Incorporating palliative care principles to improve patient care and quality of life in urologic oncology

Use of inpatient palliative care in metastatic urethral cancer

BACKGROUND

In metastatic urethral cancer, temporal trends, and patterns of inpatient palliative care (IPC) use are unknown.

METHODS

Relying on the National Inpatient Sample (2006-2019), metastatic urethral cancer patients were stratified according to IPC use. Estimated annual percentage changes (EAPC) analyses and multivariable logistic regression models (LRM) for the prediction of IPC use were fitted.

RESULTS

Of 1,106 metastatic urethral cancer patients, 199 (18%) received IPC. IPC use increased from 5.8 to 28.0% over time in the overall cohort (EAPC +9.8%; P < 0.001), from <12.5 to 35.1% (EAPC +11.2%; P < 0.001), and from <12.5 to 24.7% (EAPC +9.4%; P = 0.01) in respectively females and males. Lowest IPC rates were recorded in the Midwest (13.5%) vs. highest in the South (22.5%). IPC patients were more frequently female (44 vs. 37%), and more frequently exhibited bone metastases (45 vs. 34%). In multivariable LRM, female sex (multivariable odds ratio [OR] 1.46, 95% confidence interval [CI] 1.05-2.02; P = 0.02), and bone metastases (OR 1.46, 95%CI 1.02-2.10; P = 0.04) independently predicted higher IPC rates. Conversely, hospitalization in the Midwest (OR 0.53, 95%CI 0.31-0.91; P = 0.02), and in the Northeast (OR 0.48, 95%CI 0.28-0.82; P = 0.01) were both associated with lower IPC use than hospitalization in the West.

CONCLUSION

IPC use in metastatic urethral cancer increased from a marginal rate of 5.8% to as high as 28%. Ideally, differences according to sex, metastatic site, and region should be addressed to improve IPC use rates.

Palliative Care for Pediatric Urology

Palliative care in the field of urology has largely been limited to adult oncologic conditions. Although there is a plethora of established literature suggesting the advantageous impact of palliative care, there is limited integration of palliative care in adult urology. This underutilization is further exacerbated in pediatric urology, and palliative care in pediatric urology remains an underexplored area despite the prevalence of several life-limiting conditions in this patient population. This paper highlights the potential need for palliative care intervention in a variety of urologic conditions in the pediatric population, including congenital lower urinary tract obstruction, neurogenic bladder dysfunction, exstrophy-epispadias complex, and congenital bilateral renal agenesis. Each condition poses unique challenges that can be addressed with the inclusion of a palliative care team, including decision-making spanning prenatal-neonatal-pediatric periods, acute and chronic symptom management, family relations, body image issues, risk of recurrent hospitalizations and surgeries, and potentially fatal complications. Alongside standard urologic interventions, palliative care can serve as an additional means of addressing physical and psychosocial symptoms experienced by pediatric urology patients to enhance the quality of life of patients and their families.

The palliative care experience in Irish nursing homes during the COVID-19 pandemic: a survey of residents, family, and staff

BACKGROUND

Nursing homes and other long-term care services account for a disparate share of COVID-19 cases and casualties worldwide. During COVID-19 there is a distinct need to preserve a holistic view of the wellbeing of residents of nursing homes, be mindful of their rights as citizens, and to be aware of protecting residents from infection. The delivery of health and social care throughout a pandemic must remain person-centred and adhere to a human rights-based approach.

METHODS

This study aimed to capture nursing home residents, their families and staff's perspective of the nursing homes residents experience, approaches of staff and the nursing home environment. An online survey was distributed via stakeholder networks and online platforms across Ireland. This study was performed and reported in line with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS).

RESULTS

25 residents, 42 family members and 51 staff completed the survey (n = 118). Across the domains measured all but one aspect scored above 50% (residents get up and go to bed when they want 41.5%) with the highest score of 89.1% scored for the nursing home is comfortable and well-kept. Results highlight evidence of positive experiences and endeavours to preserve social connections, residents were in a safe place cared for by staff who did their best in a difficult position and who went above and beyond their duty of care. However, some families reported poor communication, no internet connections, not enough phones or tablets, and that staff were busy and unable at times to assist residents who needed help using phones/tablets.

CONCLUSION

This study highlights the importance of human rights and how they ought to inform and shape the advancement of public health advice and policy documents. Overall, nursing home residents, their families and staff reported favourably on the study measures. However, issues pertaining to communication are essential and there is a need to address issues such as the provision of accurate timely information, communication infrastructure and resources, and inconsistencies in communications. Of note is that while healthcare professionals have a duty to uphold the rights of nursing home residents, they themselves have human rights which must also be protected and supported.

Integrating Palliative Care Into the Management of Genitourinary Malignancies

Palliative care (PC) plays a critical role in managing the difficulties associated with genitourinary malignancies. Its primary aim is to improve the overall health of patients, provide support to both patients and their caregivers, and help individuals to navigate the complex decisions about treatment and end-of-life care. PC takes a holistic approach to patient care, recognizing that genitourinary malignancies affect multiple aspects of a person's life. By addressing physical, emotional, social, and spiritual needs, PC aims to provide comprehensive support that is consistent with the patient's values and preferences. The goal is to optimize comfort, minimize distress, and enhance the patient's quality of life throughout the course of the illness. PC is not a one-off intervention, but an ongoing source of support. This article aims to provide a thorough overview of the critical elements involved in addressing the challenges posed by genitourinary cancers, emphasizing the importance of palliative interventions. We will highlight the multifaceted aspects of care and explore strategies to optimize the overall well-being of patients throughout the course of treatment for genitourinary malignancies.

The Use of Hospital Services by Patients With Muscle Invasive Bladder Cancer in the Last Year of Life: Identifying the Areas to Improve Care

INTRODUCTION

Muscle-invasive bladder cancer (MIBC) is associated with significant morbidity. However, patients' specific health needs have not been well defined. This study analyses the utilisation of hospital resources by MIBC patients in the 12 months before death, informing healthcare modelling and enabling service redesign to improve their quality of life.

MATERIALS AND METHODS

All patients who died after being diagnosed with MIBC at a single hospital in the United Kingdom within four years were included. Patients' electronic health records were reviewed to collect data on all interactions with hospital services in their last year of life.

RESULTS

A total of 41 patients were included, with survival times ranging from one to 88 months (with a median of nine months). In the last year of life, a patient from this cohort had an average of 5.2 outpatient appointments and 2.3 emergency admissions leading to 17.1 days of inpatient stay and 1.3 operations/procedures. The most common reasons for emergency admission were for the management of haematuria (23%), urinary tract infection (23%), or chest infection (12%).

CONCLUSION

Patients with MIBC demonstrate significant utilisation of healthcare resources in their last year of life. An awareness of this should inform honest discussions with patients, earlier provision of palliative care, and proactive management of haematuria and urinary tract infections to improve care in this important stage of life.

Palliative Care Consultation Utilization Among Patient Undergoing Surgery for Metastatic Spinal Tumors

OBJECTIVE

In patients undergoing surgery for spinal metastasis, we sought to: (1) describe patterns of palliative care consultation, (2) evaluate the factors that trigger palliative care consultation, and (3) determine the association of palliative care consultation on longer-term outcomes.

METHODS

A single-center, retrospective, case-control study was conducted for patients undergoing spinal metastasis surgery from February 2010 to January 2021. The primary outcome was receiving a palliative care consultation, and the timing of consultation was divided into same hospital stay consultation, preoperative versus postoperative consultation, and early (

RESULTS

Of 363 patients undergoing surgery for spinal metastasis, 62 (17.0%) patients received palliative care consultation during the same hospitalization, 11 (17.7%) were preoperative, and 51 (82.2%) were postoperative. Among same-stay consultations, 32 (51.6%) were early and 30 (48.4%) were late. Palliative care consultation recipients had worse preoperative Karnofsky Performance Scale (KPS) score (P < 0.001), were more likely to have other organ metastases (P = 0.005) or cord compression (P = 0.026), had longer hospitalization (P < 0.001), and were less likely to be discharged home (P < 0.001). Patients presenting with mechanical pain were more likely to receive preoperative consults compared with postoperative (P = 0.029), and earlier compared with later consultations (P = 0.046). Regarding long-term outcomes, patients with same-stay palliative care consultation had significantly shorter overall survival (log-rank; P < 0.001), worse KPS postoperatively (P = 0.017), and worse KPS and Modified McCormick Scale at the last follow-up (P < 0.001).

CONCLUSIONS

Only 1 in 6 patients received palliative care consultation. Patients receiving same-stay palliative care consultation had more advanced local and systemic disease burden. Increased utilization of palliative care consultation in patients with spine metastasis is needed.

Collapse

Key Words

• Overall survival
• Palliative care
• Spinal metastasis
• Spinal tumors

Collapse

MESH Headings

• Humans
• Palliative Care
• Spinal Neoplasms/secondary
• Retrospective Studies
• Case-Control Studies
• Spinal Cord Neoplasms
• Central Nervous System Neoplasms
• Referral and Consultation

Collapse

Grants Collapse

Affiliation(s)

Jeffrey W Chen Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Hani Chanbour Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Gabriel A Bendfeldt Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Lakshmi Suryateja Gangavarapu Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
Mohana B Karlekar Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Amir M Abtahi Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Byron F Stephens Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Scott L Zuckerman Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
Silky Chotai Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

Collapse

Predicting Limited Survival Following Inguinal Lymph Node Dissection in Penile Cancer: Should We Revisit the Goals of Care?

OBJECTIVE

Patients with advanced penile squamous cell cancer have a poor prognosis and can benefit from early palliative care consultation. We built a model to identify those patients most likely to benefit.

METHODS

Patients with penile squamous cell cancer undergoing inguinal lymph node dissection were identified from the National Cancer Database (NCDB) and a multi-institutional international dataset (INT). A multivariable Cox proportional hazards model for overall survival (OS) was developed using the NCDB and applied to the INT dataset. Parameters were used to make receiver operating characteristic (ROC) curves. ROC-related criteria were optimized to identify a predictive probability cut point and dichotomize patients from INT into risk groups for limited OS of <6 and <12 months.

RESULTS

NCDB had 860 deaths; 105 (5%) at 6 months and 296 (15%) at 12 months. INT had 257 deaths; 56 (8%) at 6 months and 124 (18%) at 12 months. Limited OS was associated with older age, greater T and N stage, and fewer lymph nodes removed. Optimized ROC criteria using the OS <6 months curve best dichotomized INT patients into high-risk group with median OS of 24 months (95% CI 18-34) and low-risk group with median OS of 174 months (95% CI 120-NE).

CONCLUSION

We developed a simple model that could be used as a screening tool for early palliative care referral.

Prevalence and Factors Associated with Palliative Care Utilization among Hospitalized Patients with Esophageal Cancer in the United States

Objective: Due to poor 5-year survival and high symptom burden, esophageal cancer (EC) patients benefit markedly from palliative care utilization. However, there is scant literature exploring factors associated with receipt of palliative care in this population. The prevalence of palliative care consultations among hospitalized EC patients was assessed. Furthermore, we examined the factors associated with palliative care utilization among hospitalized patients with EC. Methods: Retrospective analyses were conducted using the National Inpatient Sample data collected between 2016 and 2018. Descriptive analyses were used to explore the overall prevalence of palliative care utilization. Univariate and multivariable regression models were used to examine factors associated with palliative care utilization among hospitalized EC patients. Results: The overall prevalence of palliative care utilization was 15.97%. Non-Hispanic Blacks had 1.16 times (95% CI: 1.00-1.34) higher odds of palliative care utilization compared to non-Hispanic Whites. Compared to patients on Medicare, those on Medicaid (AOR: 1.21; 95% CI: 1.02-1.45), private (AOR: 1.19; 95% CI: 1.06-1.35) and other insurance types (AOR: 1.68; 95% CI: 1.39-2.02) were more likely to utilize palliative care. Relative to patients hospitalized in the Northeast, those in Midwest (AOR: 1.34; 95% CI: 1.17-1.53), south (AOR: 1.28; 95% CI: 1.12-1.45), and west (AOR: 1.41; 95% CI: 1.22-1.61) were more likely to receive palliative care. Patients admitted to urban teaching hospitals (AOR: 1.28; 95% CI: 1.07-1.52) had higher odds of having palliative care consultations when compared to their counterparts in rural hospitals. Also, patients who were either discharged to a facility/with home health (OR: 5.39; 95% CI: 4.76-6.10) or died during hospitalization (OR: 26.93; 95% CI: 23.31-31.11) had higher odds of utilizing palliative care when compared to those with a routine discharge. Other factors identified were median household income quartiles, admission type, chemotherapy receipt, and the number of comorbidities. Conclusions: Our findings highlight the need to further analyze and address factors that may hinder palliative care utilization among hospitalized EC patients to decrease disparities and improve their quality of life. Hospital physicians and health systems need to be more proactive about palliative care consultations to maximize the benefits to these sick cancer patients.

Management of Locally Advanced Unresectable or Metastatic Urothelial Carcinoma: Expert Opinion from an Indian Panel via Delphi Consensus Method

Introduction Currently, there are no guidelines for the management of locally advanced unresectable or metastatic urothelial carcinoma (mUC) from an Indian perspective. There is a lack of consensus on the utility of treatment options in first-line (1L) and second-line (2L) settings, especially in cisplatin- and platinum-unfit mUC patient subgroups.

Objective This articles aims to develop evidence-based practical consensus recommendations for the management of mUC in Indian settings.

Methods Modified Delphi consensus methodology was considered to arrive at a consensus. An expert scientific committee of 15 medical oncologists from India constituted the panel. Twelve clinically relevant questions were grouped into five categories for presentation and discussion: (1) cisplatin and platinum ineligibility criteria; (2) programmed death ligand 1 and fibroblast growth factor receptor (FGFR) testing in mUC patients; (3) treatment options in 1L settings; (4) role of switch maintenance; and (5) treatment options in 2L. Statements that reached high (≥ 80%) and moderate (60–79%) levels of consensus in the first round (electronic survey) did not undergo the second Delphi round. The questions that received a low level of consensus (< 60%) were discussed during the virtual meeting.

Results Renal impairment (creatinine clearance [CrCl] < 60 mL/min) and New York Heart Association class 3 heart failure are important assessment criteria for determining cisplatin ineligibility. Patients are unfit for any platinum-based chemotherapy in case of Eastern Cooperative Oncology Group performance status> 3 or severe renal impairment (CrCl < 30 mL/min). Gemcitabine and platinum with cisplatin over carboplatin were preferred in 1L settings. In patients unfit for cisplatin-based regimens, carboplatin–gemcitabine chemotherapy was preferred over immunotherapy (atezolizumab or pembrolizumab). Selected patients who are platinum ineligible may be considered for immunotherapy. Post-induction chemotherapy, those who do not progress may be strongly considered for avelumab maintenance. Experts recommended erdafitinib in FGFR-positive mUC patients in 2L settings. In FGFR-negative patients, immunotherapy (pembrolizumab, nivolumab, or avelumab) may be preferred over chemotherapy (paclitaxel, docetaxel, or vinflunine). Enfortumab vedotin and sacituzumab govitecan may be considered for further lines of therapy.

Conclusion Expert panel consensus will offer expert guidance to oncologists/clinicians on the management of mUC in Indian settings.

Key Points

Preliminary results regarding automated identification of patients with a limited six-month survival prognosis using nursing assessment in uro-oncology patients

INTRODUCTION

Contrary to current recommendations, palliative co-management of tumor patients often occurs late in daily clinical practice. Palliative care specialist (PCS) co-management should be considered at the latest after a 6-month prognosis has been presumed. Therefore, identifying patients with a limited prognosis is a reasonable measure.

METHODS

Patients were identified using a screening tool for limited prognosis, which combined their tumor stage and data from the nursing anamnesis. In this retrospective study, a monocentric cohort of patients with urological malignancies-UICC (Union for International Cancer Control) stages III and IV - were enrolled from March to December 2019, with a 6-month follow-up period ending in May 2020.

RESULTS

Most patients were male and suffered from prostate cancer. Patients with uro-oncological tumors dying within 6 months correlated significantly with the presence of repeated hospitalizations within three months, pain on admission, malnutrition, impaired breathing and reduced mobility (P < 0.001). The test was fair in quality (AUC 0.727) at a cut-point of five; a sensitivity of 97% and a specificity of 25% were obtained. The PPV was 0.64 and NPV was 0.82.

DISCUSSION/CONCLUSION

We specifically identified the predictors of limited prognosis in urological cancer patients across several entities using an automated scoring system based on tumor stage and data from the nursing anamnesis. Therefore, we recognized hospitalization as an important transition point and determined nurses to be valuable partners in identifying unmet palliative care needs without additional technical, personnel or financial effort.

Philosophy of Cancer Theranostics

Imagine a theranostic nuclear physician oncologist engaged in a Socratic philosophic dialogue. Questions that may be posed include the status of our current knowledge base of radiomolecular tumor biology, the meaning of precision in personalized dosimetry, the nature of responsibility for direct patient care, and the moral and ethical dimensions of individual quality of life (QOL) when survival is prolonged. This review invites reflective enquiry into one's personal practice of theranostics in cancer care, with the objective of optimizing clinical outcomes, not only in terms of prolonged survival but also individual QOL, in respect of its meaning for each patient, both physically and emotionally.

Top Ten Tips Palliative Care Clinicians Should Know About Urological Care

Patients receiving palliative care (PC) can present with or develop a host of urological needs or complications. These needs can include attention to sexual health, urinary incontinence, genitourinary bleeding, and urinary tract obstruction by benign, malignant, or urinary stone diseases. These varied conditions require that PC clinicians understand invasive and noninvasive medical, surgical, and radiation options for treatment. This article, written by a team of urologists, geriatricians, and PC specialists, offers information and guidance to PC teams in an accessible "Top Ten Tips" format to increase comfort with and skills around assessment, evaluation, and specialist referral for urological conditions common in the PC setting.

Psychometric Properties of the Persian Version of Palliative Care Outcome Scale (POS) in Adult Patients With Cancer

Background

Measuring the outcomes of palliative care plays an important role to improve the quality, efficiency, and availability of these services in patients with cancer. Using valid, reliable, and culturally appropriate tools has a considerable role to measure these outcomes. This study aimed to assess the psychometric properties of the translated version of the Palliative care Outcome Scale (POS).

Methods

This methodological study was conducted in two outpatient clinics related to Shohada Tajrish and Baqiyatallah hospitals in Tehran in 2019-2020. The translation was done using the Forward-Backward approach after gaining permission from the developer. Face validity was tested with 10 patients with cancer through cognitive interviewing, as well as content validity with four experts. Construct validity was performed by (n = 203) exploratory factor analysis and confirmation (N = 150). To assess the reliability, internal consistency was assessed by using Cronbach's alpha coefficient, and relative stability was assessed using the interclass correlation coefficient (ICC). Furthermore, interpretability and ceiling and floor effects were assessed.

Results

A total of 353 patients with cancer under palliative care were included in the study. Then, three psychological (30%), physical (12.25%), and social factors (12.08%) with a cumulative variance of 54.34% were extracted in exploratory factor analysis. Confirmatory factor analysis showed that the model has a good fit of information. Cronbach's alpha coefficient for scale was 0.719. Furthermore, the ICC was 0.812. The scale was interpretable, and ceiling and floor effects were 0%.

Conclusion

Persian version of the POS was evaluated as a valid and reliable tool. Therefore, it can be used by the clinician to monitor the consequences of palliative care in Iranian cancer patients.