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Iavarone M, Canova L, Alimenti E, Aghemo A, Taveggia D, Gobber G, Cabibbo G, Veronese S, Calvaruso V, Orsi L, Caraceni P, Lampertico P. Palliative care in patients with hepatocellular carcinoma: Results from a survey among hepatologists and palliative care physicians. Palliat Med 2024:2692163241269794. [PMID: 39193728 DOI: 10.1177/02692163241269794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Delays and limitations of palliative care in patients with liver transplantation-ineligible end-stage hepatocellular carcinoma according to Barcelona Clinic Liver Cancer staging system may be explained by different perceptions between hepatologists and palliative care physicians in the absence of shared guidelines. AIM To assess physicians' attitudes toward palliative care in end-stage hepatocellular carcinoma and to understand what the obstacles are to more effective management and co-shared between palliative care physicians and hepatologists. DESIGN Members of the Italian Association for the Study of Liver Disease and the Italian Society of Palliative Care were invited to a web-based survey to investigate practical management attitude for patients with liver transplant-ineligible end-stage hepatocellular carcinoma. PARTICIPANTS Physician members of the of the two associations, representing several hospitals and services in the country. RESULTS Ninety-seven hepatologists and 70 palliative care physicians completed the survey: >80% regularly follow 1-19 patients; 58% of hepatologists collaborate with palliative care physicians in the management of patients, 55% of palliative care physicians take care of patients without the aid of hepatologists. Management of cirrhosis differed significantly between the two groups in terms of prescription of albumin, esophagogastroduodenoscopy, anti-viral treatment, anticoagulation, indication to paracentesis and management of encephalopathy. Full-dose acetaminophen is widely used among hepatologists, while opioids are commonly used by both categories, at full dosage, regardless of liver function. CONCLUSIONS This survey highlights significant differences in the approach to patients with liver transplantation-ineligible end-stage hepatocellular carcinoma, reinforcing the need for shared guidelines and further studies on palliative care in the setting.
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Affiliation(s)
- Massimo Iavarone
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, CRC "A. M. and A. Migliavacca" Center for Liver Disease, University of Milan, Milan, Italy
| | - Lorenzo Canova
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Eleonora Alimenti
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Division of Internal Medicine and Hepatology, Humanitas Research Hospital IRCCS, Rozzano, Italy
| | | | - Gino Gobber
- UO Palliative Care, Department of Primary Care, APSS Trento, Italy
| | - Giuseppe Cabibbo
- Gastroenterology & Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | | | - Vincenza Calvaruso
- Gastroenterology & Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Luciano Orsi
- Italian Journal of Palliative Care, Italian Society of Palliative Care, Milan, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Italy
- Unit of Semeiotics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, CRC "A. M. and A. Migliavacca" Center for Liver Disease, University of Milan, Milan, Italy
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Selvam D, Crawford GB, Rizvi F, Bellingham K, Philip J. CarePlus: A Model to Address Barriers to Early Palliative Care in Cancer. J Pain Symptom Manage 2024; 67:e495-e497. [PMID: 38278188 DOI: 10.1016/j.jpainsymman.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/28/2024]
Affiliation(s)
- Dalini Selvam
- University of Melbourne (D.S., F.R., K.B., J.P.), Victoria, Australia; University of Adelaide (G.B.C.), South Australia, Australia; Northern Adelaide Local Health Network (G.B.C.), South Australia, Australia; St. Vincent's Hospital (F.R., K.B., J.P.), Victoria, Australia.
| | - Gregory B Crawford
- University of Melbourne (D.S., F.R., K.B., J.P.), Victoria, Australia; University of Adelaide (G.B.C.), South Australia, Australia; Northern Adelaide Local Health Network (G.B.C.), South Australia, Australia; St. Vincent's Hospital (F.R., K.B., J.P.), Victoria, Australia
| | - Farwa Rizvi
- University of Melbourne (D.S., F.R., K.B., J.P.), Victoria, Australia; University of Adelaide (G.B.C.), South Australia, Australia; Northern Adelaide Local Health Network (G.B.C.), South Australia, Australia; St. Vincent's Hospital (F.R., K.B., J.P.), Victoria, Australia
| | - Kylee Bellingham
- University of Melbourne (D.S., F.R., K.B., J.P.), Victoria, Australia; University of Adelaide (G.B.C.), South Australia, Australia; Northern Adelaide Local Health Network (G.B.C.), South Australia, Australia; St. Vincent's Hospital (F.R., K.B., J.P.), Victoria, Australia
| | - Jennifer Philip
- University of Melbourne (D.S., F.R., K.B., J.P.), Victoria, Australia; University of Adelaide (G.B.C.), South Australia, Australia; Northern Adelaide Local Health Network (G.B.C.), South Australia, Australia; St. Vincent's Hospital (F.R., K.B., J.P.), Victoria, Australia
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Lima HA, Mavani P, Munir MM, Endo Y, Woldesenbet S, Khan MMM, Rawicz-Pruszyński K, Waqar U, Katayama E, Resende V, Khalil M, Pawlik TM. Medicaid expansion and palliative care for advanced-stage liver cancer. J Gastrointest Surg 2024; 28:434-441. [PMID: 38583893 DOI: 10.1016/j.gassur.2024.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/12/2024] [Accepted: 01/27/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Medicaid expansion (ME) has contributed to transforming the United States healthcare system. However, its effect on palliative care of primary liver cancers remains unknown. This study aimed to evaluate the association between ME and the receipt of palliative treatment in advanced-stage liver cancer. METHODS Patients diagnosed with stage IV hepatocellular carcinoma or intrahepatic cholangiocarcinoma were identified from the National Cancer Database and divided into pre-expansion (2010-2013) and postexpansion (2015-2019) cohorts. Logistic regression identified predictors of palliative treatment. Difference-in-difference (DID) analysis assessed changes in palliative care use between patients living in ME states and patients living in non-ME states. RESULTS Among 12,516 patients, 4582 (36.6%) were diagnosed before expansion, and 7934 (63.6%) were diagnosed after expansion. Overall, rates of palliative treatment increased after ME (18.1% [pre-expansion] vs 22.3% [postexpansion]; P < .001) and are more pronounced among ME states. Before expansion, only cancer type and education attainment were associated with the receipt of palliative treatment. Conversely, after expansion, race, insurance, location, cancer type, and ME status (odds ratio [OR], 1.23; 95% CI, 1.06-1.44; P = .018) were all associated with palliative care. Interestingly, the odds were higher if treatment involved receipt of pain management (OR, 2.05; 95% CI, 1.23-2.43; P = .006). Adjusted DID analysis confirmed increased rates of palliative treatment among patients living in ME states relative to non-ME states (DID, 4.4%; 95% CI, 1.2-7.7; P = .008); however, racial disparities persist (White, 5.6; 95% CI, 1.4-9.8; P = .009; minority, 2.6; 95% CI, -2.5 to 7.6; P = .333). CONCLUSION The implementation of ME contributed to increased rates of palliative treatment for patients residing in ME states after expansion. However, racial disparities persist even after ME, resulting in inequitable access to palliative care.
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Affiliation(s)
- Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States; Department of Surgery, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Parit Mavani
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Karol Rawicz-Pruszyński
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States; Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | - Usama Waqar
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States; Medical College, Aga Khan University, Karachi, Pakistan
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Vivian Resende
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States; Department of Surgery, Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, United States.
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Kinsey E, Lee HM. Management of Hepatocellular Carcinoma in 2024: The Multidisciplinary Paradigm in an Evolving Treatment Landscape. Cancers (Basel) 2024; 16:666. [PMID: 38339417 PMCID: PMC10854554 DOI: 10.3390/cancers16030666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
Liver cancer is the third most common cause of cancer-related deaths worldwide, and hepatocellular carcinoma (HCC) makes up the majority of liver cancer cases. Despite the stabilization of incidence rates in recent years due to effective viral hepatitis treatments, as well as improved outcomes from early detection and treatment advances, the burden of HCC is anticipated to rise again due to increasing rates of metabolic dysfunction-associated steatotic liver disease and alcohol-related liver disease. The treatment landscape is evolving and requires a multidisciplinary approach, often involving multi-modal treatments that include surgical resection, transplantation, local regional therapies, and systemic treatments. The optimal approach to the care of the HCC patient requires a multidisciplinary team involving hepatology, medical oncology, diagnostic and interventional radiology, radiation oncology, and surgery. In order to determine which approach is best, an individualized treatment plan should consider the patient's liver function, functional status, comorbidities, cancer stage, and preferences. In this review, we provide an overview of the current treatment options and key trials that have revolutionized the management of HCC. We also discuss evolving treatment paradigms for the future.
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Affiliation(s)
- Emily Kinsey
- Division of Hematology, Oncology, and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
- Massey Comprehensive Cancer Center, Virginia Commonwealth University, Richmond, VA 23219, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Hannah M. Lee
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University, Richmond, VA 23298, USA
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA 23298, USA
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Woodrell CD, Mulholland CN, Goldstein NE, Hutchinson CL, Schiano TD, Hansen L. Clinician Perspectives on Palliative Care for People with Hepatocellular Carcinoma: Facilitators of and Barriers to Referral. Cancers (Basel) 2023; 15:3617. [PMID: 37509278 PMCID: PMC10377573 DOI: 10.3390/cancers15143617] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Little is known about facilitators of and barriers to palliative care referral for people with hepatocellular carcinoma (HCC). The objective of this study is to identify facilitators and barriers of palliative care referral described by HCC-treating clinicians. (2) Methods: Semi-structured interviews (n = 16) were conducted with HCC-treating clinicians at two centers, focusing on referral patterns, palliative care needs, and disease course. A code book was created, axial coding was used to code all interviews, and selective coding was used to identify facilitators and barriers of palliative care referral. (3) Results: Facilitators included helpfulness at times of transition; help with management of certain symptoms; provision of psychosocial support; and positive experiences with referral. Barriers included feasibility concerns; lack of information about palliative care and who is appropriate; lack of symptoms requiring outside referral; and concerns that palliative care conveys loss of hope. (4) Conclusions: Participants noted the helpfulness of palliative care at specific points in the disease trajectory and cited barriers related to feasibility, lack of need, lack of awareness, and loss of hope. The results show actionable issues that can be addressed in future research to leverage the benefits of and overcome the barriers to palliative care for people with HCC.
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Affiliation(s)
- Christopher D Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, NY 10468, USA
| | - Christie N Mulholland
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Carole L Hutchinson
- Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Thomas D Schiano
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Recanati/Miller Transplantation Institute, Division of Liver Diseases, New York, NY 10029, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Sciences University, Portland, OR 97239, USA
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