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Xu Y, He C, Xi Y, Zhang Y, Bai Y. Gut microbiota and immunosenescence in cancer. Semin Cancer Biol 2024; 104-105:32-45. [PMID: 39127266 DOI: 10.1016/j.semcancer.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/24/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024]
Abstract
Cancer is generally defined as a disease of aging. With aging, the composition, diversity and functional characteristics of the gut microbiota occur changes, with a decline of beneficial commensal microbes triggered by intrinsic and extrinsic factors (e.g., diet, drugs and chronic health conditions). Nowadays, dysbiosis of the gut microbiota is recognized as a hallmark of cancer. At the same time, aging is accompanied by changes in innate and adaptive immunity, known as immunosenescence, as well as chronic low-grade inflammation, known as inflammaging. The elevated cancer incidence and mortality in the elderly are linked with aging-associated alterations in the gut microbiota that elicit systemic metabolic alterations, leading to immune dysregulation with potentially tumorigenic effects. The gut microbiota and immunosenescence might both affect the response to treatment in cancer patients. In-depth understanding of age-associated alterations in the gut microbiota and immunity will shed light on the risk of cancer development and progression in the elderly. Here, we describe the aging-associated changes of the gut microbiota in cancer, and review the evolving understanding of the gut microbiota-targeted intervention strategies. Furthermore, we summarize the knowledge on the cellular and molecular mechanisms of immunosenescence and its impact on cancer. Finally, we discuss the latest knowledge about the relationships between gut microbiota and immunosenescence, with implications for cancer therapy. Intervention strategies targeting the gut microbiota may attenuate inflammaging and rejuvenate immune function to provide antitumor benefits in elderly patients.
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Affiliation(s)
- Yaozheng Xu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110136, China; Liaoning Clinical Research Center for Laboratory Medicine, Shenyang, Liaoning 110136, China.
| | - Chuan He
- Department of Laboratory Medicine, The First Hospital of China Medical University, Shenyang, Liaoning 110001, China.
| | - Ying Xi
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110136, China; Liaoning Clinical Research Center for Laboratory Medicine, Shenyang, Liaoning 110136, China.
| | - Yue Zhang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110136, China; Liaoning Clinical Research Center for Laboratory Medicine, Shenyang, Liaoning 110136, China.
| | - Yibo Bai
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110136, China; Liaoning Clinical Research Center for Laboratory Medicine, Shenyang, Liaoning 110136, China.
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2
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Özkan A, van den Bos F, Mooijaart SP, Slingerland M, Kapiteijn E, de Miranda NFCC, Portielje JEA, de Glas NA. Geriatric predictors of response and adverse events in older patients with cancer treated with immune checkpoint inhibitors: A systematic review. Crit Rev Oncol Hematol 2024; 194:104259. [PMID: 38199430 DOI: 10.1016/j.critrevonc.2024.104259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 11/13/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Immunotherapy with checkpoint inhibitors (ICI) has improved cancer treatment in recent years. Older and frail patients are frequently treated with ICIs, but since they have been underrepresented in previous clinical trials, the real impact of ICI in this patient group is not well defined. The aim of this systematic review was to evaluate the evidence for associations between geriatric impairments and treatment outcomes in older patients with advanced and metastatic cancer treated with ICIs. METHODS A systematic search was conducted in PubMed, Cochrane Library, Embase, and Web of Science for relevant articles published before June 2022. Studies investigating the association between impairments in at least two geriatric domains and treatment outcome were considered eligible. Data extraction and risk of bias assessment using the QUIPS tool was performed independently by two investigators. RESULTS A total of nine studies were included. Median sample size of the studies was 92 patients (interquartile range (IQR) 47-113), with a median of 26 frail patients (IQR 21-35). Five studies investigated disease-related and survival outcomes, and two of them found a statistically significant association between geriatric impairments and either survival or disease progression. Eight studies investigated toxicity outcomes, and two of them showed a statistically significant association between geriatric impairments and immune-related adverse events (irAEs). Few studies suggested a relation between geriatric impairments and worse clinical outcomes. CONCLUSIONS Only a few studies have investigated the association between geriatric impairments and treatment outcomes and these studies were small. Older patients with geriatric impairments seem to be more likely to experience irAEs, but larger studies that include frail patients and use geriatric screening tools are required to confirm this association. These studies will be essential to improve the development of specific strategies to deal with frail patients.
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Affiliation(s)
- Asli Özkan
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederiek van den Bos
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; Center for Medicine for Older People, Leiden University Medical Center, Leiden, the Netherlands
| | - Marije Slingerland
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Nienke A de Glas
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands.
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3
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van Erning FN, Greidanus NEM, Verhoeven RHA, Buijsen J, de Wilt HW, Wagner D, Creemers GJ. Gender differences in tumor characteristics, treatment and survival of colorectal cancer: A population-based study. Cancer Epidemiol 2023; 86:102441. [PMID: 37633058 DOI: 10.1016/j.canep.2023.102441] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/20/2023] [Accepted: 08/07/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND The importance of sex and gender as modifiers of health and disease is increasingly recognized. The aim of this study was to analyze gender differences in incidence, tumor characteristics, treatment and relative survival (RS) in colorectal cancer (CRC). METHODS Observational population-based study including patients diagnosed with CRC in the Netherlands between 2010 and 2020. Stratified by localization (colon/rectum) and age (18-55/56-70/≥71years), gender differences in incidence, tumor characteristics, treatment and RS were analyzed. Multivariable regression was used to analyze the influence of gender on treatment and RS. RESULTS The age-standardized incidence per 100,000 person-years of colon and rectal cancer is higher among men than women (colon: 41.2 versus 32.4, rectum: 22.8 versus 12.6). Besides differences in patient- and tumor characteristics, differences in treatment allocation and RS were observed. Most strikingly, women aged ≥ 71 years with stage IV colon cancer are less often treated with systemic therapy (31.3 % versus 28.4 %, adjusted odds ratio (OR) 0.63, 95 % CI 0.48-0.83) and more often receive best supportive care only (47.6 % versus 40.0 %, adjusted OR 1.58, 95 % CI 1.19-2.11). CONCLUSION Statistically significant and clinically relevant gender differences in incidence, patient- and tumor characteristics and treatment allocation are observed in patients with CRC. Reasons for differences in treatment allocation deserve further investigation.
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Affiliation(s)
- Felice N van Erning
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands; Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
| | - Nynke E M Greidanus
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands; Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Rob H A Verhoeven
- Department of Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands; Amsterdam UMC location University of Amsterdam, Medical Oncology, Meibergdreef 9, Amsterdam, the Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (Maastro), Grow School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Hans W de Wilt
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dorothea Wagner
- Department of Oncology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
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4
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Canny A, Mason B, Boyd K. Public perceptions of advance care planning (ACP) from an international perspective: a scoping review. BMC Palliat Care 2023; 22:107. [PMID: 37507777 PMCID: PMC10375610 DOI: 10.1186/s12904-023-01230-4] [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: 12/08/2022] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Advance Care Planning (ACP) helps people discuss personal values, goals and priorities regarding future care with family and professionals. It can support care coordination and guide decision-making as health deteriorates. However, uptake remains low internationally. Poor communication and information due to Covid-19 pressures exacerbated public and professional criticism and concerns. Recent recommendations highlight the importance of understanding and addressing public perceptions about ACP combined with person-centred approaches to ACP conversations. OBJECTIVES To explore public perceptions of ACP to inform increased public engagement and empowerment. METHODS Joanna Briggs Institute methodology was applied in a rapid scoping review. Three databases (Embase, MEDLINE, APA PsycInfo) were searched for English language reviews and primary or secondary research studies from 2015 to 2021. Following title and abstract review, two researchers screened full-text articles and performed data extraction independently using Covidence. Charted data were analysed for themes and subthemes starting with two recent published reviews. Emerging findings were added and data synthesis reviewed by the research team, including public-patient representatives, to achieve consensus. RESULTS Of 336 studies, 20 included reviews and research papers represented diverse public views, situations and contexts. Studies found poor public knowledge of ACP and widespread perceptions of confusing or accessible information. Multiple reports described little personal relevance, perceived risks of emotional distress, fears, mistrust and misconceptions about the purpose and scope of ACP. Studies identified public concerns stemming from reluctance to discuss death and dying despite this being just one aspect of ACP. Research with minority communities and marginalised groups found intensified concerns. Some studies cited people who valued maintaining autonomy by expressing their goals and preferences. CONCLUSIONS Studies reviewed found many members of the public had negative or unclear perceptions of ACP. Improved knowledge and understanding appeared to influence perceptions of ACP but were not considered sufficient to change behaviours. The research provided valuable insights from members of the public that could inform current professional and societal debates about the future of ACP. Findings point to a need for novel approaches to ACP public information and involvement whilst bearing in mind societal norms, diverse cultures and contexts.
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Bradley NM, Dowrick CF, Lloyd-Williams M. A survey of hospice day services in the United Kingdom & Republic of Ireland : how did hospices offer social support to palliative care patients, pre-pandemic? Palliat Care 2022; 21:170. [PMID: 36195870 PMCID: PMC9532229 DOI: 10.1186/s12904-022-01061-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 09/09/2022] [Accepted: 09/15/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Social support is described by patients and other stakeholders to be a valuable component of palliative day care. Less is known about the range of hospice services that have been used in practice that facilitate social support. An online survey aimed to gain an overview of all hospice day services that facilitated social support for adults outside of their own homes. METHODS An online survey was distributed via email to people involved in managing hospice day services. Questions were asked on hospice characteristics, including staff and volunteer roles. Respondents were asked to identify services they felt offered social support to patients. Data collection took place between August 2017 and May 2018. RESULTS Responses were received from 103 hospices in the UK and ROI (response rate 49.5%). Results provide an overview of hospice day and outpatient services that offer social support to patients. These are: multi-component interventions, activity groups, formal support groups, befriending, and informal social activities. Multi-component interventions, such as palliative day care, were the most commonly reported. Their stated aims tend to focus on clinical aspects, but many survey respondents considered these multicomponent interventions to be the 'most social' service at their hospice. The survey also identified a huge variety of activity groups, as well as formal therapeutic support groups. Informal 'social-only' activities were present, but less common. Over a third of all the services were described as 'drop in'. Most responding hospices did not routinely use patient reported outcome measures in their 'most social' services. CONCLUSIONS The survey documents hospice activity in facilitating social support to be diverse and evolving. At the time of data collection, many hospices offered multiple different services by which a patient might obtain social support outside of their own home and in the presence of other patients.
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Affiliation(s)
- N M Bradley
- Research Fellow in Realist Evaluation, Centre for Health & Clinical Research, University of the West of England, Glenside Campus, BS16 1DD., Bristol, United Kingdom.
| | - C F Dowrick
- Emeritus Professor, Department of Primary Care and Mental Health, University of Liverpool, Waterhouse Building, L69 3BX., Liverpool, United Kingdom
| | - M Lloyd-Williams
- Professor & Honorary Consultant in Palliative Medicine, Department of Primary Care and Mental Health, University of Liverpool, Waterhouse Building, L69 3BX, Liverpool, United Kingdom
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6
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Nipp RD. Palliative and Supportive Care for Individuals with Pancreatic Adenocarcinoma. Hematol Oncol Clin North Am 2022; 36:1053-1061. [PMID: 36154784 DOI: 10.1016/j.hoc.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Individuals with pancreatic adenocarcinoma experience a complex constellation of palliative and supportive care needs. Notably, when caring for patients with pancreatic adenocarcinoma, clinicians must carefully assess and address these individuals' palliative and supportive care needs, as these can have important implications related to their treatment experience and care outcomes. Importantly, prior research has consistently demonstrated the benefits of palliative and supportive care interventions for patients with cancer to help address symptom burden, illness understanding, coping mechanisms, and informed decision making. However, much of this research did not specifically tailor the interventions to the unique concerns of a pancreatic cancer population. Thus, an urgent need exists to design and conduct rigorous research with the goal of enhancing care delivery and outcomes for the highly symptomatic population of individuals with pancreatic adenocarcinoma.
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Affiliation(s)
- Ryan D Nipp
- University of Oklahoma Health Sciences Center, Stephenson Cancer Center, 800 Northeast 10th Street, Oklahoma City, OK 73104, USA.
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Weetman K, Dale J, Mitchell SJ, Ferguson C, Finucane AM, Buckle P, Arnold E, Clarke G, Karakitsiou DE, McConnell T, Sanyal N, Schuberth A, Tindle G, Perry R, Grewal B, Patynowska KA, MacArtney JI. Communication of palliative care needs in discharge letters from hospice providers to primary care: a multisite sequential explanatory mixed methods study. Palliat Care 2022; 21:155. [PMID: 36064662 PMCID: PMC9444706 DOI: 10.1186/s12904-022-01038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/21/2022] [Indexed: 12/04/2022] Open
Abstract
Background The provision of palliative care is increasing, with many people dying in community-based settings. It is essential that communication is effective if and when patients transition from hospice to community palliative care. Past research has indicated that communication issues are prevalent during hospital discharges, but little is known about hospice discharges. Methods An explanatory sequential mixed methods study consisting of a retrospective review of hospice discharge letters, followed by hospice focus groups, to explore patterns in communication of palliative care needs of discharged patients and describe why these patients were being discharged. Discharge letters were extracted for key content information using a standardised form. Letters were then examined for language patterns using a linguistic methodology termed corpus linguistics. Thematic analysis was used to analyse the focus group transcripts. Findings were triangulated to develop an explanatory understanding of discharge communication from hospice care. Results We sampled 250 discharge letters from five UK hospices whereby patients had been discharged to primary care. Twenty-five staff took part in focus groups. The main reasons for discharge extracted from the letters were symptoms “managed/resolved” (75.2%), and/or the “patient wishes to die/for care at home” (37.2%). Most patients had some form of physical needs documented on the letters (98.4%) but spiritual needs were rarely documented (2.4%). Psychological/emotional needs and social needs were documented in 46.4 and 35.6% of letters respectively. There was sometimes ambiguity in “who” will be following up “what” in the discharge letters, and whether described patients’ needs were resolved or ongoing for managing in the community setting. The extent to which patients received a copy of their discharge letter varied. Focus groups conveyed a lack of consensus on what constitutes “complexity” and “complex pain”. Conclusions The content and structure of discharge letters varied between hospices, although generally focused on physical needs. Our study provides insights into patterns associated with those discharged from hospice, and how policy and guidance in this area may be improved, such as greater consistency of sharing letters with patients. A patient-centred set of hospice-specific discharge letter principles could help improve future practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01038-8.
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Affiliation(s)
- Katharine Weetman
- Interactive Studies Unit, Institute of Clinical Sciences, Birmingham Medical School, University of Birmingham, Birmingham, B15 2TT, UK. .,Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK.
| | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Claire Ferguson
- Marie Curie Hospice West Midlands, Solihull, West Midlands, UK
| | - Anne M Finucane
- Marie Curie Hospice Edinburgh, Edinburgh, UK.,The University of Edinburgh School of Health in Social Science, Clinical Psychology, Edinburgh, UK
| | - Peter Buckle
- Marie Curie Research Voices Group, Marie Curie, England, London, UK
| | | | - Gemma Clarke
- Marie Curie Hospice Bradford, Bradford, UK.,University of Leeds, Academic Unit of Palliative Care, Leeds, West Yorkshire, UK
| | | | - Tracey McConnell
- Marie Curie Hospice Belfast, Belfast, UK.,Queen's University Belfast School of Nursing and Midwifery, Belfast, UK
| | - Nikhil Sanyal
- Marie Curie Hospice West Midlands, Solihull, West Midlands, UK
| | | | - Georgia Tindle
- Marie Curie Hospice Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Rachel Perry
- Marie Curie Hospice West Midlands, Solihull, West Midlands, UK
| | | | | | - John I MacArtney
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK.,Marie Curie Hospice West Midlands, Solihull, West Midlands, UK
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Youssef I, Hoogland AI, Chahoud J, Spiess PE, Jim H, Johnstone PAS. Patient reported outcomes in advanced penile cancer. Urol Oncol 2022; 40:412.e9-412.e13. [PMID: 35662500 PMCID: PMC10766147 DOI: 10.1016/j.urolonc.2022.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/14/2022] [Accepted: 04/30/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Patient reports of their symptom burden (i.e., patient-reported outcomes or PROs) have been shown to direct clinicians' ability to personalize care and improve outcomes. A disciplined assessment of PRO in the population of patients with advanced penile cancer (PeCa) has not previously been undertaken. Our center leveraged a significant cadre of patients with PeCa and a significant experience with a well-established PRO: the Edmonton Symptom Assessment Scale (ESAS). METHODS After IRB approval, we screened ESAS surveys of 14,781 patients completed between February 2017 and February 2021; these were collected in the Supportive Care and Radiation Oncology clinics. Of these, those with PeCa were divided into 3 cohorts: (A) Those after any partial penectomy procedure without lymph node dissection (LND); (B) Those after partial penectomy procedure with LND; and (C) Those after total penectomy and LND. Patients with recurrent disease were analyzed separately (D). ESAS scores were collated and compared both by individual symptom and cumulatively. RESULTS Twenty-two PeCa patients completed 122 ESAS surveys in this time and are included in this analysis: a median of 4 ESAS surveys (mean = 5, range = 1-19) were completed by each patient. The symptom with the highest median ESAS score was Tiredness (3.00). Patients with recurrent disease had the highest cumulative symptom score (median score = 30). Patients after total penectomy with LND had a higher cumulative symptom score (14.4) than those with partial penectomy and LND (7.9). Patients with partial penectomy without LND had a cumulative score of 22. CONCLUSIONS PROs provide an insight into the morbidity of therapies for advanced PeCa, and the most symptoms are reported by patients with recurrent disease.
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Affiliation(s)
- Irini Youssef
- Department of Radiation Oncology, SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Aasha I Hoogland
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jad Chahoud
- Department of Urologic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Philippe E Spiess
- Department of Urologic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Heather Jim
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Peter A S Johnstone
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL; Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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Extermann M, Chetty IJ, Brown SL, Al-Jumayli M, Movsas B. Predictors of Toxicity Among Older Adults with Cancer. Semin Radiat Oncol 2022; 32:179-185. [DOI: 10.1016/j.semradonc.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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10
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Ingle MP, Check D, Slack DH, Cross SH, Ernecoff NC, Matlock DD, Kavalieratos D. Use of Theoretical Frameworks in the Development and Testing of Palliative Care Interventions. J Pain Symptom Manage 2022; 63:e271-e280. [PMID: 34756957 PMCID: PMC8854360 DOI: 10.1016/j.jpainsymman.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/20/2021] [Accepted: 10/22/2021] [Indexed: 11/20/2022]
Abstract
CONTEXT Palliative care (PC) research has grown over the last 20 years. Yet, the causal components and pathways of PC interventions remain unclear. OBJECTIVES To document the prevalence and application of theoretical frameworks in developing and testing PC interventions. METHODS We conducted a secondary analysis of previously published systematic reviews of PC randomized clinical trials. Trials were evaluated for explicit mention of a theoretical framework, process or delivery model, or clinical practice guideline that supported the development of the intervention. We used a structured data extraction form to document study population, outcomes, and whether and how authors used a theoretical framework, process/delivery model, or clinical practice guideline. We applied an adapted coding scheme to evaluate use of theoretical frameworks. RESULTS We reviewed 85 PC trials conducted between 1984 and 2021. Thirty-eight percent (n = 32) of trials explicitly mentioned a theoretical framework, process or delivery model, or clinical practice guideline as a foundation for the intervention design. Only nine trials included a theoretical framework, while the remaining 23 cited a process/delivery model or clinical practice guideline. CONCLUSION Most PC trials do not cite a theoretical foundation for their intervention design. Future work should focus on developing and validating new theoretical frameworks and modifying existing theories and models to better explain the mechanisms of the variety of PC interventions.
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Affiliation(s)
- Mary Pilar Ingle
- Graduate School of Social Work (M.P.I.), University of Denver, Denver, Colorado, USA
| | - Devon Check
- Department of Population Health Sciences (D.C.), Duke University School of Medicine and Duke Cancer Institute, Durham, North Carolina, USA
| | - Daniel Hogan Slack
- Department of Internal Medicine (D.H.S.), University of California Davis School of Medicine, Davis, California, USA
| | - Sarah H Cross
- Division of Palliative Medicine, Department of Family and Preventive Medicine (S.H.C., D.K.), Emory University School of Medicine, Atlanta, Georgia, USA
| | - Natalie C Ernecoff
- Division of General Internal Medicine (N.C.E.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daniel D Matlock
- Division of Geriatrics (D.D.M.), University of Colorado School of Medicine, Aurora, Colorado, USA; VA Eastern Colorado Geriatric Research Education and Clinical Center (D.D.M.), Denver, Colorado, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine (S.H.C., D.K.), Emory University School of Medicine, Atlanta, Georgia, USA; Department of Epidemiology (D.K.), Rollins School of Public Health, Emory University, Atlanta, Georgia, USA.
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Abstract
Lung cancer remains a leading cause of cancer related mortality worldwide. Despite numerous advances in treatments over the past decade, non-small cell lung cancer (NSCLC) remains an incurable disease for most patients. The optimal treatment for all patients with locally advanced, but surgically resectable, NSCLC contains at least chemoradiation. Trimodality treatment with surgical resection has been a subject of debate for decades. For patients with unresectable or inoperable locally advanced disease, the incorporation of immunotherapy consolidation after chemoradiation has defined a new standard of care. For decades, the standard of care treatment for advanced stage NSCLC included only cytotoxic chemotherapy. However, with the introduction of targeted therapies and immunotherapy, the landscape of treatment has rapidly evolved. This review discusses the integration of these innovative therapies in the management of patients with newly diagnosed NSCLC.
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Affiliation(s)
- Meagan Miller
- Indiana University School of Medicine, Indianapolis, IN 46208, USA
| | - Nasser Hanna
- Indiana University School of Medicine, Indianapolis, IN 46208, USA
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12
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Nipp RD, Temel B, Fuh CX, Kay P, Landay S, Lage D, Franco-Garcia E, Scott E, Stevens E, O'Malley T, Mohile S, Dale W, Traeger L, Hashmi AZ, Jackson V, Greer JA, El-Jawahri A, Temel JS. Pilot Randomized Trial of a Transdisciplinary Geriatric and Palliative Care Intervention for Older Adults With Cancer. J Natl Compr Canc Netw 2021; 18:591-598. [PMID: 32380460 DOI: 10.6004/jnccn.2019.7386] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/04/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Oncologists often struggle with managing the unique care needs of older adults with cancer. This study sought to determine the feasibility of delivering a transdisciplinary intervention targeting the geriatric-specific (physical function and comorbidity) and palliative care (symptoms and prognostic understanding) needs of older adults with advanced cancer. METHODS Patients aged ≥65 years with incurable gastrointestinal or lung cancer were randomly assigned to a transdisciplinary intervention or usual care. Those in the intervention arm received 2 visits with a geriatrician, who addressed patients' palliative care needs and conducted a geriatric assessment. We predefined the intervention as feasible if >70% of eligible patients enrolled in the study and >75% of eligible patients completed study visits and surveys. At baseline and week 12, we assessed patients' quality of life (QoL), symptoms, and communication confidence. We calculated mean change scores in outcomes and estimated intervention effect sizes (ES; Cohen's d) for changes from baseline to week 12, with 0.2 indicating a small effect, 0.5 a medium effect, and 0.8 a large effect. RESULTS From February 2017 through June 2018, we randomized 62 patients (55.9% enrollment rate [most common reason for refusal was feeling too ill]; median age, 72.3 years; cancer types: 56.5% gastrointestinal, 43.5% lung). Among intervention patients, 82.1% attended the first visit and 79.6% attended both. Overall, 89.7% completed all study surveys. Compared with usual care, intervention patients had less QoL decrement (-0.77 vs -3.84; ES = 0.21), reduced number of moderate/severe symptoms (-0.69 vs +1.04; ES = 0.58), and improved communication confidence (+1.06 vs -0.80; ES = 0.38). CONCLUSIONS In this pilot trial, enrollment exceeded 55%, and >75% of enrollees completed all study visits and surveys. The transdisciplinary intervention targeting older patients' unique care needs showed encouraging ES estimates for enhancing patients' QoL, symptom burden, and communication confidence.
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Affiliation(s)
- Ryan D Nipp
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Brandon Temel
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Charn-Xin Fuh
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Paul Kay
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Sophia Landay
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Daniel Lage
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Esteban Franco-Garcia
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Erin Scott
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Erin Stevens
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Terrence O'Malley
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.,3Partners Continuing Care, Partners HealthCare System, Boston, Massachusetts
| | - Supriya Mohile
- 4Department of Medicine, Division of Hematology and Oncology, University of Rochester Medical Center, Rochester, New York
| | - William Dale
- 5Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California
| | - Lara Traeger
- 6Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Ardeshir Z Hashmi
- 7Department of Internal Medicine and Geriatrics, Cleveland Clinic, Cleveland, Ohio
| | - Vicki Jackson
- 2Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- 6Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Areej El-Jawahri
- 1Department of Medicine, Division of Hematology and Oncology, and
| | - Jennifer S Temel
- 1Department of Medicine, Division of Hematology and Oncology, and
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13
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Flannery MA, Culakova E, Canin BE, Peppone L, Ramsdale E, Mohile SG. Understanding Treatment Tolerability in Older Adults With Cancer. J Clin Oncol 2021; 39:2150-2163. [PMID: 34043433 PMCID: PMC8238902 DOI: 10.1200/jco.21.00195] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/15/2021] [Accepted: 04/05/2021] [Indexed: 01/03/2023] Open
Affiliation(s)
- Marie A. Flannery
- University of Rochester Medical Center, School of Nursing, Rochester, NY
| | - Eva Culakova
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Beverly E. Canin
- SCOREboard Stakeholder Advisory Group, University of Rochester Medical Center, Rochester, NY
| | - Luke Peppone
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Erika Ramsdale
- Department of Medicine, University of Rochester, Rochester, NY
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14
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Nipp RD, Subbiah IM, Loscalzo M. Convergence of Geriatrics and Palliative Care to Deliver Personalized Supportive Care for Older Adults With Cancer. J Clin Oncol 2021; 39:2185-2194. [PMID: 34043435 PMCID: PMC8260927 DOI: 10.1200/jco.21.00158] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/07/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- Ryan D. Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ishwaria M. Subbiah
- Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
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15
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Dziedzic KL, Albert RH. Management of Intractable Symptoms in Oncologic Care. Curr Oncol Rep 2021; 23:93. [PMID: 34125305 DOI: 10.1007/s11912-021-01082-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW For patients undergoing evaluation and treatment of cancers, symptom management is a critical component of their treatment plan. For some patients, symptoms may become intractable or refractory to common therapies. Here, we review treatment options for these severe symptom conditions. RECENT FINDINGS Medication options and regimens have improved to treat refractory symptoms. Medications can be tailored to treat chemotherapy-induced nausea and vomiting based on current guidelines. Interventions such as venting gastrostomy can mitigate symptoms associated with malignant bowel obstruction, when life expectancy is long enough to realize this benefit. Opiates can reduce refractory dyspnea, consistent with guidelines from the American Thoracic Society. Interventional therapies for intractable pain, such as neurolytic blocks and intrathecal pumps, have shown promise in managing symptoms when traditional therapies have been ineffective. Refractory symptoms can be managed in cancer care. The use of multimodal therapies delivered by interdisciplinary teams appears to be the most effective way to approach these clinical situations.
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Affiliation(s)
| | - Ross H Albert
- Hospice and Palliative Care Medical Director, Hartford Healthcare at Home, 1290 Silas Deane Hwy, Suite 4B, Wethersfield, Hartford, CT, 06109, USA.
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16
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Nipp R, El-Jawahri A, Temel J. Prolonged Survival With Palliative Care-It Is Possible, but Is It Necessary? JAMA Oncol 2021; 5:1693-1694. [PMID: 31536103 DOI: 10.1001/jamaoncol.2019.3100] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Ryan Nipp
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - Areej El-Jawahri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - Jennifer Temel
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
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17
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Nipp RD, Horick NK, Deal AM, Rogak LJ, Fuh C, Greer JA, Dueck AC, Basch E, Temel JS, El-Jawahri A. Differential effects of an electronic symptom monitoring intervention based on the age of patients with advanced cancer. Ann Oncol 2021; 31:123-130. [PMID: 31912785 DOI: 10.1016/j.annonc.2019.09.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Symptom monitoring interventions enhance patient outcomes, including quality of life (QoL), health care utilization, and survival, but it remains unclear whether older and younger patients with cancer derive similar benefits. We explored whether age moderates the improved outcomes seen with an outpatient electronic symptom monitoring intervention. PATIENTS AND METHODS We carried out a secondary analysis of data from a randomized trial of 766 patients receiving chemotherapy for metastatic solid tumors. Patients received an electronic symptom monitoring intervention integrated with oncology care or usual oncology care alone. The intervention consisted of patients reporting their symptoms, which were provided to their physicians at clinic visits, and nurses receiving alerts for severe/worsening symptoms. We used regression models to determine whether age (older or younger than 70 years) moderated the effects of the intervention on QoL (EuroQol EQ-5D), emergency room (ER) visits, hospitalizations, and survival outcomes. RESULTS Enrollment rates for younger (589/777 = 75.8%) and older (177/230 = 77.0%) patients did not differ. Older patients (median age = 75 years, range 70-91 years) were more likely to have an education level of high school or less (26.6% versus 20.9%, P = 0.029) and to be computer inexperienced (50.3% versus 23.4%, P < 0.001) compared with younger patients (median age = 58 years, range 26-69 years). Younger patients receiving the symptom monitoring intervention experienced lower risk of ER visits [hazard ratio (HR) = 0.74, P = 0.011] and improved survival (HR = 0.76, P = 0.011) compared with younger patients receiving usual care. However, older patients did not experience significantly lower risk of ER visits (HR = 0.90, P = 0.613) or improved survival (HR = 1.06, P = 0.753) with the intervention. We found no moderation effects based on age for QoL and risk of hospitalizations. CONCLUSIONS Among patients with advanced cancer, age moderated the effects of an electronic symptom monitoring intervention on the risk of ER visits and survival, but not QoL. Symptom monitoring interventions may need to be tailored to the unique needs of older adults with cancer.
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Affiliation(s)
- R D Nipp
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, USA.
| | - N K Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, USA
| | - A M Deal
- Department of Medicine, Division of Hematology & Oncology, Lineberger Comprehensive Cancer Center at University of North Carolina, Chapel Hill, USA
| | - L J Rogak
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - C Fuh
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, USA
| | - J A Greer
- Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, USA
| | - A C Dueck
- Alliance Statistics and Data Center, Division of Health Sciences Research, Mayo Clinic, Scottsdale, USA
| | - E Basch
- Department of Medicine, Division of Hematology & Oncology, Lineberger Comprehensive Cancer Center at University of North Carolina, Chapel Hill, USA
| | - J S Temel
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, USA
| | - A El-Jawahri
- Department of Medicine, Division of Hematology & Oncology, Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, USA
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18
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Kadambi S, Loh KP, Dunne R, Magnuson A, Maggiore R, Zittel J, Flannery M, Inglis J, Gilmore N, Mohamed M, Ramsdale E, Mohile S. Older adults with cancer and their caregivers - current landscape and future directions for clinical care. Nat Rev Clin Oncol 2020; 17:742-755. [PMID: 32879429 PMCID: PMC7851836 DOI: 10.1038/s41571-020-0421-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 12/13/2022]
Abstract
Despite substantial improvements in the outcomes of patients with cancer over the past two decades, older adults (aged ≥65 years) with cancer are a rapidly increasing population and continue to have worse outcomes than their younger counterparts. Managing cancer in this population can be challenging because of competing health and ageing-related conditions that can influence treatment decision-making and affect outcomes. Geriatric screening tools and comprehensive geriatric assessment can help to identify patients who are most at risk of poor outcomes from cancer treatment and to better allocate treatment for these patients. The use of evidence-based management strategies to optimize geriatric conditions can improve communication and satisfaction between physicians, patients and caregivers as well as clinical outcomes in this population. Clinical trials are currently underway to further determine the effect of geriatric assessment combined with management interventions on cancer outcomes as well as the predictive value of geriatric assessment in the context of treatment with contemporary systemic therapies such as immunotherapies and targeted therapies. In this Review, we summarize the unique challenges of treating older adults with cancer and describe the current guidelines as well as investigational studies underway to improve the outcomes of these patients.
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Affiliation(s)
- Sindhuja Kadambi
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA.
| | - Kah Poh Loh
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Richard Dunne
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Allison Magnuson
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Ronald Maggiore
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Jason Zittel
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Marie Flannery
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Julia Inglis
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Nikesha Gilmore
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Mostafa Mohamed
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Erika Ramsdale
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA
| | - Supriya Mohile
- University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA.
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19
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Hertler C, Seiler A, Gramatzki D, Schettle M, Blum D. Sex-specific and gender-specific aspects in patient-reported outcomes. ESMO Open 2020; 5:e000837. [PMID: 33184099 PMCID: PMC7662538 DOI: 10.1136/esmoopen-2020-000837] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/22/2020] [Accepted: 10/07/2020] [Indexed: 01/10/2023] Open
Abstract
Patient-reported outcomes (PROs) are important tools in patient-centred medicine and allow for individual assessment of symptom burden and aspects of patients’ quality of life. While sex and gender differences have emerged in preclinical and clinical medicine, these differences are not adequately represented in the development and use of patient-reported outcome measures. However, even in personalised approaches, undesirable biases may occur when samples are unbalanced for certain characteristics, such as sex or gender. This review summarises the current status of the literature and trends in PROs with a focus on sex and gender aspects.
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Affiliation(s)
- Caroline Hertler
- Department of Radiation Oncology and Competence Center for Palliative Care, University Hospital Zurich and University of Zurich, Zurich, Switzerland.
| | - Annina Seiler
- Department of Radiation Oncology and Competence Center for Palliative Care, University Hospital Zurich and University of Zurich, Zurich, Switzerland; Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dorothee Gramatzki
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Markus Schettle
- Department of Radiation Oncology and Competence Center for Palliative Care, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - David Blum
- Department of Radiation Oncology and Competence Center for Palliative Care, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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20
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van de Wiel M, Derijcke S, Galdermans D, Daenen M, Surmont V, De Droogh E, Lefebure A, Saenen E, Vandenbroucke E, Morel AM, Sadowska A, van Meerbeeck JP, Janssens A. Coping Strategy Influences Quality of Life in Patients With Advanced Lung Cancer by Mediating Mood. Clin Lung Cancer 2020; 22:e146-e152. [PMID: 33060059 DOI: 10.1016/j.cllc.2020.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/23/2020] [Accepted: 09/10/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Patients with advanced lung cancer experience high physical symptom burden with substantial psychological distress. Depressive and anxiety symptoms are common and associated with worse quality of life (QoL). Early palliative care (EPC) addresses the complex supportive care needs improving QoL and mood. The mechanisms of EPC are uncertain. We examined whether and how coping strategy, a primary component of EPC, influenced QoL in these patients. MATERIALS AND METHODS We conducted a multicenter cross-sectional study of patients with advanced lung cancer. A total of 125 patients completed assessments of QoL (QLQ-C15-PAL), depressive and anxiety symptoms (HADS), and coping (brief COPE questionnaire). The data were analyzed by descriptive statistics. To determine whether and how coping strategy influences QoL, correlations and logistic regressions were performed. RESULTS Positive reframing correlates significantly with global QoL (r = 0.25, P < .01), emotional well-being (r = 0.33, P < .01), pain (r = -0.30, P < .01), fatigue (r = -0.22, P < .01), loss of appetite (r = -0.22, P < .01) and nausea (r = -0.24, P < .01). Self-blame correlates significantly with worse emotional well-being (r = -0.19, P < .05) and insomnia (r = 0.19, P < .05). Using a 4-step logistic regression model, it was found that anxiety and depressive symptoms fully mediated the relationship between positive reframing and QoL. CONCLUSIONS Patients with advanced lung cancer using positive reframing as coping strategy, experience higher QoL. The mechanism behind it seems that positive reframing goes along with less anxiety and depressive symptoms leading to a better QoL. Self-blame leads to more insomnia and worse emotional well-being. Providing skills to cope effectively could impact QoL in these patients.
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Affiliation(s)
- Mick van de Wiel
- University Hospital Antwerp, Department of Thoracic Oncology, Edegem, Belgium.
| | - Sofie Derijcke
- Department of Pulmonology-Thoracic Oncology, AZ Groeninge, Kortrijk, Belgium
| | - Daniella Galdermans
- Department of Pulmonology-Thoracic Oncology, ZNA Middelheim, Antwerp, Belgium
| | - Marc Daenen
- Department of Pulmonology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Veerle Surmont
- Department of Pulmonology-Thoracic Oncology, Ghent University, Ghent, Belgium
| | - Els De Droogh
- Department of Pulmonology-Thoracic Oncology, ZNA Middelheim, Antwerp, Belgium
| | - Anneke Lefebure
- Department of Pulmonology-Thoracic Oncology, ZNA STER, Antwerp, Belgium
| | - Erika Saenen
- Lung diseases/Allergology, AZ Heilige Familie, Reet, Belgium
| | - Elke Vandenbroucke
- Department of Pulmonology-Thoracic Oncology, AZ Monica, Antwerp, Belgium
| | - Ann-Marie Morel
- Department of Pulmonology, Sint-Jozefkliniek Bornem & Willebroek, Bornem, Belgium
| | - Anna Sadowska
- Department of Pulmonology, Ziekenhuis Maas en Kempen, Campus Maaseik, Maaseik, Belgium
| | - Jan P van Meerbeeck
- University Hospital Antwerp, Department of Thoracic Oncology, Edegem, Belgium
| | - Annelies Janssens
- University Hospital Antwerp, Department of Thoracic Oncology, Edegem, Belgium
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21
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Symptom Burden of Nonresected Pancreatic Adenocarcinoma: An Analysis of 10,753 Patient-Reported Outcome Assessments. Pancreas 2020; 49:1083-1089. [PMID: 32769858 DOI: 10.1097/mpa.0000000000001629] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Pancreatic adenocarcinoma (PAC) is a debilitating disease. We sought to analyze symptom burden and trajectories after diagnosis of PAC and identify predictors of severe symptoms for nonresected patients. METHODS This was a retrospective review of linked administrative health care databases examining patients with PAC not undergoing resection. Primary outcome was severe patient-reported symptoms (Edmonton Symptom Assessment System ≥7). Multivariable modified Poisson regression models were used to identify factors associated with reporting severe symptoms. RESULTS A total of 10,753 symptom assessments from 2168 patients were analyzed. The median age was 67 years, and 47% were female; median survival was 7 months. Most common severe symptoms were tiredness (54.7%), anorexia (53.6%), overall impaired well-being (45.3%), and drowsiness (37.1%). Severity of symptoms decreased 1 month after diagnosis and plateaued 4 months after diagnosis. Female sex, comorbidities, and older age were associated with reporting severe symptoms; recent radiation treatment and residence in a rural community were associated with reporting less severe symptoms. CONCLUSIONS The prevalence of severe symptoms in patients with nonresected PAC was high, but potentially modifiable. We identified vulnerable groups of patients that may benefit from focused interventions. This information is important for patient counseling and design of supportive care strategies.
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22
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Hoerger M, Wayser GR, Schwing G, Suzuki A, Perry LM. Impact of Interdisciplinary Outpatient Specialty Palliative Care on Survival and Quality of Life in Adults With Advanced Cancer: A Meta-Analysis of Randomized Controlled Trials. Ann Behav Med 2020; 53:674-685. [PMID: 30265282 DOI: 10.1093/abm/kay077] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In advanced cancer, patients want to know how their care options may affect survival and quality of life, but the impact of outpatient specialty palliative care on these outcomes in cancer is uncertain. PURPOSE To estimate the impact of outpatient specialty palliative care programs on survival and quality of life in adults with advanced cancer. METHODS Following PRISMA guidelines, we conducted a systematic review and meta-analysis of randomized controlled trials comparing outpatient specialty palliative care with usual care in adults with advanced cancer. Primary outcomes were 1 year survival and quality of life. Analyses were stratified to compare preliminary studies against higher-quality studies. Secondary outcomes were survival at other endpoints and physical and psychological quality-of-life measures. RESULTS From 2,307 records, we identified nine studies for review, including five high-quality studies. In the three high-quality studies with long-term survival data (n = 646), patients randomized to outpatient specialty palliative care had a 14% absolute increase in 1 year survival relative to controls (56% vs. 42%, p < .001). The survival advantage was also observed at 6, 9, 15, and 18 months, and median survival was 4.56 months longer (14.55 vs. 9.99 months). In the five high-quality studies with quality-of-life data (n = 1,398), outpatient specialty palliative care improved quality-of-life relative to controls (g = .18, p < .001), including for physical and psychological measures. CONCLUSIONS Patients with advanced cancer randomized to receive outpatient specialty palliative care lived longer and had better quality of life. Findings have implications for improving care in advanced cancer.
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Affiliation(s)
- Michael Hoerger
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, LA
| | | | - Gregory Schwing
- Department of Biology, University of New Orleans, New Orleans, LA
| | - Ayako Suzuki
- Department of Epidemiology, Tulane University, New Orleans, LA
| | - Laura M Perry
- Department of Psychology, Tulane University, New Orleans, LA
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23
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Nipp RD, Thompson LL, Temel B, Fuh CX, Server C, Kay PS, Landay S, Lage DE, Traeger L, Scott E, Jackson VA, Horick NK, Greer JA, El-Jawahri A, Temel JS. Screening Tool Identifies Older Adults With Cancer at Risk for Poor Outcomes. J Natl Compr Canc Netw 2020; 18:305-313. [PMID: 32135520 DOI: 10.6004/jnccn.2019.7355] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 09/03/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Oncologists often struggle with managing the complex issues unique to older adults with cancer, and research is needed to identify patients at risk for poor outcomes. METHODS This study enrolled patients aged ≥70 years within 8 weeks of a diagnosis of incurable gastrointestinal cancer. Patient-reported surveys were used to assess vulnerability (Vulnerable Elders Survey [scores ≥3 indicate a positive screen for vulnerability]), quality of life (QoL; EORTC Quality of Life of Cancer Patients questionnaire [higher scores indicate better QoL]), and symptoms (Edmonton Symptom Assessment System [ESAS; higher scores indicate greater symptom burden] and Geriatric Depression Scale [higher scores indicate greater depression symptoms]). Unplanned hospital visits within 90 days of enrollment and overall survival were evaluated. We used regression models to examine associations among vulnerability, QoL, symptom burden, hospitalizations, and overall survival. RESULTS Of 132 patients approached, 102 (77.3%) were enrolled (mean [M] ± SD age, 77.25 ± 5.75 years). Nearly half (45.1%) screened positive for vulnerability, and these patients were older (M, 79.45 vs 75.44 years; P=.001) and had more comorbid conditions (M, 2.13 vs 1.34; P=.017) compared with nonvulnerable patients. Vulnerable patients reported worse QoL across all domains (global QoL: M, 53.26 vs 66.82; P=.041; physical QoL: M, 58.95 vs 88.24; P<.001; role QoL: M, 53.99 vs 82.12; P=.001; emotional QoL: M, 73.19 vs 85.76; P=.007; cognitive QoL: M, 79.35 vs 92.73; P=.011; social QoL: M, 59.42 vs 82.42; P<.001), higher symptom burden (ESAS total: M, 31.05 vs 15.00; P<.001), and worse depression score (M, 4.74 vs 2.25; P<.001). Vulnerable patients had a higher risk of unplanned hospitalizations (hazard ratio, 2.38; 95% CI, 1.08-5.27; P=.032) and worse overall survival (hazard ratio, 2.26; 95% CI, 1.14-4.48; P=.020). CONCLUSIONS Older adults with cancer who screen positive as vulnerable experience a higher symptom burden, greater healthcare use, and worse survival. Screening tools to identify vulnerable patients should be integrated into practice to guide clinical care.
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Affiliation(s)
- Ryan D Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Leah L Thompson
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Brandon Temel
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Charn-Xin Fuh
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | | | - Paul S Kay
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Sophia Landay
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Daniel E Lage
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | | | - Erin Scott
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Vicki A Jackson
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Nora K Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Areej El-Jawahri
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts
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24
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Greer JA, Applebaum AJ, Jacobsen JC, Temel JS, Jackson VA. Understanding and Addressing the Role of Coping in Palliative Care for Patients With Advanced Cancer. J Clin Oncol 2020; 38:915-925. [PMID: 32023161 DOI: 10.1200/jco.19.00013] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Advanced cancer, with its considerable physical symptoms and psychosocial burdens, represents an existential threat and major stressor to patients and their caregivers. In response to such stress, patients and their caregivers use a variety of strategies to manage the disease and related symptoms, such as problem-focused, emotion-focused, meaning-focused, and spiritual/religious coping. The use of such coping strategies is associated with multiple outcomes, including quality of life, symptoms of depression and anxiety, illness understanding, and end-of-life care. Accumulating data demonstrate that early palliative care, integrated with oncology care, not only improves these key outcomes but also enhances coping in patients with advanced cancer. In addition, trials of home-based palliative care interventions have shown promise for improving the ways that patients and family caregivers cope together and manage problems as a dyad. In this article, we describe the nature and correlates of coping in this population, highlight the role of palliative care to promote effective coping strategies in patients and caregivers, and review evidence supporting the beneficial effects of palliative care on patient coping as well as the mechanisms by which improved coping is associated with better outcomes. We conclude with a discussion of the limitations of the state of science, future directions, and best practices on the basis of available evidence.
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Affiliation(s)
- Joseph A Greer
- Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | | | - Juliet C Jacobsen
- Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Jennifer S Temel
- Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Vicki A Jackson
- Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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25
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Loh KP, Mohile SG, Flannery M. Electronic symptom monitoring: not everyone fits the mold. Ann Oncol 2020; 31:13-14. [PMID: 31912786 DOI: 10.1016/j.annonc.2019.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- K P Loh
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, USA.
| | - S G Mohile
- James P Wilmot Cancer Institute, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, USA
| | - M Flannery
- School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, USA
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Bouleuc C, Burnod A, Angellier E, Massiani MA, Robin ML, Copel L, Chvetzoff G, Frasie V, Fogliarini A, Vinant P. [Early palliative care in oncology]. Bull Cancer 2019; 106:796-804. [PMID: 31174856 DOI: 10.1016/j.bulcan.2019.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 04/11/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
Abstract
Early palliative care is now recommended in international guidelines. A meta-analyze combining seven randomized studies has been published in 2007. It confirms that early palliative care improves patient's quality of life and reduces symptom burden. There is also a trend for the reduction of depressive disorder and the increase of overall survival. Other studies show that early palliative care improves quality of life of patient's relatives and reduces end of life care aggressiveness. Most of the time, early palliative care is introduced as soon as the diagnosis of advanced cancer is made, and the precise referral criteria need to be addressed. Other studies have assessed the palliative care consultation; patient-centered care, focusing on symptom management, filling information and education needs about illness and prognosis, helping psychologic adaptation and coping.
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Affiliation(s)
- Carole Bouleuc
- Institut Curie, département de soins de support, 26, rue d'Ulm, 75248 Paris cedex 05, France.
| | - Alexis Burnod
- Institut Curie, département de soins de support, 26, rue d'Ulm, 75248 Paris cedex 05, France
| | - Elisabeth Angellier
- Institut Curie, département de soins de support, 35, rue Dailly, 92210 Saint-Cloud, France
| | - Marie-Ange Massiani
- Institut Curie, département d'oncologie médicale, 35, rue Dailly, 92210 Saint-Cloud, France
| | - Marie-Luce Robin
- SSR de la clinique du Pont de Sèvres, 76, rue de Silly, 92100 Boulogne-Billancourt, France
| | - Laure Copel
- Centre hospitalier Diaconesses, service de soins palliatifs, 125, rue d'Avron, 75020 Paris, France
| | - Gisèle Chvetzoff
- Centre Leon-Berard, département de soins de support, 28, rue Laennec, 69008 Lyon, France
| | - Véronique Frasie
- Centre Paul-Strauss, département de soins de support, 3, rue de la Porte de l'Hôpital, 67065 Strasbourg cedex, France
| | - Anne Fogliarini
- Centre Lacassagne, service de soins palliatifs, 227, avenue de la Lanterne, 06000 Nice, France
| | - Pascale Vinant
- CHU de Cochin, services de soins palliatifs, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
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A clinical approach to the management of cancer-related pain in emergency situations. Support Care Cancer 2019; 27:3147-3157. [PMID: 31076900 DOI: 10.1007/s00520-019-04830-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 04/23/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Most cancer patients experience many pain episodes depending on disruptive elements, leading them to the emergency room. The objective of the article is to describe common pitfalls that need to be avoided, as well as opportunities to be seized for repositioning patients back on their care pathway. METHODS Critical reflection based on literature analysis and clinical practice. RESULTS Most forms of cancer are now chronic, evolving diseases, and patients are treated with high-technology targeted therapies with iatrogenic effects. Moreover, the multimorphic nature of cancer-related pain requires dynamic, interdisciplinary assessments addressing its etiology, its pathophysiology, its dimensions (sensory-discriminatory, cognitive, emotional, and behavioral), and the patient's perception of it, in order to propose the most adapted therapies. However, for most patients, cancer pain remains underestimated, poorly assessed, and under-treated. In this context, the key steps in emergency cancer pain management are as follows: • Quick relief of uncontrolled cancer pain: after eliminating potential medical or surgical emergencies revealed by pain, a brief questioning will make the use of carefully titrated morphine in most situations possible. • Assessment and re-assessment of the pain and the patient, screening specific elements, to better understand the situation and its consequences. • Identification of disruptive elements leading to uncontrolled pain, with an interdisciplinary confrontation to find a mid to long-term approach, involving the appropriate pharmaceutical and/or non-pharmaceutical strategies, possibly including interventions. CONCLUSIONS Pain emergencies should be part of the cancer care pathway and, through supportive care, provide an opportunity to help cancer patients both maintain their physical, psychological, and social balance and anticipate further painful episodes.
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Hoerger M, Perry LM, Korotkin BD, Walsh LE, Kazan AS, Rogers JL, Atiya W, Malhotra S, Gerhart JI. Statewide Differences in Personality Associated with Geographic Disparities in Access to Palliative Care: Findings on Openness. J Palliat Med 2019; 22:628-634. [PMID: 30615552 DOI: 10.1089/jpm.2018.0206] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Geographic disparities in access to palliative care cause unnecessary suffering near the end-of-life in low-access U.S. states. The psychological mechanisms accounting for state-level variation are poorly understood. Objective: To examine whether statewide differences in personality account for variation in palliative care access. Design: We combined 5 state-level datasets that included the 50 states and national capital. Palliative care access was measured by the Center to Advance Palliative Care 2015 state-by-state report card. State-level personality differences in openness, conscientiousness, agreeableness, neuroticism, and extraversion were identified in a report on 619,387 adults. The Census and Gallup provided covariate data. Regression analyses examined whether state-level personality predicted state-level palliative care access, controlling for population size, age, gender, race/ethnicity, socioeconomic status, and political views. Sensitivity analyses controlled for rurality, nonprofit status, and hospital size. Results: Palliative care access was higher in states that were older, less racially diverse, higher in socioeconomic status, more liberal, and, as hypothesized, higher in openness. In regression analyses accounting for all predictors and covariates, higher openness continued to account for better state-level access to palliative care (β = 0.428, p = 0.008). Agreeableness also emerged as predicting better access. In sensitivity analyses, personality findings persisted, and less rural states and those with more nonprofits had better access. Conclusions: Palliative care access is worse in states lower in openness, meaning where residents are more skeptical, traditional, and concrete. Personality theory offers recommendations for palliative care advocates communicating with administrators, legislators, philanthropists, and patients to expand access in low-openness states.
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Affiliation(s)
- Michael Hoerger
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana.,2 Section of Hematology and Medical Oncology, Department of Medicine, Tulane University, New Orleans, Louisiana.,3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana
| | - Laura M Perry
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana.,3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana
| | - Brittany D Korotkin
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana.,3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana
| | - Leah E Walsh
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Adina S Kazan
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana
| | - James L Rogers
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Wasef Atiya
- 1 Department of Psychology, Tulane University, New Orleans, Louisiana.,3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana
| | - Sonia Malhotra
- 3 Department of Palliative Medicine, University Medical Center, New Orleans, Louisiana.,4 Section of Palliative Medicine, Department of General Internal Medicine and Geriatrics, Tulane University, New Orleans, Louisiana
| | - James I Gerhart
- 5 Department of Psychology, Central Michigan University, Mount Pleasant, Michigan
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Saeed F, Hoerger M, Norton SA, Guancial E, Epstein RM, Duberstein PR. Preference for Palliative Care in Cancer Patients: Are Men and Women Alike? J Pain Symptom Manage 2018; 56:1-6.e1. [PMID: 29581034 PMCID: PMC6015521 DOI: 10.1016/j.jpainsymman.2018.03.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 03/02/2018] [Accepted: 03/13/2018] [Indexed: 11/21/2022]
Abstract
CONTEXT Men and those with low educational attainment are less likely to receive palliative care. Understanding these disparities is a high priority issue. OBJECTIVES In this study of advanced cancer patients, we hypothesized that men and those with lower levels of educational attainment would have less favorable attitudes toward palliative care. METHODS We performed a cross-sectional analysis of data collected from 383 patients at study entry in the Values and Options in Cancer Care (VOICE) clinical trial. Patients were asked about their preferences for palliative care if their oncologist informed them that further treatment would not be helpful. Palliative care was defined as "comfort care" that focuses on "quality of life, but not a cure." Response options were definitely no, possibly no, unsure, possibly yes, and definitely yes. Those preferring palliative care (definitely or possibly yes) were compared to all others. Predictors were patient gender and education level. Covariates included age, race, disease aggressiveness, and financial strain. RESULTS Women were more likely [odds ratio (95% CI)] than men to prefer palliative care [3.07 (1.80-5.23)]. The effect of education on preferences for palliative care was not statistically significant [0.85 (0.48-1.48)]. CONCLUSION Significant gender differences in patients' preferences for palliative care could partially account for gender disparities in end-of-life care. Interventions to promote palliative care among men could reduce these disparities.
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Affiliation(s)
- Fahad Saeed
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Michael Hoerger
- Department of Psychology, Tulane University, New Orleans, Louisiana
| | - Sally A Norton
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Elizabeth Guancial
- Division of Hematology Oncology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ronald M Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Paul R Duberstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine and Center for Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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