Assessment of patient symptom burden and information needs helps tailoring palliative care consultations: An observational study

The impact of multidisciplinary geriatric follow-up on quality of life in older, non-surgical prefrail and frail patients with cancer A randomized controlled trial

INTRODUCTION

Cancer management in older frail patients can be complex, given the high decline in functional status, comorbidity, and limited life expectancy affecting this group of patients. Therefore, this study aimed to investigate whether oncological treatment combined with comprehensive geriatric assessment (CGA) and tailored follow-up interventions improved or maintained quality of life (QoL) in older prefrail and frail patients with cancer.

MATERIALS AND METHODS

A single-center randomized controlled trial included participants aged 70 or older with head, neck, lung, upper gastrointestinal tract, colon, or rectum cancer referred to non-surgical treatment. All participants underwent CGA conducted by a multidisciplinary geriatric team in an outpatient oncological clinic. The team consisted of a geriatrician and a specialized nurse who provided tailored follow-up visits and phone calls within 90 days after randomization. Exclusion criteria were fit patients, referral for specialized palliative care, or participating in another geriatric research program. In patients with well-functioning cognition, QoL was assessed using the EORTC QLQ-C30 and QlQ-ELD-14 questionnaires before and after the intervention. In patients with cognitive impairment, the Overall QoL-Depression List was used. Changes in QoL were dichotomized into improved/unchanged or worsened and analyzed in a logistic regression model.

RESULTS

In total, 363 participants were included with a mean age of 76 years (SD 4.6) and 45 % were female. Sixty percent in the intervention group had improved or unchanged QoL compared to 66 % in the control group (odds ratio: 0.75 [95 % confidence interval(CI): 0.45-1.23]). Overall, clinically important changes were found in fatigue and reduced worries about the future. The intervention showed improvements in insomnia symptoms and reported decreased role functioning. Discrepancies were found in the burden of illness without a clinically important difference, where the intervention group experienced an increased burden while the control group had a decreased burden (coefficient: 9.02 [95 % CI, 0.49-17.5]).

DISCUSSION

Multidisciplinary geriatric follow-up did not universally improve QoL in older frail patients with cancer. However, positive changes in specific aspects of QoL revealed nuanced impacts, warranting further exploration and larger studies to validate these observations. Tailored interventions targeting fatigue, insomnia, and emotional well-being are crucial for improving QoL in this population.

TRIAL REGISTRATION

Registered in January 2016 at ClinicalTrials.gov (ID: NCT02837679).

Exploring the Influence of the Edmonton Symptom Assessment System Implementation in Palliative Care Patients: A Systematic Review

One of the most essential elements of providing high-quality palliative care is good symptom control, which is guided through an assessment of the evolution of the patient's level of distress over time. The Edmonton Symptom Assessment System (ESAS) was created to measure diverse symptoms in palliative care patients. It is a user-friendly, validated, and reliable multi-item instrument. Globally, ESAS is extensively used to direct daily clinical care and foster communication across multidisciplinary teams, ensuring coordinated patient management, facilitating referrals to specialized programs, and evaluating the quality of care. In this systematic review, we aim to evaluate the influence of using ESAS on symptom assessment and control among palliative care patients and settings. We have employed both manual and electronic search strategies among databases to determine relevant studies. This systematic review included original studies published between 2013 and 2023 that implemented the ESAS as part of palliative care for adult patients with terminal illness or advanced disease. Studies recruiting pediatric patients, case reports with limited sample sizes and no descriptive statistics, and nonhuman or laboratory studies were excluded. The ROBINS-I (Risk Of Bias In Non-randomized Studies-of Interventions) tool was used to assess the quality of the included studies, which assessed the methodological quality and potential risk of bias in non-randomized clinical studies. We included eight studies that recruited a total of 3184 patients. Fatigue followed by pain were the symptoms with the highest score on ESAS among all the studies, while the lowest score was recorded for nausea and dyspnea in most of the studies. ESAS scores showed improvement in the follow-up visits. Two of the included studies reported satisfaction with the utilization of the ESAS tool. As stated in our results, it can improve the overall quality of life for patients receiving palliative care by assisting healthcare professionals, family members, and caregivers in methodically assessing and treating symptoms over time. By fostering better communication among care teams and involving caregivers in the process, the use of ESAS promotes a more patient-centered approach to care, ensuring that both the patient's needs and the perspectives of their loved ones are considered.

Symptom burden, palliative care knowledge, and palliative care needs in advanced gynecological cancer patients in Korea

Advanced gynecological cancer patients endure numerous symptoms resulting from both the disease itself and the treatments they undergo. This symptom burden significantly impacts the quality of life for both patients and their caregivers, as well as escalating medical costs. Palliative care presents a solution to alleviate these challenges. However, in Korea, there exists a low level of awareness regarding palliative care and consequently, a low utilization rate. Providing timely palliative care to advanced gynecological cancer patients in Korea necessitates a comprehensive understanding of their symptom burden, palliative care knowledge, and palliative care needs. However, no previous studies have addressed this critical issue. The purpose of this study is to determine the impact of advanced gynecological cancer on palliative care needs in Korea according to patient demographic and clinical characteristics, symptom burden, and palliative care knowledge. This study was a descriptive cross-sectional study of data from 115 participants with stage III or IV gynecological cancer, collected through an online questionnaire. The main variables were symptom burden (Functional Assessment of Cancer Therapy-General), palliative care knowledge (Palliative Care Knowledge Scale), and palliative care needs (Problems and Needs in Palliative Care questionnaire-short version). Multiple hierarchical regression analyses were used to determine the relationships between variables. Palliative care needs were divided into perceived problems and requests for professional support. The most common perceived problems were financial problems, psychological issues, and physical symptoms, and the most frequent requests for professional support were financial problems, psychological issues, and the need for information. The perceived problem score increased with age, not having surgical experience, and significant symptom burden. Additionally, the requests for professional support score rose in cases of ovarian cancer, not having surgical history, substantial symptom burden, and limited palliative care knowledge. Advanced gynecological cancer patients have palliative care needs that differ according to patient characteristics, symptom burden, and palliative care knowledge. Identifying factors influencing palliative care needs can aid clinicians in identifying target groups in need of palliative care and providing them with professional palliative care.

Dry mouth in patients with a life-limiting condition or frailty: a study protocol for two intervention studies and a nested qualitative sub-study (the Dry mOuth Project, DROP)

BACKGROUND

Despite its prevalent and impactful nature, dry mouth remains an underexposed and undertreated symptom in patients with a life-limiting condition or frailty. The main contributing factors are a lack of awareness and knowledge amongst both healthcare professionals and patients, and a scarcity of effective, evidence-based interventions. In the DRy mOuth Project (DROP), we address these factors by investigating both a non-pharmacological and a pharmacological intervention: a nurse-led patient education program and locally applied pilocarpine.

METHODS

This intervention-based research project consists of two parallel studies. The non-pharmacological study is a cluster non-randomized controlled trial in 228 palliative nursing home and hospital patients, investigating the effect of structured use of guidelines and of patient education on dry mouth symptoms. This intervention, a nurse-led patient education program (the Mouth Education Program, MEP), will be compared to care as usual, the control. The pharmacological study is a double-blind placebo-controlled randomized trial that examines the effect of locally applied pilocarpine drops in 120 patients with dry mouth symptoms. Both studies use the same mixed-methods study design, in which the primary outcome is the clinical response to the intervention at 4 weeks, as measured by a dry mouth severity score (numeric rating scale from 0 to 10). Other outcomes, as measured by questionnaires over a 12-week follow-up period, include durability of the effect, impact on quality of life and, adherence and acceptability of the intervention. In addition, the feasibility and cost-effectiveness are evaluated by means of questionnaires and focus groups with healthcare professionals, and interviews with patients.

DISCUSSION

This study investigates the effectiveness and feasibility of two interventions for dry mouth symptoms in patients with life-limiting conditions or frailty. Due to the large-scale and mixed-method nature of the study, this study will also improve our understanding of dry mouth and its relating factors and of the patients' and healthcare professionals' experiences with symptoms, care and guidelines of dry mouth, including any perceived barriers and facilitators.

TRIAL REGISTRATION

NCT05964959 & NCT05506137.