = 6, P = .018 and analgesic prescriptions, P < .03). The frequency of high pain intensity scores was not decreased over a recent 11-year span.

CONCLUSIONS

PC pain continues to be a prominent PC symptom. Patients reporting pre-diagnosis PC pain experience increased GI metastasis, symptoms burden, and are often undertreated. Its mitigation may require novel treatments, more resources dedicated to ongoing pain management and surveillance to improve outcomes.

What is an "early palliative care" intervention? A scoping review of controlled studies in oncology

INTRODUCTION

Early palliative care (EPC) has been advocated to improve cancer patients' health. However, EPC differs with regard to its elements and target groups. It is not known which parts of EPC contribute to effectiveness for which patient group. This scoping review provides a structured analysis of EPC interventions and outcome measures.

DESIGN

We searched EMBASE, MEDLINE, CINAHL, and CENTRAL up to February 2022. We included randomized controlled trials (RCT), nonrandomized trials, cohort studies (CS), and controlled before-after studies of EPC in adult patients in English, Dutch, and German language. Interventions had to be self-labeled as EPC. Screening and data extraction were performed by two raters. A structured analysis incorporating the TIDieR checklist was performed to describe the elements of the interventions.

RESULTS

We screened 2651 articles, resulting in 40 articles being included: 34 studies were RCT and six studies were CS with a mean sample size of 208 patients. Patients with pancreatic (n = 10) and lung cancer (n = 9) were most often included. Studies reported different reference points for the onset of EPC such as time after diagnosis of incurable cancer (n = 18) or prognosis (n = 9). Thirteen studies provided information about elements of EPC and eight studies about the control intervention. Most frequent elements of EPC were symptom management (n = 28), case management (n = 16), and advance care planning (ACP; n = 15). Most frequently reported outcome measures were health-related quality of life (n = 26), symptom intensity (n = 6), resource use, and the patient's mood (n = 4 each).

CONCLUSION

The elicited heterogeneity of ECP in combination with deficits of reporting are considerable barriers that should be addressed to further develop effective EPC interventions for different groups of cancer patients.

Acute palliative care units: characteristics, activities and outcomes - scoping review

Acute palliative care units (APCUs) are lacking in most cancer hospitals and even when palliative care units are present, they are predominantly based on a traditional hospice-like model for patients with short life expectancy. This scoping review examined the papers assessing the activities of APCU. Data from literature regarding APCU characteristics, activities and outcomes have shown important differences among different countries.In comparison with existing data on traditional hospices, APCU provided a whole range of palliative care interventions, from an early treatment of pain and symptoms at time diagnosis and during the oncological treatment, up to the advanced stage of disease when they may favour the transition to the best supportive care or palliative care only, also indicating the best palliative care service that may fits the clinical and social condition of individuals. Large differences in the characteristics of such units, including hospital stay and mortality, have been evidenced, in some cases resembling those of a traditional hospice. It likely that in some countries such units supply the lack of other palliative care services.Further studies on APCUs are needed, even on other outcome processes, to provide a more precise identification among the palliative care settings, which should not interchangeable, but complimentary to offer the full range of activities to be activated according to the different needs of the patients.

Impact of an Institution-Wide Goals of Care Program on the Timing of Referrals to Outpatient Palliative Care

CONTEXT

Palliative care has received increased interest since the COVID-19 pandemic due to its role in guiding goals of care (GOC) discussions.

OBJECTIVES

We assessed the change in the timing of outpatient palliative care referrals before and after implementing an institution-wide multicomponent interdisciplinary GOC (myGOC) program.

METHODS

We reviewed 200 random supportive care center (SCC) consult visits each from June to November 2019 (before myGOC) and June to November 2020 (after myGOC). Data regarding Edmonton Symptom Assessment Scale (ESAS) scores, time from hospital registration to SCC visit, SCC visit until death/last follow-up, and advance care planning (ACP) notes were collected. Kaplan-Meier curves were used to evaluate overall survival (OS).

RESULTS

The median OS from the SCC consult visit was 15.2 months (95% CI:11.7-19.7) before and 14.0 months (95% CI:10.8-17.9) after the myGOC program (P = 0.646). There were no significant differences in the median time between the SCC consult visit to death/last follow-up (11.95 vs. 12.0 months after myGOC; P = 0.841) and the first visits to our cancer center and SCC (6.1 vs. 5.29 months after myGOC; P = 0.689). Patients seen after myGOC had significantly lower ESAS symptom scores, better performance status (2 [1-2] vs. 2 [1-3]; P = 0.018], and more ACP notes composed by medical oncology teams (25.5% vs. 4.5%; P < 0.001).

CONCLUSION

There were no significant differences in OS among patients seen in the SCC before and after myGOC, likely related to a ceiling effect. More oncologists had ACP discussions with patients, and patients had lower symptom scores on ESAS after myGOC, likely indicating that more patients were referred for GOC discussions and ACP rather than for symptom distress.

Hospice and Palliative Care-Men and Gender-Specific Roles

All people face end of life as the final health outcome. When a person's health focus shifts from quantity to quality of life, palliative care comes into view. Clinicians serving patients across the health care spectrum must be aware of the nature and efficacy of palliative and hospice care, indications for referral to services, and current best practices. Creating an end-of-life trajectory requires an individualized and global personal plan, which palliative and hospice care can provide. Gender-specific care that includes gender minorities provides special and unique challenges to those seeking palliative and hospice care.

The experience of bereaved cancer carers in rural and regional areas: The impact of the COVID-19 pandemic and the potential of peer support

BACKGROUND

Caring for someone with cancer during end of life care can be a challenging and complex experience. Those living in rural and regional areas are less likely to have local healthcare services and may be physically isolated. Even where support services such as respite do exist, they may be less likely to be accessed due to the time burden in travelling to services. This was compounded by the COVID-19 pandemic.

AIM

To understand the potential benefits of peer support for bereaved carers of people with cancer from rural and regional locations during the COVID-19 period.

METHODS

Phone interviews were conducted with bereaved cancer carers living in rural and regional areas in Victoria. Semi-structured interviews were used, and participants were asked about their experience as a carer, bereavement and the potential for peer support. Interviews were audio recorded and transcribed verbatim; transcripts were coded and a thematic analysis was conducted.

FINDINGS

12 interviews were conducted. Carers were mostly female (85%) and were on average 58 years of age (range 42-71). Interviews lasted an average of 58 minutes (range 53-91 minutes). Three themes were derived from the data; 1) Supportive care needs while caring and the impact of COVID-19; 2) Isolation during bereavement compounded by the COVID-19 pandemic; and 3) Peer support requires flexibility to meet diverse needs.

CONCLUSION

Peer support has potential to assist bereaved carers of people with cancer. A co-design approach may be beneficial for developing a flexible model for supporting and linking carers together.

Psychosocial Interventions at the End-of-Life: A Scoping Review

BACKGROUND

The integration of holistic and effective end-of-life (EOL) care into cancer management has increasingly become a recognized field. People living with terminal cancer and their caregivers face a unique set of emotional, spiritual, and social stressors, which may be managed by psychosocial interventions.

OBJECTIVES

This study aimed to explore the types and characteristics of psychosocial interventions at the EOL for adult cancer patients and their caregivers and to identify gaps in the current literature.

METHODS

A systematic search was conducted through MEDLINE (Ovid) and CINAHL from January 1, 2011, to January 31, 2021, retrieving 2453 results. A final 15 articles fulfilled the inclusion criteria, reviewed by 2 independent reviewers. Ten percent of the original articles were cross-checked against study eligibility at every stage by 2 experienced researchers.

RESULTS

Most interventions reported were psychotherapies, with a predominance of meaning or legacy-related psychotherapies. Most interventions were brief, with significant caregiver involvement. Most studies were conducted in high-income, English-speaking populations.

CONCLUSION

There is robust, although heterogeneous, literature on a range of psychosocial interventions at the EOL. However, inconsistencies in the terminology used surrounding EOL and means of outcome assessment made the comparison of interventions challenging.

IMPLICATION FOR PRACTICE

Future studies will benefit from increased standardization of study design, EOL terminology, and outcome assessment to allow for a better comparison of intervention efficacy. There is a need for increased research in psychosocial interventions among middle- to low-income populations exploring social aspects, intimacy, and the impact of COVID-19.

Meta-Analysis of Effects of Early Palliative Care on Health-Related Outcomes Among Advanced Cancer Patients

BACKGROUND

Early palliative care (PC) has received more attention for improving health-related outcomes for advanced cancer patients in recent years, but the results of previous studies are inconsistent.

OBJECTIVES

This study aimed to use meta-analysis and trial sequence analysis to evaluate the effect of early PC on health-related outcomes of advanced cancer patients.

METHODS

All English publications were searched in PubMed, Web of Science, Embase, and the Cochrane Library from inception to March 2023, with a restriction that the study type was a randomized controlled trial.

RESULTS

The results showed that early PC positively affected quality of life, satisfaction with care, and symptom burden reduction. However, early PC had no significant effect on anxiety or survival. Trial sequence analysis results showed that the effect of early PC on the quality of life was stable.

DISCUSSION

This systematic review suggested that early PC could positively affect health-related outcomes for advanced cancer patients. Early PC can be used widely in clinical settings to improve health-related outcomes of advanced cancer. However, because of the trial sequence analysis results, further well-designed, clinical, randomized controlled trials with larger sample sizes are necessary to draw definitive conclusions.

Specialty Palliative Care and Symptom Severity and Control in Adolescents and Young Adults With Cancer

Importance

Adolescents and young adults (AYAs) with cancer experience substantial symptom burden. Specialty palliative care (SPC) is recommended but often not involved or involved late.

Objectives

To determine whether patient-reported symptom severity was associated with subsequent SPC involvement and whether SPC was associated with symptom improvement in AYAs with cancer.

Design, Setting, and Participants

This cohort study comprised AYAs (aged 15-29 years) with primary cancer diagnosed between January 1, 2010, and June 30, 2018, in Ontario, Canada. Data, including self-reported Edmonton Symptom Assessment System (ESAS) scores, were obtained from health care databases. Specialty palliative care was identified through billing codes and validated algorithms. Final data analysis was performed on April 4, 2023.

Main Outcomes and Measures

Associations of ESAS scores with subsequent SPC involvement were determined. A difference-in-differences approach was used for patients who died within 5 years of their cancer diagnosis. Case patients (SPC predeath, index date equals first SPC service) were matched 1:1 to control patients (no SPC at equivalent time before death). The study examined whether the difference between 90-day postindex and preindex mean ESAS scores was itself different between case and control patients.

Results

This study included 5435 AYAs with cancer, with a median follow-up of 5.1 (IQR, 2.5-7.9) years for analyses of general palliative care. Their median age at cancer diagnosis was 25 (IQR, 22-27) years, and more than half were male (2809 [51.7%]). For all symptoms, moderate and severe ESAS scores were associated with an increased likelihood of SPC involvement compared with mild scores. The greatest magnitude of association was seen for pain scores (hazard ratio for severe vs mild, 7.7 [95% CI, 5.8-10.2]; P < .001). A total of 721 AYAs (13.3%) died within 5 years of diagnosis, and 612 of these patients (84.9%) had received SPC before death. Among 202 case-control pairs, SPC involvement was associated with improved pain trajectories (mean scores improved from 3.41 to 3.07 in case patients and worsened from 1.86 to 2.16 in control patients; P = .003). Other symptom trajectories were not affected.

Conclusions and Relevance

In this cohort study of AYAs with cancer, those reporting moderate or severe symptoms through a screening program were more likely to subsequently receive SPC. These findings suggest that SPC was associated with a subsequent decrease in pain severity but did not affect other symptoms. New interventions targeting other symptoms during treatment and particularly at the end of life are needed.

[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

An evidence-base for the implementation of hospital-based palliative care programs in routine cancer practice: A systematic review

BACKGROUND

Despite global support, there remain gaps in the integration of early palliative care into cancer care. The methods of implementation whereby evidence of benefits of palliative care is translated into practice deserve attention.

AIM

To identify implementation frameworks utilised in integrated palliative care in hospital-based oncology services and to describe the associated enablers and barriers to service integration.

DESIGN

Systematic review with a narrative synthesis including qualitative, mixed methods, pre-post and quasi experimental designs following the guidance by the Centre for Reviews and Dissemination (PROSPERO registration CRD42021252092).

DATA SOURCES

Six databases searched in 2021: EMBASE, EMCARE, APA PsycINFO, CINAHL, Cochrane Library and Ovid MEDLINE searched in 2023. Included were qualitative or quantitative studies, in English language, involving adults >18 years, and implementing hospital-based palliative care into cancer care. Critical appraisal tools were used to assess the quality and rigour.

RESULTS

Seven of the 16 studies explicitly cited the use of frameworks including those based on RE-AIM, Medical Research Council evaluation of complex interventions and WHO constructs of health service evaluation. Enablers included an existing supportive culture, clear introduction to the programme across services, adequate funding, human resources and identification of advocates. Barriers included a lack of communication with the patients, caregivers, physicians and palliative care team about programme goals, stigma around the term 'palliative', a lack of robust training, or awareness of guidelines and undefined staff roles.

CONCLUSIONS

Implementation science frameworks provide a method to underpin programme development and evaluation as palliative care is integrated within the oncology setting.

A Systematic Approach to Assessing and Addressing Palliative Care Needs in an Outpatient Population

CONTEXT/OBJECTIVES

A critical frontier for palliative medicine is to develop systems to routinely and equitably address the palliative care (PC) needs of seriously ill populations.

METHODS

An automated screen identified Medicare primary care patients who had serious illness based on diagnosis codes and utilization patterns. A stepped-wedge design was used to evaluate a six-month intervention through which a healthcare navigator assessed these seriously ill patients and their care partners for PC needs in the domains of 1) physical symptoms, 2) emotional distress, 3) practical concerns, and 4) advance care planning (ACP) via telephone surveys. Identified needs were addressed with tailored PC interventions.

RESULTS

A total of 292/2175 (13.4%) patients screened positive for serious illness. A total of 145 completed an intervention phase; 83 completed a control phase. Severe physical symptoms were identified in 27.6%, emotional distress in 57.2%, practical concerns in 37.2%, and ACP needs in 56.6%. Twenty-five intervention patients (17.2%) were referred to specialty PC compared to six control patients (7.2%). Prevalence of ACP notes increased 45.5%-71.7% (p = 0.001) during the intervention and remained stable during the control phase. Quality of life remained stable during the intervention and declined 7.4/10-6.5/10 (P =0.04) during the control phase.

CONCLUSION

Through an innovative program, patients with serious illness were identified from a primary care population, assessed for PC needs, and offered specific services to meet those needs. While some patients were appropriate for specialty PC, even more needs were addressed without specialty PC. The program resulted in increased ACP and preserved quality of life.

Specialist and Primary Physicians' Experiences and Perspectives of Collaboration While Caring for Palliative Patients-A Qualitative Study

Increasing numbers of people living with chronic and life-limiting diseases are actualising a greater need for palliative care. Physicians are an important provider for identifying the need for palliation, and effective follow-up requires physician collaboration across different service levels. This study aimed to explore and describe how physicians in hospitals and municipalities experience their roles and interactions in the care of palliative patients. Pair interviews were performed with seven physicians working in hospitals, primary care and nursing homes in Mid-Norway. Systematic text condensation was used to analyse the data, resulting in three main themes: The boundaries of palliative care, Alternating understandings of roles and Absence of planning. The physicians' interactions with palliative patients appeared as a fragmented distribution of tasks rather than a real collaboration with shared responsibility. At both levels, the physicians seemed to assume withdrawn roles as a reaction to unclear and unspoken expectations and to avoid interfering with others' responsibilities. Moreover, their understanding of palliative care and which groups should be included varied. Realising a collaboration between physicians that is beneficial for both patients and physicians, greater openness and real arenas for discussion and decision-making support are required.

Acute Oncologic Complications: Clinical-Therapeutic Management in Critical Care and Emergency Departments

Introduction. It is now known that cancer is a major public health problem; on the other hand, it is less known, or rather, often underestimated, that a significant percentage of cancer patients will experience a cancer-related emergency. These conditions, depending on the severity, may require treatment in intensive care or in the emergency departments. In addition, it is not uncommon for a tumor pathology to manifest itself directly, in the first instance, with a related emergency. The emergency unit proves to be a fundamental and central unit in the management of cancer patients. Many cancer cases are diagnosed in the first instance as a result of symptoms that lead the patient's admittance into the emergency room. Materials and Methods. This narrative review aims to analyze the impact of acute oncological cases in the emergency setting and the role of the emergency physician in their management. A search was conducted over the period January 1981-April 2023 using the main scientific platforms, including PubMed, Scopus, Medline, Embase and Google scholar, and 156 papers were analyzed. Results. To probe into the main oncological emergencies and their management in increasingly overcrowded emergency departments, we analyzed the following acute pathologies: neurological emergencies, metabolic and endocrinological emergencies, vascular emergencies, malignant effusions, neutropenic fever and anemia. Discussion/Conclusions. Our analysis found that a redefinition of the emergency department connected with the treatment of oncology patients is necessary, considering not only the treatment of the oncological disease in the strict sense, but also the comorbidities, the oncological emergencies and the palliative care setting. The need to redesign an emergency department that is able to manage acute oncological cases and end of life appears clear, especially when this turns out to be related to severe effects that cannot be managed at home with integrated home care. In conclusion, a redefinition of the paradigm appears mandatory, such as the integration between the various specialists belonging to oncological medicine and the emergency department. Therefore, our work aims to provide what can be a handbook to detect, diagnose and treat oncological emergencies, hoping for patient management in a multidisciplinary perspective, which could also lead to the regular presence of an oncologist in the emergency room.

Suicidal Ideation Among Patients with Gastrointestinal Cancer

BACKGROUND

Mental illness (MI) and suicidal ideation (SI) often are associated with a diagnosis of cancer. We sought to define the incidence of MI and SI among patients with gastrointestinal cancers, as well as ascertain the predictive factors associated with SI.

METHODS

Patients diagnosed between 2004 and 2016 with stomach, liver, pancreatic, and colorectal cancer were identified from the SEER-Medicare database. County-level social vulnerability index (SVI) was extracted from the Centers for Disease Control database. Multivariable logistic regression was used to identify factors associated with SI.

RESULTS

Among 382,266 patients, 83,514 (21.9%) individuals had a diagnosis of MI. Only 1410 (0.4%) individuals experienced SI, and 359 (0.1%) committed suicide. Interestingly, SI was least likely among patients with pancreatic cancer (ref: hepatic cancer; odds ratio [OR] 0.67, 95% confidence interval [CI] 0.52-0.86; p = 0.002), as well as individuals with stage III/IV disease (OR 0.59, 95% CI 0.52-067; p < 0.001). In contrast, male (OR 1.34, 95% CI 1.19-1.50), White (OR 1.34, CI 1.13-1.59), and single (OR 2.03, 95% CI 1.81-2.28) patients were at higher odds of SI risk (all p < 0.001). Furthermore, individuals living in relative privilege (low SVI) had markedly higher risk of SI (OR 1.33, 95% CI 1.14-1.54; p < 0.001). Moreover, living in a county with a shortage of mental health professionals was associated with increased odds of developing SI (OR 1.21, 95% CI 1.04-1.40; p = 0.012).

CONCLUSIONS

Oncology care teams should incorporate routine mental health and SI screening in the treatment of patients with gastrointestinal cancers, as well as target suicide prevention towards patients at highest risk.

Phases and Transitions of Serious Illness: A Structure for Teaching Palliative Care

BACKGROUND

Palliative care (PC) focuses on listening to patient preferences, goals, and values to help health care providers educate, support, and collaborate during challenging disease processes, demanding treatments, and difficult decision-making.

METHOD

A recently developed Phases and Transitions Model for Serious Illness helps guide nursing students in initiating therapeutic conversations about PC. Each phase and transition shows unique characteristics of illness and treatment to clarify the importance of introducing PC for that phase. Interventions in education, support, and treatment help students guide patients and families through the trajectory of serious illness.

RESULTS

The Phases and Transitions Model for Serious Illness and PC interventions provide a clear and practical structure to educate and empower nursing students to engage in PC conversations.

CONCLUSION

Nursing educators can integrate this new model to broaden the perspective of PC as an everyday nursing practice for patients who have a serious illness. [J Nurs Educ. 2023;62(5):279-284.].

Assessing the implementation and effectiveness of early integrated palliative care in long-term care facilities in France: an interventional mixed-methods study protocol

BACKGROUND

Majority of residents in long-term care facilities (LTCF) have limited and delayed access to palliative care even though many suffer from incurable chronic illnesses that will likely require the provision of palliative care. We present the study protocol of "PADI-Palli", an intervention aims to advance early integrated palliative care into standard care delivered in LTCF. This study will assess the effectiveness of early integrated palliative care on palliative care accessibility for older persons in LTCF, and identify the key factors for the successful implementation of early integrated palliative care and its sustainability in the LTCF context.

METHODS

This multicentre interventional study utilises a pragmatic research design with a convergent parallel mixed-methods approach. The qualitative study will use a case study design and the quantitative study will use a stepped wedge cluster randomised trial. In total, 21 participating LTCF from three French regions will be randomly allocated to one of seven clusters. The clusters will cross over from the usual care to the active intervention condition over the course of the study. The primary outcome relates to the accurate identification of palliative care needs and early access to palliative care for LTCF residents. Secondary outcomes are quality of care, quality of life for residents and their families, and quality of life at work for professionals. Measurements will be performed before and after the intervention. Implementation and evaluation of PADI-Palli intervention is grounded in the Consolidated Framework for Implementation Research.

DISCUSSION

Existing evidence demonstrates that early integrated palliative care in cancer care leads to a significant improvement in patient outcomes and processes of care. Little is known, however, about early integrated palliative care in the context of LTCF for older persons. This study has the potential to fill this gap in the literature by providing evidence on the effectiveness of early integrated palliative care for older persons in LTCF. Moreover, this study will provide a better understanding of the relevant contextual elements that facilitate or hinder early integrated palliative care implementation and transferability. If proven effective, this intervention can be scaled to other care settings in which older persons require palliative care.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04708002; National registration: ID-RCB number: 2020-A01832-37.

The impact of early palliative care on the quality of life of patients with advanced pancreatic cancer: The IMPERATIVE case-crossover study

PURPOSE

Pancreatic cancer is a lethal disease. Many patients experience a heavy burden of cancer-associated symptoms and poor quality of life (QOL). Early palliative care alongside standard oncologic care results in improved QOL and survival in some cancer types. The benefit in advanced pancreatic cancer (APC) is not fully quantified.

METHODS

In this prospective case-crossover study, patients ≥ 18 years old with APC were recruited from ambulatory clinics at a tertiary cancer center. Patients underwent a palliative care consultation within 2 weeks of registration, with follow up visits every 2 weeks for the first month, then every 4 weeks until week 16, then as needed. The primary outcome was change in QOL between baseline (BL) and week 16, measured by Functional Assessment of Cancer Therapy - hepatobiliary (FACT-Hep). Secondary outcomes included symptom control (ESAS-r), depression, and anxiety (HADS, PHQ-9) at week 16.

RESULTS

Of 40 patients, 25 (63%) were male, 28 (70%) had metastatic disease, 31 (78%) had ECOG performance status 0-1, 31 (78%) received chemotherapy. Median age was 70. Mean FACT-hep score at BL was 118.8, compared to 125.7 at week 16 (mean change 6.89, [95%CI (-1.69-15.6); p = 0.11]). On multivariable analysis, metastatic disease (mean change 15.3 [95%CI (5.3-25.2); p = 0.004]) and age < 70 (mean change 12.9 [95%CI (0.5-25.4); p = 0.04]) were associated with improved QOL. Patients with metastatic disease had significant improvement in symptom burden (mean change -7.4 [95%CI (-13.4 to -1.4); p = 0.02]). There was no difference in depression or anxiety from BL to week 16.

CONCLUSION

Palliative care should be integrated early in the journey for patients with APC, as it can improve QOL and symptom burden.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03837132.

Access to advanced cancer care services in the West Bank-occupied Palestinian territory

Introduction

Universal Health Coverage (UHC) identifies the provision of palliative care for people with advanced disease as an essential health service. Palliative care is also stipulated as a human right under existing covenants. Oncology services provided by the Palestinian Authority under Israeli military occupation are limited to surgery and chemotherapy treatment. Our study aimed to describe the experiences of patients with advanced-stage cancer in the West Bank in accessing oncology services and meeting their health care needs.

Methodology

We conducted a qualitative study among adult patients diagnosed with advanced lung, colon, or breast cancer in three Palestinian governmental hospitals, and with oncologists. Thematic analysis was conducted on the verbatim interview transcripts.

Results

The sample consisted of 22 Palestinian patients (10 men and 12 women) and 3 practicing oncologists. The findings reveal that cancer care is fragmented, with limited access to the services needed. Patients face referral delays in accessing treatment which worsen their health condition in some cases. Some patients reported difficulties in getting Israeli permits to access radiotherapy treatment in East-Jerusalem, and others experienced interruptions of their chemotherapy treatment sessions due to the unavailability of chemotherapy medications caused by Israeli-side delays. Other reported problems were related to the Palestinian health system and service delivery and quality, including fragmentation of services, infrastructure issues, and unavailability of medications. Advanced diagnostic services and palliative care are almost absent at Palestinian governmental hospitals, and patients need to seek these services in the private sector.

Conclusion

The data demonstrate specific access restrictions to cancer care in the West Bank due to Israeli military occupation of Palestinian land. This affects all stages of the care pathway, from restricted diagnosis services, to limited treatment and then poor availability of palliative care. Cancer patients will continue to suffer if the root causes of these structural constraints are not addressed.

A complex communication skills training program for physicians providing advanced cancer care - content development and barriers and solutions for implementation

Background: Early integration of oncology and patient-centered palliative care is the recommended clinical practice model for patients with advanced cancer. General and specific communication skills are necessary to achieve integrated patient-centered care, but require organized training to be adequately mastered. Challenges and barriers on several levels, i.e. organizational, professional and individual may, however, hamper implementation. The development, implementation, and evaluation of such an educational program focusing on communication skills contain many steps, considerations and lessons learned, which are described in this article.Methods: A multi-professional faculty developed, implemented, and evaluated an educational program through a 5-step approach. The program was part of a Norwegian cluster-randomized controlled trial aiming to test the effect of early integration of oncology and palliative care for patients with advanced cancer.Results: The result is the PALLiON educational program; a multi-faceted, evidence-based, and learner-centered program with a specific focus on physicians' communication skills. Four modules were developed: lectures, discussion groups, skills training, and coaching. These were implemented at the six intervention hospitals using different teaching strategies. Evaluation in a subgroup of participants showed a positive appraisal of the group discussions and skills training.Conclusion:We present our experiences and reflections regarding implementation and lessons learned, which should be considered in future developments and implementations; (1) Include experienced faculty with various backgrounds, (2) Be both evidence-based and learner-centered, (3) Choose teaching strategies wisely, (4) Expect resistance and skepticism, (5) Team up with management and gatekeepers, (6) Expect time to fly, and (7) Plan thorough assessment of the evaluation and effect.Trial registration: ClinicalTrials.gov identifier: NCT03088202.

Outcomes of an Acute Palliative Care Unit at a Comprehensive Cancer Center in Korea

Background

The acute palliative care unit (APCU) bridges between active cancer treatment and hospice care. However, no study has proven the efficacy of APCU in Korea.

Objective

To evaluate the first-year outcomes of the patients admitted to an APCU at a tertiary hospital in Korea.

Design

The APCU admitted 205 patients between April 14, 2014, and April 30, 2015. Of these patients, 57 were evaluable for baseline and one-week follow-up Edmonton Symptom Assessment System (ESAS).

Results

Of the 57 participants, 56.1% were male, with a median age of 60 years (range, 52.8-69.5 years). All patients had advanced cancer, and 42 out of 57 had terminal illnesses. The median APCU stay was 14 days (range, 10-17 days). The 42 (73.7%) patients were referred to the APCU after anticancer treatment was completed. Ten (17.5%) patients died during their stay, and 20 (35.1%) were discharged home. Among those who completed the ESAS, there were significant improvements in scores in the following symptoms: fatigue, depression, loss of appetite, and shortness of breath. Physical symptoms (pain, fatigue, nausea, drowsiness, appetite, and shortness of breath) and the total ESAS scores were significantly improved (p = 0.002 and p = 0.005, respectively). Each non-medical palliative care program, such as art and music therapy, yoga, foot massage, haircut, and body care, showed no significant differences between the group who received them and those who did not.

Conclusion

During the APCU stay, the overall symptoms of inpatients were reduced. A comprehensive and multidisciplinary team approach is essential for patients who need palliative care.

Barriers to palliative care in hepatocellular carcinoma: A review of the literature

Hepatocellular carcinoma (HCC) is a deadly and burdensome form of liver cancer with an increasing global prevalence. Its course is unpredictable as it frequently occurs in the context of underlying end-stage liver disease, and the associated symptoms and adverse effects of treatment cause severe suffering for patients. Palliative care (PC) is a medical specialty that addresses the physical, emotional, and spiritual needs of patients and their carers in the context of life-limiting illness. In other cancers, a growing body of evidence has demonstrated that the early introduction of PC at diagnosis improves patient and carer outcomes. Despite this, the integration of palliative care at the diagnosis of HCC remains suboptimal, as patients usually receive PC only at the very terminal phase of their disease, even when diagnosed early. Significant barriers to the uptake of palliative care in the treatment algorithm of hepatocellular carcinoma fall under four main themes: data limitations, disease, clinician, and patient factors. Barriers relating to data limitations mainly encapsulated the risk of bias inherent in published work in the field of PC. Clinician-reported barriers related to negative attitudes towards PC and a lack of time for PC discussions. Barriers related to the disease align with prognostic uncertainty due to the unpredictable course of HCC. Significantly, there exists a paucity of evidence exploring patient-perceived barriers to timely PC implementation in HCC. Given that patients are often the underrepresented stakeholder in the delivery of PC, future research should explore the patient perspective in adequately designed qualitative studies as the first step.

Benefits of integrating palliative care: a qualitative exploration of the perspectives of palliative care providers in a tertiary health facility in Ghana

Background

Integration of palliative care (PC) services entails combining administrative, organisational, clinical and service elements to ensure continuity of care between all parties participating in the care network of patients. There is a need to understand the benefits of integrating PC to inform policy making and advance advocacy, especially in resource-constrained settings such as Ghana where PC is sub-optimally implemented. Yet, existing research in Ghana is sparse on what benefits are likely to be experienced as a result of integrating PC.

Objective

The study explored service providers' perspectives on the benefits of integrating PC in Ghana.

Design

The design was an exploratory descriptive qualitative research design.

Methods

A total of seven in-depth interviews were conducted using semi-structured interview guides. The data were managed using NVivo-12. Inductive thematic analysis was carried out following Haase's modification of Colaizzi's approach to qualitative research analysis. The study follows the COREQ guidelines and the ICMJE recommendations.

Result

Two main themes emerged: patient-related outcomes, and system/institution-related outcomes. For the patient-related outcomes, the following sub-themes emerged: restored hope, appreciated care and better preparation for the end of life (EoL). The emerging sub-themes under the system/institution-related outcomes include the following: early initiation of care, enhanced communication between primary healthcare providers and the PC team and strengthening staff capacity to provide PC services.

Conclusion

In conclusion, there are substantial benefits to be experienced from integrating PC. For the patients, it would restore shattered hopes, result in appreciated care and better preparation for the EoL. For the healthcare system, it would promote early initiation of care, enhance communication between primary healthcare providers and the PC team and strengthen service providers' capacity to provide PC services. This study, thus, furthers the case for a more integrated PC service in Ghana.

Exploring the Potential Use of Wearable Devices as a Prognostic Tool among Patients in Hospice Care

Background: Smartphones and wearable devices have become a part and parcel of the healthcare industry. The use of wearable technology has already proved its potentials in improving healthcare research, clinical work, and patient care. The real time data allows the care providers to monitor the patients' symptoms remotely, prioritize the patients' visits, assist in decision-making, and carry out advanced care planning. Objectives: The primary objective of our study was to investigate the potential use of wearable devices as a prognosis tool among patients in hospice care and palliative care, and the secondary objective was to examine the association between wearable devices and clinical data in the context of patient outcomes, such as discharge and deceased at various time intervals. Methods: We employed a prospective observational research approach to continuously monitor the hand movements of the selected 68 patients between December 2019 and June 2022 via an actigraphy device at hospice or palliative care ward of Taipei Medical University Hospital (TMUH) in Taiwan. Results: The results revealed that the patients with higher scores in the Karnofsky Performance Status (KPS), and Palliative Performance Scale (PPS) tended to live at discharge, while Palliative Prognostic Score (PaP) and Palliative prognostic Index (PPI) also shared the similar trend. In addition, the results also confirmed that all these evaluating tools only suggested rough rather than accurate and definite prediction. The outcomes (May be Discharge (MBD) or expired) were positively correlated with accumulated angle and spin values, i.e., the patients who survived had higher angle and spin values as compared to those who died/expired. Conclusion: The outcomes had higher correlation with angle value compared to spin and ACT. The correlation value increased within the first 48 h and then began to decline. We recommend rigorous prospective observational studies/randomized control trials with many participants for the investigations in the future.

Pediatric palliative care for children with cancer: a concept analysis using Rodgers' evolutionary approach

BACKGROUND

Providing access to pediatric palliative care (PPC) for children living with a serious illness, such as cancer, is of critical importance, although this specialized intervention, as a novel concept, still seems vague and complicated. The present study analyzed the concept of PPC for children with cancer.

METHODS

Rodgers' evolutionary method was employed for the concept analysis. Articles on PPC, particularly those for children suffering from cancer, published between 2010 and 2021 were searched in valid academic research databases. The inclusion criteria for the full-text articles were based on the characteristics, antecedents, and consequences of PPC for children with cancer.

RESULTS

In total, 19 relevant articles were selected and then reviewed and analyzed after applying the inclusion criteria and the final sampling. The analysis of the concept of PPC for children affected with cancer revealed four characteristics, including "PPC as holistic and integrated care", "PPC as patient- and family-centered care", "PPC as early-start continuous care", and "PPC as interdisciplinary and team-based care". Some effective factors could also act as antecedents for this concept, i.e., health care providers' training and expertise as well as human resources and financing. Moreover, improved quality of life, symptom reduction, and coordination between patient care and family support were among the PPC consequences for such children.

CONCLUSIONS

The study results demonstrated that delivering PPC to children with cancer demanded a comprehensive view of its various dimensions. Furthermore, numerous factors need to be delineated for its accurate and complete implementation.

Advanced Adrenocortical Carcinoma: From Symptoms Control to Palliative Care

The prognosis of patients with advanced adrenocortical carcinoma (ACC) is often poor: in the case of metastatic disease, five-year survival is reduced. Advanced disease is not a non-curable disease and, in referral centers, the multidisciplinary approach is the standard of care: if a shared decision regarding several treatments is available, including the correct timing for the performance of each one, overall survival is increased. However, many patients with advanced ACC experience severe psychological and physical symptoms secondary to the disease and the cancer treatments. These symptoms, combined with existential issues, debase the quality of the remaining life. Recent strong evidence from cancer research supports the early integration of palliative care principles and skills into the advanced cancer patient's trajectory, even when asymptomatic. A patient with ACC risks quickly suffering from symptoms/effects alongside the disease; therefore, early palliative care, in some cases concurrent with oncological treatment (simultaneous care), is suggested. The aims of this paper are to review current, advanced ACC approaches, highlight appropriate forms of ACC symptom management and suggest when and how palliative care can be incorporated into the ACC standard of care.

Development of the palliative care referral system: proposal of a tool for the referral of cancer patients to specialized palliative care

BACKGROUND

Early palliative care (PC) has shown beneficial effects for advanced cancer patients. However, it is still debated what criteria to use to identify patients for PC referral.

AIM

To document the initial steps of the development of the Palliative Care Referral System (PCRS), a tool to be used by oncologists in clinical practice.

METHODS

A multiprofessional working group developed the PCRS based on the results of a scoping literature review on PC referral criteria. PCRS criteria were evaluated by experts via a nominal group technique (NGT). Descriptive statistics were used to summarize expert scores on relevance, appropriateness and perceived feasibility of the criteria proposed. Quotations of participants during the discussion were also reported.

RESULTS

Sixteen studies, including PC referral criteria/tools, emerged from the scoping review. Severe symptoms, poor performance status, comorbidities and prognosis were the most commonly used criteria. The PCRS included nine major criteria and nine assessment methods; a scoring procedure was also proposed. Answers to the questionnaire during the NGT showed that five criteria reached full agreement on all items, while four did not, and were then discussed within the group. Participants agreed on the relevance of all criteria and on the appropriateness of methods proposed to assess most of them, while issues were raised about potential feasibility of the overall assessment of the PCRS in clinical practice.

CONCLUSION

The PCRS has been developed as an help for oncologists to timely identify patients for specialized PC referral. Since feasibility emerged as the main concern, implementation strategies have to be tested in subsequent studies.

Simultaneous care in oncology: Assessment of benefit in relation to symptoms, sex, and age in 753 patients

BACKGROUND

Early activation of palliative care for patients with advanced cancer is central in the treatment trajectory. At the Veneto Institute of Oncology, a simultaneous-care outpatient clinic (SCOC) has been active since 2014, where patients are evaluated by an oncologist together with a palliative care team. Recently, we reported on consecutive patients admitted at SCOC from 2018 to 2021 in terms of appropriateness, process, and outcome indicators. Here, we report further analysis in the same group of 753 patients, evaluating other parameters and the correlation between symptom intensity, gender, age, and survival.

METHODS

SCOC data were retrieved from a prospectively maintained database.

RESULTS

Among the patients, 42.2% were women, and the median age was 68 years, with 46.7% of patients aged ≥70 years. The most prevalent disease type was gastrointestinal cancer (75.2%), and 90.9% of the patients had metastatic disease. The median score for the distress thermometer was 4; the vast majority of the patients (98.6%) reported physical problems, and 69.4% presented emotional issues. Younger women demonstrated a significantly greater median distress than other patients (p=0.0018). Almost all symptoms had a higher prevalence on the 0-3 Edmonton Symptom Assessment Scale (ESAS) score, except for fatigue. About 43.8% of the patients received systemic anticancer treatment (SAT) in the last 60 days of life, 15.0% of whom received SAT in the last month and 3.1% in the last 2 weeks. For some symptoms, women frequently had more ESAS >3. Pain and nausea were significantly less reported by older patients compared with younger adults. Men had a lower risk of having MUST score ≥ 2 (p=0.0311). Men and older patients showed a lower prognosis awareness (p=0.0011 and p=0.0049, respectively). Older patients received less SAT within the last 30 days of life (p=0.0006) and had death risk decreased by 20.0%.

CONCLUSION

Our study identified two subgroups of patients with advanced cancer who require special attention and support due to important symptoms' burden detected by Patient Reported Outcome Measures tests: women and younger adults. These categories of patients require special attention and should be provided early access at SCOC. The role of an oncologist remains crucial to intercept all patients in need of early palliative care and balancing trade-offs of anticancer treatment in advanced metastatic disease.

Intérêts de l’intégration précoce de soins palliatifs aux soins oncologiques : une revue rapide des écrits

Devant le nombre grandissant de personnes diagnostiquées d’un cancer et de décès qui y sont associés, les soins palliatifs gagnent en importance pour améliorer la qualité de vie et soutenir la personne et sa famille durant leurs expériences de santé. Dans ce contexte, l’intégration précoce des soins palliatifs aux soins oncologiques standards semble être une approche sous-utilisée et novatrice qui pourrait répondre aux besoins spécifiques de la clientèle oncologique palliative. Les infirmières en oncologie doivent assumer un rôle crucial en dispensant des soins tout au long de la trajectoire de la maladie, soins palliatifs compris. Le but de cette revue rapide est de synthétiser et présenter les avantages des interventions de soins palliatifs précoces et de décrire leurs caractéristiques. La recherche documentaire sur CINAHL et PubMed a fait ressortir cinq essais randomisés réalisés entre 2010 et 2018, qui ont été analysés. La majorité des études sélectionnées ont conclu que l’intégration précoce des soins palliatifs aux soins oncologiques standards, tels que la chimiothérapie et la radiothérapie, permettrait d’améliorer la qualité de vie, les symptômes anxiodépressifs et la survie globale.

The early integration of palliative care into oncology care: A rapid review

With the number of cancer diagnoses and cancer-related deaths on the rise, palliative care is becoming a more important consideration for helping to improve the quality of life of patients and families and the support they receive during their healthcare journey. Accordingly, the early integration of palliative care into standard oncology care would appear to be an underutilized and novel approach that could be used to address the specific needs of palliative oncology patients. Oncology nurses play a central role in this process, delivering care throughout the health continuum, including palliative care. The purpose of this rapid review is to outline the benefits of early palliative care interventions and describe their characteristics. A literature search on CINAHL and PubMed returned five randomized trials conducted between 2010 and 2018. An analysis of these papers showed that the majority of the selected studies concluded that the early integration of palliative care into standard oncology care, which includes such treatments as chemotherapy and radiation therapy, can lead to improvements in quality of life, symptoms of anxiety and depression, and overall survival rate.

Benefits of Structured Advance Care Plan in end-of-Life Care Planning among Older Oncology Patients: A Retrospective Pilot Study

Objectives: Studies suggest that advance care planning (ACP) results in improved quality of life and reduced healthcare consumption. We assessed how the use of a structured advance care planning tool (ACPT) in oncology patients relates to their healthcare consumption before death, and to the match between preferred and actual place of death. Methods: We performed a pilot study at a teaching hospital in the Netherlands. Endpoints were 1) healthcare consumption at three and one month(s) before death, and 2) the match between preferred and actual place of death. Results: The study included 75 patients without an ACPT (group 1) and 59 patients with an ACPT (group 2) of whom the preferred place of care or death were documented at least three months before death in 15 patients (subgroup 2b). Compared to group 1, patients in group 2 had significantly more healthcare consumption. However, compared to group 1, patients in subgroup 2b underwent significantly less diagnostic (33.3% (n  =  5) versus 69.3% (n  =  52), p < 0.05) and laboratory tests (33.3% (n  =  5) versus 62.7% (n  =  47), p < 0.05) one month before death. Patients in subgroup 2b died at their preferred place more often (76.9%, n  =  10) compared to patients in group 1 (58.3%, n  =  7) (NS), which meant more deaths at home and less in-hospital-deaths. Conclusions: The results suggest that timely documentation of the preferred place of care or death in a structured ACPT may result in less healthcare consumption and a better match between the preferred and actual place of death.

An Evolutionary Concept Analysis of Palliative Care in Oncology Care

This evolutionary concept analysis reports on the concept of palliative care in oncology. Despite its relevance to oncology, the concept of palliative care remains misunderstood, resulting in erroneous interpretations by nurses and health care providers alike. Consequently, integration of palliative care remains heterogeneous and highly contextual. Findings highlight the complexity and ambiguity of the concept of palliative care in the context of oncology care. The nuances and complexity of when to integrate palliative care for patients living with cancer, as well as its evolution from its origins in the hospice movement, have led to its ambiguity in clinical practice.

Contribution of Synthetic Data Generation towards an Improved Patient Stratification in Palliative Care

AI model development for synthetic data generation to improve Machine Learning (ML) methodologies is an integral part of research in Computer Science and is currently being transferred to related medical fields, such as Systems Medicine and Medical Informatics. In general, the idea of personalized decision-making support based on patient data has driven the motivation of researchers in the medical domain for more than a decade, but the overall sparsity and scarcity of data are still major limitations. This is in contrast to currently applied technology that allows us to generate and analyze patient data in diverse forms, such as tabular data on health records, medical images, genomics data, or even audio and video. One solution arising to overcome these data limitations in relation to medical records is the synthetic generation of tabular data based on real world data. Consequently, ML-assisted decision-support can be interpreted more conveniently, using more relevant patient data at hand. At a methodological level, several state-of-the-art ML algorithms generate and derive decisions from such data. However, there remain key issues that hinder a broad practical implementation in real-life clinical settings. In this review, we will give for the first time insights towards current perspectives and potential impacts of using synthetic data generation in palliative care screening because it is a challenging prime example of highly individualized, sparsely available patient information. Taken together, the reader will obtain initial starting points and suitable solutions relevant for generating and using synthetic data for ML-based screenings in palliative care and beyond.

Inpatient Hospices in Germany: Medical Care Situation and Use of Supportive Oncological Therapies for Symptom Control in Tumor Patients

Background:

More than 80% of the residents in German hospices suffer from tumor disease. But the administration of supportive-oncological therapies in hospices for symptom control is controversially discussed.

Objectives:

This study aims to investigate the care situation of tumor patients in German hospices with regard to medical care and the use of supportive-oncological therapies.

Methods:

In February 2019, all hospices in Germany were offered the opportunity to participate in an anonymous online survey on medical and drug care for their tumor patients. The survey was conducted using the online platform SoSci Survey and ended in April 2019. The analysis was descriptive.

Results:

Of 202 hospices, 112 responded to the questionnaire. The hospices were distributed nationwide. Most have 8 to 10 places. More than 80% of hospice residents are tumor patients, and the length of stay is usually three to four weeks. Medical care is primarily provided by primary care physicians. While specialized outpatient palliative care is increasingly involved in care, hematologists/oncologists are rarely represented. Supportive-oncological therapies are rarely prescribed, whereas medication for other chronic conditions is often continued. The percentage of supportive-oncological therapies prescribed is higher in hospices with oncology co-care.

Conclusions:

Although most hospice residents suffer from malignant disease, co-care by a hematologist/oncologist is rare. Supportive-oncology therapies, particularly for symptom relief, may therefore be rarely used. However, since a small select group of hospice residents may benefit from these therapies, further investigation in this direction should be undertaken.

Palliative oncology and palliative care

New therapeutic approaches can produce promising results even in severely ill cancer patients. But they also pose new challenges with respect to prognostication, as patients who were once not eligible for treatment, due to age or comorbidities, now are. Palliative oncology constitutes a major part of oncological care, with life prolongation and quality of life as its main goals. Palliative care specialists are experts in symptom control and psychosocial and existential support, and the integration of their expertise early on in patient care can prolong survival. In this article, I discuss the need to integrate specialist palliative care into early cancer treatment plans to achieve quality of life for patients. I also discuss the ways in which palliative care specialists balance the benefits of novel treatments against their adverse effects for patients, particularly for the elderly, the frail and those in advance stages of disease. I highlight the need to ensure equal access to palliative care to improve cancer patients' quality of life but also why futile, burdensome treatments should be avoided especially in the frail, elderly patients. Further, I discuss benefits and problems related to nutritional support in patients with cachexia and exemplify why translational research is needed to link basic research with clinical oncology and effective symptom control.

Assessment of symptoms among among patients living with cancer: prevalence, distress and its correlation with quality of life

Background: Several symptoms known to be experienced by cancer patients receiving palliative care remain under-reported, inadequately managed and unexplored in Jordan. Aim: To describe the prevalence of symptoms, the distress caused and the correlation with quality-of-life among cancer patients receiving palliative care in Jordan. Methods: A cross-sectional correlational survey design was used. The Rotterdam Symptom Checklist and the Quality-of-Life Index-Cancer version were used for data collection. Data were analysed using descriptive statistics, unpaired t-test and Pearson correlation coefficients. Results: The sample comprises of 124 patients with a mean age of 55.7 years (SD=12.9). A total of 57.3% of them were females. Patients reported having an average of 17.3 (SD=7.1) symptoms. The most reported symptoms were tiredness (90.3%), lack of energy (81.5%), sore muscles (81.5%) and worry (76.6%). The mean total score for quality of life was 17.9 (SD=5.9) out of 30. A negative (P<0.05) relationship was found between the number of concurrent symptoms and the total quality of life score. Conclusions: Palliative care patients in Jordan reported a high number of co-occurring symptoms and experienced high levels of symptom distress, which negatively impacted their quality of life. Further research to evaluate the impact of total symptom management, its efficacy and feasibility is needed.