The Role of Palliative Care in Oncology

The Perspective of Cancer Patients in Palliative Care on Unmet Needs: A Qualitative Synthesis Using Meta-Ethnography

BACKGROUND

As cancer patients approach the end of life, their needs become more complex, increasing the demand for palliative care. Advanced-stage cancer patients encounter increasing unmet psychological, physical, autonomy, and communication needs, reflecting the difference between patients' perceived requirements and the support from health care professionals. The objective of this study was to synthesize qualitative evidence on unmet needs in palliative cancer care among inpatient and outpatient adults.

METHODS

We conducted a meta-ethnographic review according to Noblit and Hare's framework and the operationalized guidelines developed by Sattar. The eMERGe Reporting Guidance was followed. A literature search was conducted in Cinahl, Embase, Medline, Scopus, Web of Science, PsycINFO and Google Scholar for gray literature. For all the studies, direct quotes from the participants and authors' results were identified, coded and analyzed in NVivo 1.7.1 and extracted as I and II order constructs from which higher third-order themes originated.

RESULTS

Eight studies were included. Four new themes emerged, representing areas where palliative cancer care patients expressed a need for help: the need for comprehensive, patient-centered care, the need for maintaining a sense of autonomy and dignity, the need for attentive support to patients' soul and the need for accessible and timely care.

CONCLUSIONS

Palliative care patients require a secure, suffering-free end-of-life journey with informed decision-making and team support. Ensuring continuity of care, validating their suffering, and allocating sufficient time are crucial aspects of care. This involves maintaining a consistent care plan, respecting patients' emotions and experiences, and providing services tailored to individual needs.

Prevalence of oral diseases in patients under palliative care: a systematic review and meta-analysis

PURPOSE

Oral alterations are frequently observed in patients undergoing palliative care and are linked to the direct or indirect effects of the primary medical condition, comorbidities and medical management, leading to oral pain, impacting oral intake, and affecting quality of life. This systematic review aims to assess the prevalence of oral disease in palliative care patients.

METHODS

The protocol was registered at the PROSPERO database, and a systematic review of the literature was performed based on the PRISMA statement. A thorough evaluation of studies from five databases and gray literature was conducted. The risk of bias in each study was assessed using the Joanna Briggs Institute checklist for cross-sectional and case-control studies. A quantitative analysis was conducted on five studies using meta-analysis, and the degree of certainty in the evidence was determined using the GRADE tool.

RESULTS

The sample consisted of 2,502 patients, with a slight male predominance (50.43%). The average age was 66.92 years. The prevalence of oral diseases among palliative care patients was as follows: caries 32% (95% CI, 0.11-0.56; I2 = 93%), and oral candidiasis 17% (95% CI,0.11-0.25; I2 = 74%). Gingivitis and stomatitis were also reported, but with less frequency.

CONCLUSION

Dental intervention should take place as early as possible, ideally from the time of the patient's initial admission to palliative care, with regular monitoring of oral health. This approach can enhance the patient's comfort and quality of life and help prevent more severe complications in the future.

Supportive care interventions in metastatic bone disease: scoping review

BACKGROUND

Patients with secondary metastatic involvement of the musculoskeletal system due to primary cancers are a rapidly growing population with significant risks for health-related end-of-life morbidities. In particular, bone metastases or metastatic bone disease (MBD) imparts significant adversity to remaining quality of life. No rigorous review of clinical trials on the use of supportive care interventions for MBD has been conducted. The objective of this review was to examine the characteristics of supportive care interventions for MBD and critically appraise study designs, key findings, and quality of evidence of the research.

METHODS

We searched for published clinical trials, systematic reviews and meta-analyses in PubMED, CINAHL and Google Scholar for articles published between September 2017 and September 2022. Some examples of Medical Subject Headings terms were: 'secondary neoplasm', 'metastatic bone disease', 'palliative care' and 'supportive care intervention'. Quality of published evidence was evaluated based on treatment types and study design.

RESULTS

After reviewing 572 publications, 13 articles were included in the final review and evaluation including seven clinical trials, two trial protocols and four systematic reviews. Feasible interventions included enhanced palliative care consultation, palliative radiotherapy and alternative medicines. Interventions addressed primary endpoints of fatigue (N=4, 31%), pain (N=3, 23%) or cancer-related symptoms (N=3, 23%) with patient-reported outcome instruments. No interventions reported on fracture complications or endpoints, specifically. The quality of most studies was moderate to strong.

CONCLUSION

Supportive care interventions for MBD are feasible and the impact is measurable via patient-reported outcome measures. While the evidence for interventions was moderate to strong, there are very few specific controlled trials for skeletal-related events and impacts of social determinants of health. Further clinical trials are needed to define supportive care interventions for MBD that demonstrate reduced risk of fracture and that mitigate the reduced quality of life when negative musculoskeletal outcomes arise.

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.

Oral hygiene care and the management of oral symptoms in patients with cancer in palliative care: a mixed methods systematic review protocol

OBJECTIVE

The objective of this review is to examine the effectiveness of oral hygiene care in the management of oral symptoms in patients with cancer under specialist palliative care and the patients' experience of such symptoms and care.

INTRODUCTION

Oral symptoms, such as xerostomia, mouth pain, or dysgeusia, are highly prevalent in patients with cancer under specialist palliative care. These symptoms have a negative effect on patients' quality of life. Oral hygiene care can manage oral symptoms and could be improved with a more systematized approach, adequate guidelines, and training to properly integrate oral hygiene into the care provided in specialist palliative care.

INCLUSION CRITERIA

This review will consider quantitative, qualitative, and mixed methods studies on the effectiveness and experience of oral hygiene care intended to manage oral symptoms in patients with cancer aged 18 years or older, diagnosed with any type of cancer, under specialist palliative care.

METHODS

The search will be conducted in MEDLINE (PubMed), CINAHL (EBSCOhost), Cochrane Central Register of Controlled Trials, Dentistry and Oral Sciences Source (EBSCOhost), and MedicLatina (EBSCOhost). Sources of unpublished studies and gray literature to be searched will include Networked Digital Library of Theses and Dissertations and Repositórios Científicos de Acesso Aberto de Portugal. Studies in English, Portuguese, and Spanish published from 2000 to the present will be considered. Methodological quality of included studies will be assessed and data will be extracted. Synthesis and integration will follow the JBI segregated approach for mixed methods reviews.

REVIEW REGISTRATION

PROSPERO CRD42023400554.

Optimizing quality of life: integrating palliative care for patients with hand-foot syndrome in oncology practice

Hand-foot syndrome (HFS) emerges as one of the common dermatological side effects associated with anticancer medications such as 5-fluorouracil (5-FU), capecitabine and docetaxel. This condition can be notably debilitating, exerting a predominant impact on the clinical, functional and psychosocial domains of health. With prevalence rates of HFS, ranging from 43% to 71%, there exists an unmet need among palliative care physicians to comprehend this syndrome in addressing physical, psychological dimensions and its integrated management within healthcare. This understanding enables them to adopt diverse approaches aimed at preserving the quality of life for patients, by enhancing the overall healthcare experience. Our primary objective is to underscore the imperative for the high-quality integration of palliative care with respect to HFS in contemporary oncology practices. We aim to achieve this by providing evidence-based insights to enhance patient outcomes.The intent of this study: (1) The article delves into the range of symptoms linked to HFS, and stresses the necessity of a holistic strategy and the difference that a palliative physician can contribute during cancer treatment-in picking up certain intricate aspects of patient care and addressing them. (2) The article also highlights the comprehensive approach through the incorporation of quality-of-life assessments, with the goal of enhancing patient outcomes, overall care experience within an integrated healthcare framework.

Therapeutic Approaches to Increase the Survival Rate of Cancer Patients in the Younger and Older Population

Various developments have been observed in the treatment of cancer patients, such as higher survival rates and better treatment outcomes. However, expecting similar outcomes in older patients remains a challenge. The main reason for this conclusion is the exclusion of older people from clinical trials for cancer drugs, as well as other factors, such as comorbidity, side effects, age-related frailties and their willingness to undergo multiple treatments. However, the discovery of new techniques and drug combinations has led to a significant improvement in the survival of the elderly population after the onset of the disease. On the other hand, cancer treatments have not become more complex for the younger population when compared to the older population, as the younger population tends to respond well to treatment trials and their physiological conditions are stable in response to treatments. In summary, this review correlates recent cancer treatment strategies and the corresponding responses and survival outcomes of older and younger patients.

Comparison of palliative care education for family caregivers in high-and-low-income countries: An integrative review

Background

In most resource-limited countries, palliative care is still under development. Despite the differences, the involvement of family caregivers is fundamental in both High-Income Countries (HICs) and Low-Income Countries (LICs). The lack of formal support in LICs implies that educational interventions to support family caregivers in this region could be more complex and urgently needed than in HICs. To comprehend the existing situation and identify the gaps in LICs, using HICs as a benchmark standard and conducting a review comparing educational interventions in both regions is essential.

Objective

To identify and compare the existing implementation of education for family caregivers of patients with advanced cancer in LICs and HICs.

Design

An integrative review guideline by Whittemore and Knafl was followed. Interventional studies related to education for family caregivers providing care for adult patients with cancer were included, and review articles were excluded.

Data Sources

Data were obtained from PubMed, EBSCO, ProQuest, and ClinicalKey. The search was conducted on 18 November 2021 and updated on 9 August 2023.

Review methods

Data reduction, data comparison, conclusion drawing, and data verification were conducted.

Results

Out of the 11 studies included, nine were randomized controlled trials, and two were quasi-experimental studies. Among them, seven (63%) were conducted in HICs, and four (37%) were carried out in LICs. In both regions, the psychological aspect was the most commonly addressed subject in palliative care education for family caregivers. However, in LICs, no articles specifically addressed the social and spiritual aspects of family caregivers' education. Research conducted in LICs mostly involved nurses, while studies in HICs included a more diverse range of healthcare professionals. Typically, these programs required two to three sessions, with 30-60 minutes duration for 3-12 weeks.

Conclusion

The social and spiritual aspects can be integrated into family caregivers' training programs in LICs in the near future. Nurses, as an integral part of the multidisciplinary team, are capable of contributing to the development of educational programs for family caregivers, especially in resource-limited countries where patients rely heavily on their caregivers and relatives. Support from nurses is fundamental in such contexts.

Barriers, blocks, and barricades: Disparities to access of palliative care in cancer care

Palliative care (PC) is specialized medical care for people living with a serious illness. PC models have stressed pain and symptom management, communication that is patient- and family-centric and longitudinal support for families living with serious illness that is contiguous across multiple settings. Despite the benefits that PC provides from a patient, family and quality of care standpoint, several barriers and disparities exist. Included in these barriers are the lack of geographic access to PC programs as well as the focus on inpatient, hospital-based PC programs versus outpatient and home-based models. Workforce shortages, challenges with defining and designing PC, and racial, cultural and language barriers have all contributed to disparities within PC. This review article outlines PC disparities including geographic access challenges, cross-cultural barriers and symptom and communication specific disparities. We discuss the impact these inequities have on patients living with cancer.

Factors associated with palliative care symptoms in cancer patients in Palestine

Palliative care is critical to redundancy in cancer patients seeking to improve their quality of life. Evaluation should be incorporated into clinical practice routines at all stages of cancer. The Edmonton Symptom Assessment System (ESAS) was used to rate the intensity of ten symptom evaluations designed and validated for cancer patients in various languages and cultures. Therefore, the study aims to assess the symptoms reported using ESAS scores to identify patients who would benefit from palliative care that can improve the integration of palliative care into standard cancer care at An-Najah National University Hospital (NNUH). A cross-sectional study was selected for 271 cancer patients using a convenience sampling method at NNUH. Demographic, clinical, and lifestyle characteristics are described. Furthermore, patients' moderate to severe symptoms (score > 4) were obtained using ESAS-R. The survey consisted of 271 patients, with a response rate of 95%. The average age of the patients was 47 ± 17.7 years, ranging from 18 to 84 years. The male-to-female ratio was approximately 1:1, 59.4% of the patients were outpatients, and 153 (56.5%) had hematologic malignancies. Fatigue (62.7%) and drowsiness (61.6%) were the most common moderate to severe symptoms in ESAS. Furthermore, pain (54.6%), nausea (40.2%), lack of appetite (55.0%), shortness of breath (28.5%), depression (40.6%), anxiety (47.2%) and poor well-being (56.5%) were reported. In conclusion, fatigue and drowsiness were the most reported symptoms according to the ESAS scale among cancer patients, while moderate to severe symptoms were reported in cancer patients using the ESAS. The ESAS is a functional tool for assessing cancer patients' symptoms and establishing palliative care services.

Providing person-centered palliative care in conflict-affected populations in the Middle East: What matters to patients with advanced cancer and families including refugees?

Introduction

Universal health coverage highlights palliative care as an essential component of health services. However, it is unclear what constitutes person-centered care in populations affected by conflict, as they may have specific concerns in the dimensions of physical, emotional, social, and spiritual wellbeing. This study aimed to identify what matters to patients with advanced cancer and family caregivers in Jordan including refugees, to inform appropriate person-centered assessment and palliative care in conflict-affected populations.

Methods

Cross-sectional face-to-face, semi-structured interviews were conducted at two sites in Amman. Adult patients with advanced cancer and family caregivers were purposively sampled to maximize diversity and representation. Interviews were digitally audio recorded, anonymized, and transcribed verbatim for thematic analysis.

Findings

Four themes were generated from 50 patients (22 refugees; 28 Jordanians) and 20 caregivers (7 refugees; 13 Jordanians) (1). Information, communication, and decision-making. Truth-telling and full disclosure from clinicians was valued, and participants expressed concerns that information was not shared in case patients would disengage with treatment. (2) Priorities and concerns for care and support. Participants’ top priority remained cure and recovery (which was viewed as possible). Other priorities included returning to their “normal” life and their “own” country, and to continue contributing to their family. (3) Role of spirituality and Islam. Most participants had strong faith in God and felt that having faith could comfort them. For refugees whose social network was fractured due to being away from home country, prayer and Quran reading became particularly important. (4) Unmet support needs of family caregivers. Family caregivers were affected physically and emotionally by worrying about and caring for the patients. They needed support and training, but often could not access this.

Discussion

Truth-telling is highly valued and essential to achieving person-centered care and informed decision-making. This study also reveals specific concerns in conflict-affected populations, reflecting the experience of prior losses and fracturing of existing social networks and support. The role of religion is crucial in supporting refugee communities, and consideration should be paid to the needs of patients and caregivers when caring for a patient at home without access to their communities of origin and the support they accessed.

Effects of an Oncology Nurse-Led, Primary Palliative Care Intervention (CONNECT) on Illness Expectations Among Patients With Advanced Cancer

PURPOSE

Patients with advanced cancer often have unrealistic expectations about prognosis and treatment. This study assessed the effect of an oncology nurse-led primary palliative care intervention on illness expectations among patients with advanced cancer.

METHODS

This study is a secondary analysis of a cluster-randomized trial of primary palliative care conducted at 17 oncology clinics. Adult patients with advanced solid tumors for whom the oncologist would not be surprised if died within 1 year were enrolled. Monthly visits were designed to foster realistic illness expectations by eliciting patient concerns and goals for their medical care and empowering patients and families to engage in discussions with oncologists about treatment options and preferences. Baseline and 3-month questionnaires included questions about life expectancy, treatment intent, and terminal illness acknowledgment. Odds of realistic illness expectations at 3 months were adjusted for baseline responses, patient demographic and clinical characteristics, and intervention dose.

RESULTS

Among 457 primarily White patients, there was little difference in realistic illness expectations at 3 months between intervention and standard care groups: 12.8% v 11.4% for life expectancy (adjusted odds ratio [aOR] = 1.15; 95% CI, 0.59 to 2.22; P = .684); 24.6% v 33.3% for treatment intent (aOR = 0.76; 95% CI, 0.44 to 1.27; P = .290); 53.6% v 44.7% for terminal illness acknowledgment (aOR = 1.28; 95% CI, 0.81 to 2.00; P = .288). Results did not differ when accounting for variation in clinic sites or intervention dose.

CONCLUSION

Illness expectations are difficult to change among patients with advanced cancer. Additional work is needed to identify approaches within oncology practices that foster realistic illness expectations to improve patient decision making.

Onco-Anaesthesiology and palliative medicine: Opportunities and challenges

Global cancer burden is on the rise and many more patients present for surgery or other oncological diagnostic or therapeutic interventions requiring anaesthesia. Oncology therapy is unique as it requires a multidisciplinary team of surgical, medical and radiation oncologists apart from palliative medicine (PM) specialists, and anaesthesiologists. Anaesthetic management can affect the outcome of oncology treatment both by ensuring early return to oncology treatment and some anaesthetic techniques being innately associated with recurrence. Hence, the time has come for a separate super-speciality of onco-anaesthesiology to cater to the complex unmet needs of cancer patients. PM is the fourth dimension of oncology care and so mandatory education and training should be included in the undergraduate curriculum.

Stakeholder perspectives and requirements to guide the development of digital technology for palliative cancer services: a multi-country, cross-sectional, qualitative study in Nigeria, Uganda and Zimbabwe

Introduction

Coverage of palliative care in low and middle-income countries is very limited, and global projections suggest large increases in need. Novel approaches are needed to achieve the palliative care goals of Universal Health Coverage. This study aimed to identify stakeholders’ data and information needs and the role of digital technologies to improve access to and delivery of palliative care for people with advanced cancer in Nigeria, Uganda and Zimbabwe.

Methods

We conducted a multi-country cross-sectional qualitative study in sub-Saharan Africa. In-depth qualitative stakeholder interviews were conducted with N = 195 participants across Nigeria, Uganda and Zimbabwe (advanced cancer patients n = 62, informal caregivers n = 48, health care professionals n = 59, policymakers n = 26). Verbatim transcripts were subjected to deductive and inductive framework analysis to identify stakeholders needs and their preferences for digital technology in supporting the capture, transfer and use of patient-level data to improve delivery of palliative care.

Results

Our coding framework identified four main themes: i) acceptability of digital technology; ii) current context of technology use; iii) current vision for digital technology to support health and palliative care, and; iv) digital technologies for the generation, reporting and receipt of data. Digital heath is an acceptable approach, stakeholders support the use of secure data systems, and patients welcome improved communication with providers. There are varying preferences for how and when digital technologies should be utilised as part of palliative cancer care provision, including for increasing timely patient access to trained palliative care providers and the triaging of contact from patients.

Conclusion

We identified design and practical challenges to optimise potential for success in developing digital health approaches to improve access to and enhance the delivery of palliative cancer care in Nigeria, Uganda and Zimbabwe. Synthesis of findings identified 15 requirements to guide the development of digital health approaches that can support the attainment of global health palliative care policy goals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-020-00694-y.

Multidisciplinary care in the hematology clinic: Implementation of geriatric oncology

Multidisciplinary care is believed to provide benefits to patients with cancer. Tumor board conferences as well aspalliative care or psycho-oncological services have not only become common in oncology, but also in hematology clinics dedicated to the treatment of hematological cancers. Malignant hematological diseases are highly prevalent among older persons. Demographic changes in many countries worldwide are prompting the integration of geriatric principles, methodology, and expertise into existing procedures and infrastructure of multidisciplinary care in hematology clinics. Achieving this goal requires the close collaboration or even incorporation of multiple new professions in the hematology clinic in order to meet the needs of older patients with hematological malignancies who also have comorbidities and functional impairments. We here review the rationale, current evidence, and practical approaches of integrating geriatric oncology into multidisciplinary care in the hematology clinic.