Use of Palliative Chemo- and Radiotherapy at the End of Life in Patients With Cancer: A Retrospective Cohort Study

Anti-tumor treatment and healthcare consumption near death in the era of novel treatment options for patients with melanoma brain metastases

Background

Effective systemic treatments have revolutionized the management of patients with metastatic melanoma, including those with brain metastases. The extent to which these treatments influence disease trajectories close to death is unknown. Therefore, this study aimed to gain insight into provided treatments and healthcare consumption during the last 3 months of life in patients with melanoma brain metastases.

Methods

Retrospective, single-center study, including consecutive patients with melanoma brain metastases diagnosed between June-2015 and June-2018, referred to the medical oncologist, and died before November-2019. Patient and tumor characteristics, anti-tumor treatments, healthcare consumption, presence of neurological symptoms, and do-not-resuscitate status were extracted from medical charts.

Results

100 patients were included. A BRAF-mutation was present in 66 patients. Systemic anti-tumor therapy was given to 72% of patients during the last 3 months of life, 34% in the last month, and 6% in the last week. Patients with a BRAF-mutation more frequently received systemic treatment during the last 3 (85% vs. 47%) and last month (42% vs. 18%) of life than patients without a BRAF-mutation. Furthermore, patients receiving systemic treatment were more likely to visit the emergency room (ER, 75% vs. 36%) and be hospitalized (75% vs. 36%) than those who did not.

Conclusion

The majority of patients with melanoma brain metastases received anti-tumor treatment during the last 3 months of life. ER visits and hospitalizations occurred more often in patients on anti-tumor treatment. Further research is warranted to examine the impact of anti-tumor treatments close to death on symptom burden and care satisfaction.

Knowledge and use of prognostic scales by oncologists and palliative care physicians in adult patients with advanced cancer: A national survey (ONCOPRONO study)

BACKGROUND

Prognostic scales exist to estimate patient survival in advanced cancer. However, there are no studies evaluating their use and practice. The objective of this study was to evaluate in a nationwide study the proportion of oncologists and palliative care physicians who had knowledge of these scales.

METHODS

A descriptive, national, cross-sectional study was conducted via an online questionnaire to oncologists and palliative care physicians across France.

RESULTS

Palliative care physicians had better knowledge of the scales than oncologists (42.3% (n = 74) vs. 27.8% (n = 33), p = 0.015). The Palliative Performance Status (PPS) and Pronopall Scale were the best-known (51.4% (n = 55) and 65.4% (n = 70), respectively) and the most widely used (35% (n = 28) and 60% (n = 48), respectively). Improved training in the use of these scales was requested by 85.4% (n = 251) of participants, while 72.8% (n = 214) reported that they did not use them at all. Limited training and lack of consensus on which scale to use were cited as the main obstacles to use.

CONCLUSION

This is the first national study on the use of prognostic scales in advanced cancer. Our findings highlight a need to improve training in these scales and to reach a consensus on scale selection.

Efficacy of systemic oncological treatments in patients with advanced esophageal or gastric cancers at high risk of dying in the middle and short term: an overview of systematic reviews

Background

Esophageal and gastric cancers are a significant public health problem worldwide, with most patients presenting with advanced-stage disease and, consequently, poor prognosis. Systemic oncological treatments (SOT) have been widely used over more conservative approaches, such as supportive care. Nevertheless, its effectiveness in this scenario is not sufficiently clear. This paper provides an overview of systematic reviews that assessed the effectiveness of SOT compared with the best supportive care (BSC) or placebo in patients with advanced esophageal or gastric cancers in an end-of-life context.

Methods

We searched MEDLINE, EMBASE, The Cochrane Library, Epistemonikos, and PROSPERO for eligible systematic reviews (SRs) published from 2008 onwards. The primary outcomes were overall survival (OS), progression-free survival (PFS), functional status, and toxicity. Two authors assessed eligibility and extracted data independently. We evaluated the methodological quality of included SRs using the AMSTAR-2 tool and the overlap of primary studies (corrected covered area, CCA). Also, we performed a de novo meta-analysis with data reported for each primary study when it was possible. We assessed the certainty of evidence using the GRADE approach.

Results

We identified 16 SRs (19 included trials) for inclusion within this overview. Most reviews had a critically low methodological quality, and there was a very high overlap of primary studies. It is uncertain whether SOT improves OS and PFS over more conservative approaches due to the very low certainty of evidence.

Conclusions

The evidence is very uncertain about the effectiveness of SOT for advanced esophageal or gastric cancers. High-quality SRs and further randomized clinical trials that include a thorough assessment of patient-centered outcomes are needed.

Trial registration

Open Science Framework, 10.17605/OSF.IO/7CHX6.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08330-5.

Systemic Anti-Cancer Therapy Use in Palliative Care Outpatients With Advanced Cancer

PURPOSE

To evaluate factors associated with continuation of systemic anti-cancer therapy (SACT) after palliative care consultation, and SACT administration in the last 30 days of life, in outpatients with cancer referred to palliative care. Timing of referral was of particular interest.

METHODS

Patient, disease, and treatment-related factors associated with SACT before and after palliative care, and in the last 30 days of life, were identified using 3-level multinomial logistic regression. Referral to palliative care was categorized by time from death as early (>12 months), intermediate (6-12 months), and late (≤6 months).

RESULTS

Of the 337 patients, 240 (71.2%) received SACT for advanced cancer; of these, 126 (52.5%) received SACT only prior to palliative care while 114 (47.5%) also received SACT afterward. Only 35/337 (10.4%) received SACT in the last 30 days of life. On multivariable analysis, factors associated with continuing SACT after palliative care consultation were a cancer diagnosis for <1 year (OR 3.09, p = 0.01), breast primary (OR 11.88, p = 0.0008), and early (OR 28.8, p < 0.001) or intermediate (OR 6.67, p < 0.001) referral timing. No factors were significantly associated with receiving SACT in the last 30 days versus earlier, but the median time from palliative care referral to death in those receiving SACT in the last 30 days versus stopping SACT earlier was 1.78 versus 4.27 months.

CONCLUSION

Patients who received SACT following palliative care consultation were more likely to be referred early; however, patients receiving SACT in their last 30 days tended to be referred late.

Prioritizing Chinese Medicine Clinical Research Questions in Cancer Palliative Care: International Delphi Survey

CONTEXT

Chinese medicine modalities, including acupuncture and Chinese herbal medicine (CHM), have been used as palliative interventions among cancer patients. More research should be conducted to confirm their effectiveness.

OBJECTIVES

The objective of this study was to prioritize Chinese medicine clinical research questions for cancer palliative care.

METHODS

Twelve international experts, including physicians, Chinese medicine practitioners, nurses, and clinical research methodologists (n = 3 from each category), from Asia, North America, Australia, and Europe participated in a two-round Delphi survey for prioritizing 29 research questions identified from existing systematic reviews. The experts were asked to 1) rate clinical importance of answering the questions on a nine-point Likert scale; 2) provide qualitative comments on their ratings; and 3) suggest outcome measurement approaches.

RESULTS

Eight research priorities reached positive consensus after the two-round Delphi survey. Six of the priorities focused on acupuncture and related therapies, of which median ratings on importance ranged from 7.0 to 8.0 (interquartile range: 1.00 to 2.50), and the percentage agreement ranged from 75.0% to 91.7%. The remaining two priorities related to CHM, with median ratings ranged from 7.0 to 8.0 (interquartile range: 1.00 to 1.50) and percentage agreement ranged from 75.0% to 83.3%. Neither positive nor negative consensus was established among the remaining 21 questions.

CONCLUSION

The findings will inform rational allocation of scarce research funding for evaluating the effectiveness of Chinese medicine for cancer palliative care, especially on acupuncture and related therapies. Further research on herb safety and herb-drug interaction should be performed before conducting international trials on CHM.

Palliative Radiotherapy: Inpatients, Outpatients, and the Changing Role of Supportive Care in Radiation Oncology

Palliative radiotherapy is an effective treatment in alleviating many symptoms of advanced cancer. Short courses of radiotherapy provide rapid symptom relief and minimize impact on patients. Patients referred for palliative radiotherapy have many concerns beyond radiotherapy; often, these concerns are not fully addressed in traditional radiotherapy clinics. Discussions of prognosis, patient goals, and concerns are areas for improved collaboration. Innovative, dedicated palliative radiotherapy programs have developed over the past 20 years to provide holistic care to patients referred for palliative radiotherapy and have improved patient-focused outcomes. Advanced radiotherapy techniques may provide opportunities to further improve palliative radiotherapy outcomes.

Immune Checkpoint Inhibitor Use Near the End of Life Is Associated With Poor Performance Status, Lower Hospice Enrollment, and Dying in the Hospital

Background:

Immune checkpoint inhibitors have changed the landscape of cancer care by increasing progression-free and overall survival in some patients with cancer. We evaluated use and variables contributing to immune checkpoint inhibitor treatment near the end of life.

Methods:

We studied 157 patients who received immune checkpoint inhibitors and died between January 2015 and December 2018. All patients had a palliative care consult any time between starting an immune checkpoint inhibitor and death. Univariate and multivariate models were used to examine variables related to immune checkpoint inhibitor use near the end of life.

Results:

Among 157 patients studied, 42 (27%) received a dose of immune checkpoint inhibitor in the last 30 days of life. Those who received treatment in the last 30 days of life had lower hospice enrollment (19 [45%] vs 78 [69%], P = .007) and higher rates of dying in the hospital (23 [56%] vs 33 [29%], P = .002). The percentage of patients with Eastern Cooperative Oncology Group (ECOG) ≥3 at the time of last immune checkpoint inhibitor dose was higher in the group that received immune checkpoint inhibitor treatment in the last 30 days of life (11 [26%] vs 9 [8%], P = .003). Lack of traditional chemotherapy after immune checkpoint inhibitor, ECOG ≥3, and lack of hospice enrollment were independently associated with receiving immune checkpoint inhibitor in the last 30 days of life.

Conclusion:

Immune checkpoint inhibitor use in the last 30 days of life is common and associated with poor performance status, lower hospice enrollment, and dying in the hospital.

Palliative and End-of-Life Care for Patients with Malignancy

Patients with cancer continue to have unmet palliative care needs. Concurrent palliative care is tailored to the needs of patients as well as their families to relieve suffering. Specialty palliative care referral is associated with improved symptom management, improved end-of-life quality, and higher family-rated satisfaction. Optimal timing for palliative care referral has not been determined. Barriers to palliative care referral include workforce limitations, provider attitudes and perceptions, and potential ethnic and racial disparities in access to palliative care. Future work should focus on novel, patient-centered approaches to identify and address unmet palliative care needs for patients living with cancer.

Complementary and Alternative Medicine Use and Its Association with Emotional Status and Quality of Life in Patients with a Solid Tumor: A Cross-Sectional Study

Objectives: Complementary and alternative medicine (CAM) has been used widely in various populations for various purposes, including emotional support and improvement of quality of life (QOL). However, CAM use and purposes for using CAM are less clear among Korean patients with a solid tumor. The purpose of this study was to determine the prevalence and type of CAM use, and the association between CAM use and anxiety, depression, and QOL in patients with a solid tumor.

Design: A cross-sectional survey.

Setting: A cancer center in Korea.

Subjects: Two hundred and sixteen patients diagnosed with a solid tumor.

Outcome measures: Standard questionnaires on CAM use, Hospital Anxiety and Depression Scale, and European Organization for Research and Treatment of Cancer QLQ-C30.

Results: One hundred thirty one patients (60.6%) reported using CAM. CAM users, compared with non-CAM users, were significantly younger (57.8 vs. 60.9 years, p = 0.05), had higher level of education (p = 0.008), had higher income (p = 0.008), were less likely to seek physician consultation on CAM use (p = 0.002), and had a more advanced stage of tumor (p = 0.003) with more distant metastasis (p = 0.001). The most commonly used CAM was herbal medicine (n = 89, 67.9%). CAM users had significantly lower anxiety (t = 5.21, p < 0.001) and depression (t = 4.90, p < 0.001) than non-CAM users. When the effects of CAM use were tested on anxiety, depression, and QOL, controlling for covariates, CAM use was significantly associated with 8.7% and 8.8% of variance in decreasing anxiety and depression, but there was no unique association of CAM use with variance in QOL.

Conclusions: CAM use is prevalent and younger age, higher education levels, higher income, less physician consultation, and higher cancer stage are significant correlates to CAM use. Controlling for covariates (e.g., gender, BMI), CAM use is significantly associated with lower anxiety and depression compared with those of non-CAM users.