Using the New ASCO Clinical Practice Guideline for Palliative Care Concurrent With Oncology Care Using the TEAM Approach

Early integration of palliative care in haemato-oncology: latest developments

PURPOSE OF REVIEW

This review aimed to explore recent progress made in the past five years towards early access to, and integration of palliative care services within the haemato-oncology context to address the unique needs of patients with Haematological malignancies (HMs).

RECENT FINDINGS

We included 14 articles in our review. We identified three themes, namely (i) disparities in the timing of referrals remain, (ii) specialist palliative care and impact on quality of life and (iii) perceptions on early integration. Patients with HM, receive less palliative care services, regardless of their higher symptom burden compared to patients with solid tumours. Structured approaches and models of early integration have shown substantial benefits, including improved pain and symptom management, shorter hospital stays and better end of life planning. Perceptions on existing barriers include the curative treatment focus, haematologists' personal perceptions on timing of palliative care and lack of palliative care training.

SUMMARY

For early integration to happen, it is crucial to address training gaps, improve communication skills, and foster interdisciplinary collaboration. Standardised organisational pathways can facilitate early and concurrent palliative care integration. System-level flexibility and supportive policies are essential to ensure that patients with HM receive comprehensive and high-quality care.

Identifying research priorities and essential elements of palliative care services for people facing malignant brain tumors: A participatory co-design approach

Background

Primary malignant brain tumors (ie, brain cancer) impact the quality of life (QoL) for patients and care partners in disease-specific ways involving cognition and communication. Palliative care (PC) addresses patient/care partner QoL, but it is not known how PC may address the unique needs of brain cancer patients. The purpose of this project was to identify brain cancer PC research priorities using participatory co-design methods.

Methods

Participatory co-design included the formation of a longitudinal, collaborative advisory group, engagement frameworks, design-thinking processes, and social media-based engagement over a 1-year period. Community-identified brain cancer QoL needs and research priorities were mapped to proposed "essential elements" of brain cancer PC services.

Results

We engaged an estimated 500 patients, care partners, healthcare professionals, and others with an interest in QoL and PC services for people with malignant brain tumors. Research priorities included testing the early introduction of PC services designed to address the unique QoL needs of brain cancer patients and care partners. Essential elements of brain cancer PC include: (1) addressing brain cancer patients' unique range of QoL needs and concerns, which change over time, (2) tailoring existing services and approaches to patient needs and concerns, (3) enhancing the involvement of interprofessional care team members, and (4) optimizing timing for PC services. This was the first participatory research effort exploring brain cancer patient and care partner QoL needs and PC services.

Conclusions

The brain tumor community calls for research testing PC service models for patients that incorporate the "essential elements" of palliative care.

The Use of Palliative Therapy in Patients With Advanced Retroperitoneal Sarcoma

INTRODUCTION

Advanced retroperitoneal sarcoma (RPS) can include unresectable locoregional disease, systemic or multifocal intra-abdominal metastasis, or abdominal sarcomatosis, all of which are associated with high morbidity and may be addressed through palliative therapy. Current trends in the use of palliative therapy and factors associated with its use in patients with advanced RPS remain largely unexplored. The objectives of this study are to (1) describe the temporal trend in the use of palliative therapy and (2) identify factors associated with its use in patients with advanced RPS in the United States from 2004 to 2020.

METHODS

This study is a retrospective cohort study using the National Cancer Database. We identified adult patients who were diagnosed with advanced RPS (American Joint Committee on Cancer stages III and IV) from 2004 to 2020. We performed a trend analysis to describe the use of palliative therapy over time, followed by univariable and multivariable logistic regression analyses to identify predictors of palliative therapy use in this patient population.

RESULTS

A total of 6149 patients with advanced RPS were identified, of which only 383 used palliative therapy, including surgery (n = 28), radiation therapy (n = 87), systemic therapy (n = 115), pain management (n = 61), combination therapy (n = 55), or other palliative therapy (n = 37). The proportion of patients using palliative therapy increased significantly from 2.6% in 2004 to 6.5% in 2020 (Ptrend < 0.001). On multivariable logistic regression, age (odds ratio [OR] 1.03, 95 confidence interval [CI] 1.01-1.04), year of diagnosis (OR 1.05, 95 CI 1.02-1.08), lack of insurance (OR 2.18, 95 CI 1.17-4.04), community cancer program status (OR 1.83, 95 CI 1.05-3.19), stage IV disease (OR 5.19, 95 CI 4.49-7.79), and rhabdomyosarcoma (OR 2.75, 95 CI 1.32-5.72) histology were found to be predictors of palliative therapy use.

CONCLUSIONS

This study sheds light on the evolving landscape of palliative therapy use for patients with advanced RPS in the United States from 2004 to 2020. The observed gradual increase in the use of palliative therapy underscores the growing recognition of its importance in managing the unique challenges associated with this complex disease. Despite this positive trend, the persistently low overall rates highlight the need for further efforts to enhance awareness and accessibility of palliative therapy for this patient population.

Rural-urban disparities and trends in utilization of palliative care services among US patients with metastatic breast cancer

PURPOSE

To assess trends and rural-urban disparities in palliative care utilization among patients with metastatic breast cancer.

METHODS

We analyzed data from the 2004-2019 National Cancer Database. Palliative care services, including surgery, radiotherapy, systemic therapy, and/or other pain management, were provided to control pain or alleviate symptoms; utilization was dichotomized as "yes/no." Rural-urban residence, defined by the US Department of Agriculture Economic Research Service's Rural-Urban Continuum Codes, was categorized as "rural/urban/metropolitan." Multivariable logistic regression was used to examine rural-urban differences in palliative care use. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated.

FINDINGS

Of 133,500 patients (mean age 62.4 [SD = 14.2] years), 86.7%, 11.7%, and 1.6% resided in metropolitan, urban, and rural areas, respectively; 72.5% were White, 17.0% Black, 5.8% Hispanic, and 2.7% Asian. Overall, 20.3% used palliative care, with a significant increase from 15.6% in 2004-2005 to 24.5% in 2008-2019 (7.0% increase per year; p-value for trend <0.001). In urban areas, 23.3% received palliative care, compared to 21.0% in rural and 19.9% in metropolitan areas (p < 0.001). After covariate adjustment, patients residing in rural (AOR = 0.84; 95% CI: 0.73-0.98) or metropolitan (AOR = 0.85, 95% CI: 0.80-0.89) areas had lower odds of having used palliative care than those in urban areas.

CONCLUSIONS

In this national, racially diverse sample of patients with metastatic breast cancer, the utilization of palliative care services increased over time, though remained suboptimal. Further, our findings highlight rural-urban disparities in palliative care use and suggest the potential need to promote these services while addressing geographic access inequities for this patient population.

Palliative Care in the Intensive Care Unit: The Standard of Care

Intensive care unit-based palliative care has evolved over the past 30 years due to the efforts of clinicians, researchers, and advocates for patient-centered care. Although all critically ill patients inherently have palliative care needs, the path was not linear but rather filled with the challenges of blending the intensive care unit goals of aggressive treatment and cure with the palliative care goals of symptom management and quality of life. Today, palliative care is considered an essential component of high-quality critical care and a core competency of all critical care nurses, advanced practice nurses, and other intensive care unit clinicians. This article provides an overview of the current state of intensive care unit-based palliative care, examines how the barriers to such care have shifted, reviews primary and specialist palliative care, addresses the impact of COVID-19, and presents resources to help nurses and intensive care unit teams achieve optimal outcomes.

Palliative Care Use Trends, Racial/Ethnic Disparities, and Overall Survival Differences Among Patients With Metastatic Breast Cancer

Background: Palliative care improves cancer patients' quality of life. Limited research has investigated racial/ethnic disparities in palliative care utilization and its associated survival among metastatic breast cancer (MBC) patients. Objectives: To examine racial/ethnic palliative care use disparities and assess racial/ethnic overall survival differences in MBC patients stratified by palliative care use. Design: A retrospective study of MBC patients from the 2004-2020 National Cancer Database. Measurements: Palliative care was defined as noncurative cancer treatment, including surgery, radiotherapy, systemic therapy, and/or pain management; utilization was coded "yes/no." Racial/ethnic groups included Asian, American Indian or Alaska Native (AIAN), Black, Hawaiian or Other Pacific Islander (HPI), Hispanic, and White. Logistic regression was performed to assess palliative care use disparities. Overall survival was modeled using Cox regression. Results: Of 148,931 patients, the mean age was 62 years; 99% were female; 73% identified as White, 17% as Black, 6% as Hispanic, 3% as Asian, 0.3% as AIAN, and 0.3% as HPI; 42% and 39% had Medicare and private insurance, respectively. Overall, 21% used palliative care, with an increasing utilization rate from 2004 to 2020 (3.6% increase per year, p-trend <0.001). Black (adjusted odds ratio [aOR] = 0.89; 95% confidence interval [CI]: 0.84 to 0.94), Asian (aOR = 0.76; 95% CI: 0.68 to 0.86), and Hispanic (aOR = 0.68; 95% CI: 0.62 to 0.74) patients had a lower likelihood of palliative care utilization than White patients. Among palliative care users, compared with White patients, Black (adjusted hazard ratio [aHR] = 1.14, 95% CI: 1.07 to 1.21) patients had a greater mortality risk, while Asian (aHR = 0.83, 95% CI: 0.71 to 0.97) and Hispanic (aHR = 0.77, 95% CI: 0.69 to 0.87) patients had a lower mortality risk. Conclusions: Palliative care utilization among MBC patients significantly increased but remained suboptimal. Racial/ethnic minority patients were less likely to use palliative care, and Black patients had worse survival, than White patients, suggesting the need for improving palliative care access and ameliorating disparities in MBC patients.

Palliative care in the treatment of women with breast cancer: A scoping review

OBJECTIVES

Recent studies on the quality of life in women with breast cancer show a high prevalence of signs and symptoms that should be the focus of palliative care (PC), leading us to question the current role they play in addressing breast cancer. Therefore, the objective of this review is to map the scope of available literature on the role of PC in the treatment of women with breast cancer.

METHODS

This is a methodologically guided scoping review by the Joanna Briggs Institute and adapted to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) Checklist for report writing. Systematic searches were conducted in 8 databases, an electronic repository, and gray literature. The searches were conducted with the support of a librarian. The study selection was managed through the RAYYAN software in a blind and independent manner by 2 reviewers. The extracted data were analyzed using the qualitative thematic analysis technique and discussed through textual categories.

RESULTS

A total of 9,812 studies were identified, of which only 136 articles and 3 sources of gray literature are included in this review. In terms of general characteristics, the majority were published in the USA (35.7%), had a cross-sectional design (44.8%), and were abstracts presented at scientific events (19.6%). The majority of interventions focused on palliative radiotherapy (13.6%). Thematic analysis identified 14 themes and 12 subthemes.

SIGNIFICANCE OF RESULTS

Our findings offer a comprehensive view of the evidence on PC in the treatment of breast cancer. Although a methodological quality assessment was not conducted, these results could guide professionals interested in the topic to position themselves in the current context. Additionally, a quick synthesis of recommendations on different palliative therapies is provided, which should be critically observed. Finally, multiple knowledge gaps are highlighted, which could be used for the development of future studies in this field.

Health Care Access Dimensions and Racial Disparities in End-of-Life Care Quality among Patients with Ovarian Cancer

This study investigated the association between health care access (HCA) dimensions and racial disparities in end-of-life (EOL) care quality among non-Hispanic Black (NHB), non-Hispanic White (NHW), and Hispanic patients with ovarian cancer. This retrospective cohort study used the Surveillance, Epidemiology, and End Results-linked Medicare data for women diagnosed with ovarian cancer from 2008 to 2015, ages 65 years and older. Health care affordability, accessibility, and availability measures were assessed at the census tract or regional levels, and associations between these measures and quality of EOL care were examined using multivariable-adjusted regression models, as appropriate. The final sample included 4,646 women [mean age (SD), 77.5 (7.0) years]; 87.4% NHW, 6.9% NHB, and 5.7% Hispanic. In the multivariable-adjusted models, affordability was associated with a decreased risk of intensive care unit stay [adjusted relative risk (aRR) 0.90, 95% confidence interval (CI): 0.83-0.98] and in-hospital death (aRR 0.91, 95% CI: 0.84-0.98). After adjustment for HCA dimensions, NHB patients had lower-quality EOL care compared with NHW patients, defined as: increased risk of hospitalization in the last 30 days of life (aRR 1.16, 95% CI: 1.03-1.30), no hospice care (aRR 1.23, 95% CI: 1.04-1.44), in-hospital death (aRR 1.27, 95% CI: 1.03-1.57), and higher counts of poor-quality EOL care outcomes (count ratio:1.19, 95% CI: 1.04-1.36). HCA dimensions were strong predictors of EOL care quality; however, racial disparities persisted, suggesting that additional drivers of these disparities remain to be identified.

SIGNIFICANCE

Among patients with ovarian cancer, Black patients had lower-quality EOL care, even after adjusting for three structural barriers to HCA, namely affordability, availability, and accessibility. This suggests an important need to investigate the roles of yet unexplored barriers to HCA such as accommodation and acceptability, as drivers of poor-quality EOL care among Black patients with ovarian cancer.

Outpatient Embedded Palliative Care for Patients with Advanced Thoracic Malignancy: A Retrospective Cohort Study

Although cancer care is often contextualized in terms of survival, there are other important cancer care outcomes, such as quality of life and cost of care. The ASCO Value Framework assesses the value of cancer therapies not only in terms of survival but also with consideration of quality of life and financial cost. Early palliative care for patients with advanced cancer is associated with improved quality of life, mood, symptoms, and overall survival for patients, as well as cost savings. While palliative care has been shown to have numerous benefits, the impact of real-world implementation of outpatient embedded palliative care on value-based metrics is not fully understood. We sought to describe the association between outpatient embedded palliative care in a multidisciplinary thoracic oncology clinic and inpatient value-based metrics. We performed a retrospective cohort study of 215 patients being treated for advanced thoracic malignancies with non-curative intent. We evaluated the association between outpatient embedded palliative care and inpatient clinical outcomes including emergency room visits, hospitalizations, intensive care unit admissions, hospital charges, as well as hospital quality metrics including 30-day readmissions, admissions within 30 days of death, inpatient mortality, and inpatient hospital charges. Outpatient embedded palliative care was associated with lower hospital charges per day (USD 3807 vs. USD 4695, p = 0.024). Furthermore, patients who received outpatient embedded palliative care had lower hospital admissions within 30 days of death (O.R. 0.45; 95% CI 0.29, 0.68; p < 0.001) and a lower inpatient mortality rate (IRR 0.67; 95% CI 0.48, 0.95; p = 0.024). Our study further supports that outpatient palliative care is a high-value intervention and alternative models of palliative care, including one embedded into a multidisciplinary thoracic oncology clinic, is associated with improved value-based metrics.

Association of Inpatient Palliative Care Consultation with Clinical and Financial Outcomes for Pancreatic Cancer

BACKGROUND

Palliative care consultation (PCC) has been shown to improve quality of life and reduce costs for various chronic life-threatening diseases. Despite PCC incorporation into modern pancreatic cancer care guidelines, limited data regarding its specific utilization and impact on resource use is available.

METHODS

The 2016-2020 Nationwide Readmissions Database was used to identify all adult hospitalizations entailing pancreatic cancer. Only patients with at least one readmission within 90 days were included to account for uncaptured out-of-hospital mortality. Multivariable regression models were used to ascertain the relationship between inpatient PCC during initial hospitalization and index as well as cumulative costs, overall length of stay (LOS), readmission rate, and number of repeat hospitalizations.

RESULTS

Of an estimated 175,805 patients with pancreatic cancer, 11.1% had inpatient PCC during the index admission. PCC utilization significantly increased from 10.5% in 2016 to 11.6% in 2020 (nptrend < 0.001). After adjustment, PCC was associated with reduced index hospitalization costs [β: - $1100; 95% confidence interval (CI) - 1500, - 800; P < 0.001] and cumulative 90-day costs (β: - $11,700; 95% CI - 12,700, - 10,000; P < 0.001). PCC was associated with longer index LOS (β: + 1.12 days, 95% CI 0.92-1.31, P < 0.001) but significantly reduced cumulative LOS (β: - 3.16 days; 95% CI - 3.67, - 2.65; P < 0.001). Finally, PCC was linked with decreased odds of 30-day nonelective readmission (AOR: 0.48, 95% CI 0.45-0.50, P < 0.001).

DISCUSSION

PCC was associated with decreased costs, readmission rates, and number of hospitalizations among patients with pancreatic cancer. Directed strategies to increase utilization and reduce barriers to consultation should be implemented to encourage practitioners to maximize inpatient PCC referral rates.

Characterization of patients with brain metastases referred to palliative care

PURPOSE

In this study, we aimed to assess the clinical characteristics, reasons for referral, and outcomes of patients with brain metastases (BM) referred to the supportive care center.

METHODS

Equal numbers of patients with melanoma, breast cancer, and lung cancer with (N = 90) and without (N = 90) BM were retrospectively identified from the supportive care database for study. Descriptive statistics were used to analyze demographic, disease, and clinical data. Kaplan Meier method was used to evaluate survival outcomes.

RESULTS

While physical symptom management was the most common reason for referral to supportive care for both patients with and without BM, patients with BM had significantly lower pain scores on ESAS at time of referral (p = 0.002). They had greater interaction with acute care in the last weeks of life, with higher rates of ICU admission, emergency room visits, and hospitalizations after initial supportive care (SC) visit. The median survival time from referral to Supportive Care Center (SCC) was 0.90 years (95% CI 0.73, 1.40) for the brain metastasis group and 1.29 years (95% CI 0.91, 2.29) for the group without BM.

CONCLUSIONS

Patients with BM have shorter survival and greater interaction with acute care in the last weeks of life. This population also has distinct symptom burdens from patients without BM. Strategies to optimize integration of SC for patients with BM warrant ongoing study.

Palliative care outpatients and improved documentation-what matters most? Quality improvement project

OBJECTIVE

Patients needs should be regularly assessed. We aimed to improve assessment and documentation of needs from baseline 25% in June 2022 to 75% in December 2022.

METHODS

The A3, a structured problem-solving continuous-improvement methodology was used. Fish-bone analysis and pareto charts identified root causes; key drivers and interventions were developed. Interventions included (1) documentation templates, (2) a brochure about services, (3) extra team communication skills training, (4) repository in different languages to help patients identify needs, and (5) weekly review meetings. Reliability and sustainability were ensured through ownership and delegation to team members.

RESULTS

Documentation of needs increased from baseline 25% to 75% within 3 months. This has been sustained at 83% in August 2023. The total number of patients assessed during the project was 1818. Maximum percentage of documentation was 91%. Mean additional time taken to ask and document needs was 2 min.

CONCLUSIONS

Identification and documentation of patient needs and prioritisation are feasible in palliative medicine outpatient clinics. This project has directed the team to provide patient-led palliative care interventions.

The importance of a continuum of rehabilitation from diagnosis of advanced cancer to palliative care

PURPOSE

Identifying the evidence found in the international scientific literature, referring to the concept of rehabilitation in the setting of oncologic palliative care.

METHODS

Integrative literature review based on articles published in indexed journals on the electronic databases: LILACS, CINAHL and PubMed/MEDLINE, WEB OF SCIENCE, OTSEEKER and PEDRO, following the PRISMA criteria. The quantitative articles were evaluated using the McMaster form for quantitative studies and the qualitative studies were assessed by the Critical Appraisal Skills Program. The studies were inserted in the Rayyan™ application.

RESULTS

The final sample was composed of 21 qualitative and quantitative articles published in the period from 2004 to 2021, in nine different countries. Three thematic units were defined addressing the interface between palliative care and rehabilitation, the concept of palliative rehabilitation and the barriers to its implementation. The quality of the articles reviewed varied from 31% to 100% of the criteria met.

CONCLUSION

The international scientific production reinforces the importance of including rehabilitation in care in oncologic palliative care, highlighting the concept of palliative rehabilitation, but there is a need for expanding and divulging new research on the theme and the results.IMPLICATIONS FOR REHABILITATIONPalliative care services and rehabilitation services should take and create opportunities to promote rehabilitation for people living with incurable cancer.Palliative rehabilitation has an important role in the treatment of people with advanced cancer, helping increase the quality of life, relief of pain, symptoms, and distress.It is considered an integral part of palliative care, given that rehabilitation and palliative care are related to the continuum of care.It is important to understand this gap in the international literature on the continuum between rehabilitation and palliative rehabilitation to improve the provision of this approach in both rehabilitation and palliative care services.

Anxiety and Depression in Metastatic Cancer: A Critical Review of Negative Impacts on Advance Care Planning and End-of-Life Decision Making With Practical Recommendations

PURPOSE

Providers treating adults with advanced cancer increasingly seek to engage patients and surrogates in advance care planning (ACP) and end-of-life (EOL) decision making; however, anxiety and depression may interfere with engagement. The intersection of these two key phenomena is examined among patients with metastatic cancer and their surrogates: the need to prepare for and engage in ACP and EOL decision making and the high prevalence of anxiety and depression.

METHODS

Using a critical review framework, we examine the specific ways that anxiety and depression are likely to affect both ACP and EOL decision making.

RESULTS

The review indicates that depression is associated with reduced compliance with treatment recommendations, and high anxiety may result in avoidance of difficult discussions involved in ACP and EOL decision making. Depression and anxiety are associated with increased decisional regret in the context of cancer treatment decision making, as well as a preference for passive (not active) decision making in an intensive care unit setting. Anxiety about death in patients with advanced cancer is associated with lower rates of completion of an advance directive or discussion of EOL wishes with the oncologist. Patients with advanced cancer and elevated anxiety report higher discordance between wanted versus received life-sustaining treatments, less trust in their physicians, and less comprehension of the information communicated by their physicians.

CONCLUSION

Anxiety and depression are commonly elevated among adults with advanced cancer and health care surrogates, and can result in less engagement and satisfaction with ACP, cancer treatment, and EOL decisions. We offer practical strategies and sample scripts for oncology care providers to use to reduce the effects of anxiety and depression in these contexts.

Validation Study of the PALCOM Scale of Complexity of Palliative Care Needs: A Cohort Study in Advanced Cancer Patients

BACKGROUND

In a patient-centred model of care, referral to early palliative care (EPC) depends on both the prognosis and the complexity of care needs. The PALCOM scale is a 5-domain multidimensional assessment tool developed to identify the level of complexity of palliative care needs of cancer patients. The aim of this study was to validate the PALCOM scale.

PATIENT AND METHODS

We conducted a prospective cohort study of cancer patients to compare the PALCOM scale and expert empirical assessment (EA) of the complexity of palliative care needs. The EA had to categorise patients according to their complexity, considering that medium to high levels required priority attention from specialist EPC teams, while those with low levels could be managed by non-specialist teams. Systematically collected multidimensional variables were recorded in an electronic report form and stratified by level of complexity and rating system (PALCOM scale versus EA). The correlation rank (Kendall's tau test) and accuracy test (F1-score) between the two rating systems were analysed. ROC curve analysis was used to determine the predictive power of the PALCOM scale.

RESULTS

A total of 283 advanced cancer patients were included. There were no significant differences in the frequency of the levels of complexity between the EA and the PALCOM scale (low 22.3-23.7%; medium 57.2-59.0%; high 20.5-17.3%). The prevalence of high symptom burden, severe pain, functional impairment, socio-familial risk, existential/spiritual problems, 6-month mortality and in-hospital death was significantly higher (p < 0.001) at the high complexity levels in both scoring systems. Comparative analysis showed a high correlation rank and accuracy between the two scoring systems (Kendall's tau test 0.81, F1 score 0.84). The predictive ability of the PALCOM scale was confirmed by an area under the curve in the ROC analysis of 0.907 for high and 0.902 for low complexity.

CONCLUSIONS

In a patient-centred care model, the identification of complexity is a key point to appropriate referral and management of shared care with EPC teams. The PALCOM scale is a high precision tool for determining the level of complexity of palliative care needs.

Global Geriatric Palliative Care

Global palliative medicine is a priority for global health. The aging world population lives with multiple chronic diseases and malignancies that often lead to debility, morbidity, mortality, and decreased quality of life. In the United States, 68% of adults aged older than 65 years live with 2 or more chronic conditions. Endeavors to improve access to palliative care for seniors are ongoing within "age-friendly health systems." This review article aims to provide an overview of the present state of global geriatric palliative care and to identify potential areas for future improvement.

Interdisciplinary care of pediatric oncology patients: A survey of clinicians in Central America and the Caribbean

BACKGROUND

Quality cancer care depends on interdisciplinary communication. This study explored the communication practices of interdisciplinary clinicians, the types of healthcare services for which they engage in interdisciplinary collaboration, and the association between interdisciplinary care and perceived quality of care, as well as job satisfaction.

METHODS

We conducted a survey of interdisciplinary clinicians from cancer centers in Guatemala, Honduras, Panama, El Salvador, and Haiti. The survey included 68 items including previously validated tools and novel questions.

RESULTS

Total 174 interdisciplinary clinicians completed the survey: nurses (n = 60), medical subspecialists (n = 35), oncologists (n = 22), psychosocial providers (n = 20), surgeons (n = 12), pathologists (n = 9), radiologists (n = 9), and radiation oncologists (n = 5). Oncologists reported daily communication with nurses (95%) and other oncologists (91%). While 90% of nurses reported daily communication with other nurses, only 66% reported daily communication with oncologists, and more than 50% of nurses reported never talking to pathologists, radiologists, radiation oncologists, or surgeons. Most clinicians described interdisciplinary establishment of cancer treatment goals and prognosis (84%), patient preferences (81%), and determination of first treatment modality (80%). Clinicians who described more interdisciplinary collaboration had higher job satisfaction (p = .04) and perceived a higher level of overall quality of care (p = .004).

CONCLUSIONS

Clinicians in these limited resource settings describe strong interdisciplinary collaboration contributing to higher job satisfaction and perceived quality of care. However, nurses in these settings reported more limited interdisciplinary communication and care. Additional studies are necessary to further define clinical roles on interdisciplinary care teams and their associations with patient outcomes.

Trends in pain relief and the role of interventional radiology

In order to orientate readers to the context of care in which interventional radiology has an important place in pain management, a brief history of the approach to analgesia is presented with a focus on cancer pain. The difficulty in establishing a modern evidence base in an ethically challenging area of medicine is discussed. The pendulum of public opinion about opioid and cannabinoid medicines for pain in the context of recreational drug use and substance use disorders is presented. The lack of direct relationship between opioid analgesic prescribing and the suffering caused by poisoning of the recreational drug supply is emphasised. The three primary contexts where interventional radiology has a role in analgesia are described: to minimise the use of opioids and other analgesics; when opioids and other analgesics are not working; and when access to analgesics is restricted. The practical aspects of delivery of interventional radiological palliative procedures are discussed, particularly the vital collaboration and coordination between services needed to ensure success, and the need for interventional radiologists to ensure that post-procedural care is provided safely, particularly the tapering of opioids, which requires focused training and support. The need to consider the patient's situation and goals of care when developing a treatment plan are emphasised and illustrated.

Variation in hospital utilization of palliative interventions for patients with advanced gastrointestinal cancer near end of life

BACKGROUND

Patients with advanced gastrointestinal (GI) cancer often undergo noncurative interventions with palliative intent to relieve high symptom burden near end of life. Hospital-level variation in intervention utilization remains unclear.

METHODS

National cohort study of 142 304 patients with stage III or IV GI cancer within the National Cancer Database (2004-2014) who died within 1-year of diagnosis. Hospitals were stratified by palliative intervention utilization (surgery, chemotherapy, radiation, pain management). Multivariable, multinomial regression evaluated the association between patient/hospital factors and palliative intervention utilization.

RESULTS

Across 1322 hospitals, median hospital palliative intervention utilization was 12.0% [interquartile range: 0.0%-26.1%]. Utilization increased over time in all but lowest utilizing hospitals. Relative to lowest utilizing hospitals, factors associated with a lower likelihood of care at highest utilizing hospitals included: race (White [ref]; Black-Relative Risk Ratio [RRR] 0.81, 95% confidence interval [0.77-0.85]) and lower income (RRR 0.81 [0.78-0.84]). Factors associated with a higher likelihood included: lower education level (RRR 1.62 [1.55-1.69]) and hospital type (community program [ref]; comprehensive community-RRR 1.33 [1.26-1.41]; academic-RRR 1.88 [1.77-1.99]; integrated network-RRR 1.79 [1.66-1.93]).

CONCLUSION

Hospital variation in palliative intervention use is substantial and potentially associated with sociodemographic and hospital characteristics. Future work can examine how differences in hospital care processes translate to quantity/quality of life for cancer patients.

Motivations and experiences of patients with advanced cancer participating in Phase 1 clinical trials: A qualitative study

BACKGROUND

Persons with advanced cancer may participate in Phase 1 clinical trials - first-in-human trials that are conducted with the main objectives of safety and dosing. The motivations for participation are not well understood and may include hope for cure.

AIM

To explore the perspectives of persons with advanced cancer in order to understand the motivations for participating in Phase 1 clinical trials, experiences while being on trial and views on palliative care provision.

DESIGN

Qualitative study with a constructivist stance, using thematic analysis based upon the grounded theory approach.

SETTING/PARTICIPANTS

20 persons with advanced cancer who were participating in a Phase 1 clinical trial.

RESULTS

Many participants described how Phase 1 clinical trial participation was their last hope, as they were cognisant of their advanced disease. Information-seeking needs differed - some needed comprehensive information while others relied on the doctor's recommendation. Participants experienced varied negative and positive physical and psycho-emotional concerns, and needed to draw on multiple sources of support such as family, friends and healthcare professionals. Some could list potential benefits of palliative care but felt they did not require it yet. The overarching theme was hope and positive thinking as a way of coping.

CONCLUSIONS

The concepts of hope as a way of coping and the supportive presence of healthcare professionals could be weaved into a future model of palliative care to improve the illness journey for patients considering Phase 1 clinical trial participation and other persons with advanced cancer.

Metastatic extent-specific prognosis of women with stage IVB cervical cancer: multiple versus single distant organ involvement

PURPOSE

Despite the heterogeneity of anatomical sites that metastases may affect, within the current cancer staging schematic, stage IVB encompasses all distant metastasis. This study examined survival outcomes based on the extent of distant organ metastasis in stage IVB cervical cancer.

METHODS

This retrospective cohort study utilized the National Cancer Institute's Surveillance, Epidemiology, and End Result Program from 2010 to 2018. The study population included 1772 women with stage IVB cervical cancer who had tumor metastasis to one or more of the following four organs: bone, brain, liver, or lung. Overall survival was assessed based on the metastatic extent in multivariable analysis.

RESULTS

The most common metastatic site was lung (68.3%) followed by bone (35.2%), liver (30.0%), and brain (1.2%). Multiple organ metastases were seen in 26.5% of study population, with lung / liver metastases being the most frequent combination pattern (9.6%) followed by lung / bone (9.4%), and lung / bone / liver (6.4%). A total of 1442 (81.4%) deaths occurred during the follow-up. The cohort-level median overall survival was 7 months, ranging from 3 months in all four organ metastases to 11 months in bone metastasis alone when stratified (absolute difference 8 months, P < 0.001). Multiple organ metastases were independently associated with nearly 50% increased all-cause mortality risk compared to single organ metastasis (adjusted-hazard ratio 1.51, 95% CI 1.34-1.70).

CONCLUSION

Survival outcomes in those with stage IVB cervical cancer with distant organ involvement can vary based on the extent of metastasis. Incorporation of single versus multiple distant organ metastasis into the cancer staging schema may be valuable (IVB1 versus IVB2).

End-of-Life Care and Advanced Directives in Hispanic/Latinx Patients: Challenges and Solutions for the Practicing Oncologist

Advanced end-of-life care (EOL) comprises a group of strategies to provide comfort to patients at the end of life. These are associated with better quality of life, better satisfaction, and a lower rate of hospitalizations and aggressive medical treatment. Advanced EOL care, including advanced directives completion and hospice enrollment, is suboptimal among Hispanic/Latinx patients with cancer due to personal, socio-cultural, financial, and health system-related barriers, as well as due to a lack of studies specifically designed for this population. In addition, the extrapolation of programs that increase participation in EOL for non-white Hispanics may not work appropriately for Hispanic/Latinx patients and lead to overall lower satisfaction and enrollment in EOL care. This review will provide the practicing oncologist with the tools to address EOL in the Hispanic/Latinx population. Some promising strategies to address the EOL care disparities in Latinx/Hispanic patients have been culturally tailored patient navigation programs, geriatric assessment-guided multidisciplinary interventions, counseling sessions, and educational interventions. Through these strategies, we encourage oncologists to take advantage of every clinical setting to discuss EOL care. Treating physicians can engage family members in caring for their loved ones while practicing cultural humility and respecting cultural preferences, incorporating policies to foster treatment for the underserved migrant population, and providing patients with validated Spanish language tools.

Therapeutic Options for Brain Metastases in Gynecologic Cancers

OPINION STATEMENT

Brain metastases (BM) are rare in gynecologic cancers. Overall BM confers a poor prognosis but other factors such as number of brain lesions, patient age, the presence of extracranial metastasis, the Karnofsky Performance Status (KPS) score, and the type of primary cancer also impact prognosis. Taking a patient's whole picture into perspective is crucial in deciding the appropriate management strategy. The management of BM requires an interdisciplinary approach that frequently includes oncology, neurosurgery, radiation oncology and palliative care. Treatment includes both direct targeted therapies to the lesion(s) as well as management of the neurologic side effects caused by mass effect. There is limited evidence of when screening for BM in the gynecology oncology patient is warranted but it is recommended that any cancer patient with new focal neurologic deficit or increasing headaches should be evaluated. The primary imaging modality for detection of BM is MRI, but other imaging modalities such as CT and PET scan can be used for certain scenarios. New advances in radiation techniques, improved imaging modalities, and systemic therapies are helping to discover BM earlier and provide treatments with less detrimental side effects.

Use of Palliative Interventions at End of Life for Advanced Gastrointestinal Cancer

BACKGROUND

Despite the well-established benefits of palliative care, little is known about the use of palliative interventions among patients with advanced gastrointestinal (GI) cancer near the end of life (EOL).

METHODS

A national cohort study analyzed 142,304 patients with advanced GI cancers (stage 3 or 4) near EOL (death within 1 year of diagnosis) in the National Cancer Database (2004-2014) who received palliative interventions (defined as treatment to relieve symptoms: surgery, radiation, chemotherapy, and/or pain management). The study used multivariable hierarchical regression evaluate the association between the use of palliative interventions, temporal trends, and patient and hospital factors.

RESULTS

Overall, 16.5% of the patients were treated with a palliative intervention, and use increased over time (13.4% in 2004 vs 19.8% in 2014; trend test, p < 0.001). Palliative interventions were used most frequently for esophageal cancer (20.6%) and least frequently for gallbladder cancer (13.3%). Palliative interventions were associated with younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99), recent diagnosis year (OR, 1.05; 95% CI, 1.04-1.06), black race (white [ref]; OR, 1.07; 95% CI, 1.01-1.12), insurance status (no insurance [ref]; private: OR, 0.92; 95% CI ,0.95-0.99), hospital type (community cancer program [ref]; integrated network cancer programs: OR, 1.37; 95% CI ,1.07-1.75), and stage 4 disease (OR, 2.17; 95% CI, 2.07-2.27). Patients in southern and western regions were less likely to receive palliative intervention (Northeast [ref]; OR, 0.76; 95% CI, 0.62-0.94 and OR 0.46; 95% CI, 0.37-0.57, respectively).

CONCLUSION

Increased palliative intervention use over time suggests ongoing changes in how care is delivered to GI cancer patients toward EOL. However, sociodemographic and geographic variation suggests opportunities to address barriers to optimal EOL care.

Integration of Specialized Palliative Care with Oncological Treatment in Patients with Advanced Pancreatic Cancer

Introduction:

The incidence of pancreatic cancer is around 5 in 100,000, and the 5-year survival is poor. Pancreatic cancer patients have a high disease-specific burden of symptoms, and palliative chemotherapy has varying side effects. The American Society of Clinical Oncology (ASCO) suggests integrating specialized palliative care (SPC) with standard oncological treatment for pancreatic cancer patients at stage ≥III. This study investigated the effects of enrollment into SPC >30 days before death.

Materials and Methods:

This retrospective study included 170 patients with histopathologically verified pancreatic adenocarcinoma who received palliative chemotherapy at Skåne University Hospital and died between February 1, 2015, and December 31, 2017.

Results:

Of the 170 patients, 151 were enrolled within the SPC unit; 97 of them for >30 days before death (group A). The remainder (group B) received SPC for ≤30 days before death (n = 54) or not at all (n = 19). Patients in groups A and B lived a median of 73 and 44 days, respectively, after the last palliative chemotherapy treatment (p < 0.001), but did not differ in terms of median overall survival (11.2 months vs. 10.9 months). Death in the hospital occurred in 84% of patients never admitted to SPC and 2% of patients ever admitted to SPC.

Conclusion:

Enrollment in SPC for longer than 30 days may lower the risk of receiving futile palliative chemotherapy at the end of life, compared with patients enrolled in SPC for 30 days or less before death. Enrollment in SPC lowers the risk of dying in a hospital.

Palliative Care Needs and Clinical Outcomes of Patients with Advanced Cancer in the Emergency Department

Background: Older adults with cancer use the emergency department (ED) for acute concerns. Objectives: Characterize the palliative care needs and clinical outcomes of advanced cancer patients in the ED. Design: A planned secondary data analysis of the Comprehensive Oncologic Emergencies Research Network (CONCERN) data. Settings/Subjects: Cancer patients who presented to the 18 CONCERN affiliated EDs in the United States. Measurements: Survey included demographics, cancer type, functional status, symptom burden, palliative and hospice care enrollment, and advance directive code status. Results: Of the total (674/1075, 62.3%) patients had advanced cancer and most were White (78.6%) and female (50.3%); median age was 64 (interquartile range 54-71) years. A small proportion of them were receiving palliative (6.5% [95% confidence interval; CI 3.0-7.6]; p = 0.005) and hospice (1.3% [95% CI 1.0-3.2]; p = 0.52) care and had a higher 30-day mortality rate (8.3%, [95% CI 6.2-10.4]). Conclusions: Patients with advanced cancer continue to present to the ED despite recommendations for early delivery of palliative care.

End-of-life care in cancer patients: how much drug therapy and how much palliative care? Record linkage study in Northern Italy

OBJECTIVES

Investigating end-of-life use of anticancer drugs and of palliative care services.

DESIGN

Population based cohort linked to mortality registry and administrative databases.

SETTING

Emilia-Romagna Region (Northern Italy).

PARTICIPANTS

55 625 residents who died of cancer between 2017 and 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Multivariate analyses were carried out to assess the relationship between cancer drug therapy and palliative care services, and their association with factors related to tumour severity.

RESULTS

In the last month of life, 15.3% of study population received anticancer drugs (from 12.5% to 16.9% across the eight Local Health Authorities-LHA) and 40.2% received palliative care services (from 36.2% to 43.7%). Drug therapy was inversely associated with receiving palliative care services within the last 30 days (OR 0.92, 95% CI 0.87 to 0.97), surgery within the last 6 months (OR 0.59, 95% CI 0.52 to 0.67), aggressive tumours (OR 0.88, 95% CI 0.84 to 0.93) and increasing age (OR 0.95, 95% CI 0.95 to 0.95). Drug therapy was more likely among those with haematologic tumours (OR 2.15, 95% CI 2.00 to 2.30) and in case of hospital admissions within the last 6 months (OR 1.63, 95% CI 1.55 to 1.72). Palliative care was less likely among those with haematologic compared with other tumours (OR 0.52, 95% CI 0.49 to 0.56), in case of surgery (OR 0.44, 95% CI 0.39 to 0.49) or hospital admissions (OR 0.70, 95% CI 0.67 to 0.72) within the last 6 months, if receiving anticancer drugs during the last 30 days (OR 0.90, 95% CI 0.85 to 0.94) and for each year of increasing age (OR 0.99, 95% CI 0.99 to 0.99). Palliative care was more likely in the presence of aggressive tumours (OR 1.12, 95% CI 1.08 to 1.16).

CONCLUSION

Use of anticancer drugs and palliative care in the last month of life were inversely associated, showing variability across different LHAs. While administrative data have limits, our findings are in line with conclusions of other studies.

Administration of Immune Checkpoint Inhibitors Near the End of Life

PURPOSE

Recent literature suggests an increasing use of systemic treatment in patients with advanced cancer near the end of life (EOL), partially driven by the increasing adoption of immune checkpoint inhibitors (ICIs). While studies have identified this trend, additional variables associated with ICI use at EOL are limited. Our aim was to characterize a population of patients who received a dose of ICI in the last 30 days of life.

METHODS

We performed a manual retrospective chart review of patients ≥ 18 years who died within 30 days of receiving a dose of ICI. Metrics such as Eastern Cooperative Oncology Group performance status (ECOG PS), number of ICI doses, need for hospitalization, and numerous other variables were evaluated.

RESULTS

Over a 4-year time period, 97 patients received an ICI at EOL. For 40% of patients, the ICI given in the 30 days before death was their only dose. Over 50% of patients had an ECOG PS of ≥ 2, including 17% of patients with an ECOG PS of 3. Over 60% were hospitalized, 65% visited the emergency department, 20% required intensive care unit admission, and 25% died in the hospital.

CONCLUSION

Our study contributes to the ongoing literature regarding the risks and benefits of ICI use in patients with advanced cancer near the EOL. While accurate predictions regarding the EOL are challenging, oncologists may routinely use clinical factors such as ECOG PS along with patient preferences to guide recommendations and shared decision making. Ultimately, further follow-up studies to better characterize and prognosticate this population of patients are needed.

Impact of ambulatory palliative care on symptoms and service outcomes in cancer patients: a retrospective cohort study

BACKGROUND

The integration of palliative care into routine cancer care has allowed for improved symptom control, relationship building and goal setting for patients and families. This study aimed to assess the efficacy of an ambulatory palliative care clinic on improving symptom burden and service outcomes for patients with cancer.

METHODS

A retrospective review of data of cancer patients who attended an ambulatory care clinic and completed the Symptom Assessment Scale between January 2015 and December 2019. We classified moderate to severe symptoms as clinically significant. Clinically meaningful improvement in symptoms (excluding pain) was defined by a ≥ 1-point reduction from baseline and pain treatment response was defined as a ≥ 2-point or ≥ 30% reduction from baseline.

RESULTS

A total of 249 patients met the inclusion criteria. The most common cancer diagnosis was gastrointestinal (32%) and the median time between the initial and follow-up clinic was 4 weeks. The prevalence of clinically significant symptoms at baseline varied from 28% for nausea to 88% for fatigue, with 23% of the cohort requiring acute admission due to unstable physical/psychosocial symptoms. There was significant improvement noted in sleep (p < 0.001), pain (p = 0.002), wellbeing (p < 0.001), and overall symptom composite scores (p = 0.028). Despite 18-28% of patients achieving clinically meaningful symptom improvement, 18-66.3% of those with moderate to severe symptoms at baseline continued to have clinically significant symptoms on follow-up. A third of patients had opioid and/or adjuvant analgesic initiated/titrated, with 39% educated on pain management. Goals of care (31%), insight (28%) and psychosocial/existential issues (27%) were commonly explored.

CONCLUSIONS

This study highlights the burden of symptoms in a cohort of ambulatory palliative care patients and the opportunity such services can provide for education, psychosocial care and future planning. Additionally routine screening of cohorts of oncology patients using validated scales may identify patients who would benefit from early ambulatory palliative care.

Neuropsychiatric Disorders and Frailty in Older Adults over the Spectrum of Cancer: A Narrative Review

BACKGROUND

The interplay between different neuropsychiatric conditions, beyond dementia, in the presence of a diagnosis of cancer in older adults may mediate patients' fitness and cancer-related outcomes. Here, we aimed to investigate the presence of depression, sleep disturbances, anxiety, attitude, motivation, and support in older adults receiving a diagnosis of cancer and the dimension of frailty in order to understand the magnitude of the problem.

METHODS

This review provides an update of the state of the art based on references from searches of PubMed between 2000 and June 2021.

RESULTS

The evidence obtained underscored the tight association between frailty and unfavorable clinical outcomes in older adults with cancer. Given the intrinsic correlation of neuropsychiatric disorders with frailty in the realm of cancer survivorship, the evidence showed they might have a correlation with unfavorable clinical outcomes, late-life geriatric syndromes and higher degree of frailty.

CONCLUSIONS

The identification of common vulnerabilities among neuropsychiatric disorders, frailty, and cancer may hold promise to unmask similar shared pathways, potentially intercepting targeted new interventions over the spectrum of cancer with the delivery of better pathways of care for older adults with cancer.

Socioeconomic and racial/ethnic disparities in receipt of palliative care among patients with metastatic hepatocellular carcinoma

BACKGROUND

Patients with metastatic hepatocellular carcinoma (HCC) suffer symptoms of both end-stage liver disease and cancer. Palliative care (PC) enhances the quality of life via symptom control and even improves survival for some cancers. Our study characterized rates of PC utilization among metastatic HCC patients and determined factors associated with PC receipt.

METHODS

We conducted a retrospective review of adult National Cancer Database patients diagnosed with metastatic HCC between 2004 and 2016. Chi-square tests were used to analyze two cohorts: those who received PC and those who did not. Logistic regression was performed to assess the impact of clinicodemographic factors on the likelihood of receiving PC.

RESULTS

PC utilization was low at just 17%. Later year of diagnosis, insured status, and higher education level were associated with an increased likelihood of receiving PC. Treatment at academic centers or integrated network cancer programs increased the likelihood of receiving PC compared to treatment at a community center (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.03-1.33 and OR = 1.25, 95% CI = 1.07-1.45; respectively). Hispanics were significantly less likely to received PC than non-Hispanic Whites (OR = 0.73, 95% CI = 0.64-0.82).

CONCLUSIONS

PC utilization among patients with metastatic HCC remains low. Targeted efforts should be enacted to increase the delivery of PC in this group.

Palliative care use among bladder cancer patients treated with radical cystectomy

INTRODUCTION

Practice guidelines recommend early consideration for palliative care for patients with advanced malignancies, and there has been limited research regarding the use of palliative care for patients with advanced bladder cancer. Our aim is to describe the rate and determinants of the use of palliative care consultation for patients treated with radical cystectomy at our institution.

METHODS

A retrospective review was performed to identify patients who underwent cystectomy for bladder cancer between September 2014 and June 2019 at our institution. Our primary outcome was receipt of palliative care, defined as receiving a palliative care consult. We tested for associations between factors and our outcome of interest, and then estimated the impact on various determinants of palliative care use by fitting a multivariable logistic regression model.

RESULTS

Over the study period, 294 patients underwent radical cystectomy. Of those patients, 29 (9.9%) received palliative care. Mean time from surgery to palliative care consult was 11.4 months. Palliative care consults were initiated by urologists in 32.1% of cases. On multivariable analysis, patients were more likely to receive palliative care if they had pT3+ disease (P < 0.001), were readmitted after surgery (P = 0.028), or had any major complication after surgery (P = 0.025).

CONCLUSION

Rates of palliative care consults in patients with advanced bladder cancer at our institution are higher than other population-based estimates nationally. The majority of palliative care consults were requested by medical oncologists, highlighting an opportunity for educational initiatives for urologic oncologists to promote earlier consideration of palliative care referrals.

Medical costs of Japanese lung cancer patients during end-of-life care

OBJECTIVE

The medical costs associated with cancer treatment have increased rapidly in Japan; however, little data exist on actual costs, especially for end-of-life care. Therefore, this study aimed to examine the medical costs of lung cancer patients during the last 3 months before death and to compare the costs with those of initial anticancer treatment.

METHODS

We retrospectively evaluated all patients who died from lung cancer at the Japanese Red Cross Medical Center between 1 January 2008 and 31 August 2019. Patients were classified into three cohorts (2008-2011, 2012-2015 and 2016-2019) according to the year of death; the medical costs were evaluated for each cohort. Costs were then divided into outpatient and inpatient costs and calculated per month.

RESULTS

Seventy-nine small cell lung cancer and 213 non-small cell lung cancer patients were included. For small cell lung cancer and non-small cell lung cancer patients, most end-of-life medical costs were inpatient costs across all cohorts. The median monthly medical costs for the last 3 months among both small cell lung cancer and non-small cell lung cancer patients did not differ significantly among the cohorts, but the mean monthly costs for non-small cell lung cancer tended to increase. The monthly medical costs for the last 3 months were significantly higher than those for the first year in SCLC (P = 0.013) and non-small cell lung cancer (P < 0.001) patients and those for the first 3 months in non-small cell lung cancer patients (P = 0.005).

CONCLUSIONS

The medical costs during the end-of-life period for lung cancer were high and surpassed those for initial treatment.

The power of specialty palliative care: moving towards a systems perspective

Three palliative care clinical trials were presented at the 2020 American Society for Clinical Oncology Annual Meeting. The heterogeneity in populations, models of care, study design, and assessment of clinical outcomes across these three studies show the broad opportunities for research into interventions for palliative care. In this Viewpoint, we summarise the characteristics of these studies, discuss their novel features and lingering questions, and offer a suggestion for further expanding the focus of clinical trials for delivery of palliative care in the future. We particularly argue that the propensity to characterise palliative care as if it was a clinical or biomedical intervention hampers the design and evaluation of complex clinical interventions that influence clinicians, systems for health-care delivery, individual patients, and their families.

Roles and Responsibilities of Nurses in Advance Care Planning in Palliative Care in the Acute Care Setting: A Scoping Review

Palliative care focuses on symptom management, discussion of treatment and care decisions, network organization, and support of the family. As part of the advance care planning (ACP) process, staff nurses in the acute care setting are often involved in all of the above areas. It is yet unclear what nurses' roles and responsibilities are and what skills are needed in the ACP process. The themes that staff nurses and advanced practice registered nurses (APRNs) discuss in relationship to ACP are manifold. This scoping review demonstrates that staff nurses' core role is advocating for the wishes and values of patients with any life-limiting disease. Staff nurses also serve as facilitators, educators, and advocates to help start ACP conversations and ease patients' transitions between settings based on well-discussed decisions. To be able to engage in ACP discussions, APRNs must have excellent communication skills. Continuous training to improve these skills is mandatory. In the future, clarifying the contribution of staff nurses and APRNs in the ACP process in relation to other members of the interprofessional team can lay the groundwork for improved interprofessional collaboration.

Impacts of multidisciplinary meeting case discussion on palliative care referral and end-of-life care in lung cancer: a retrospective observational study

BACKGROUND

Multidisciplinary meeting (MDM) discussion and early palliative care are recommended in lung cancer management. The literature is unclear whether MDM discussion leads to early palliative care and improved end-of-life care.

AIMS

To evaluate impacts of discussion at an Australian lung MDM on palliative care referral, and MDM and early palliative care on aggressive end-of-life care.

METHODS

A retrospective, cross-sectional study was conducted of 352 patients diagnosed with primary lung cancer from 2017 to 2019 at the Alfred Hospital, Melbourne. The primary question was whether MDM discussion influenced palliative care referrals. Secondary questions were whether MDM discussion and early palliative care reduced aggressive treatment (chemotherapy, hospitalisation, emergency department visits, intensive care admission and in-hospital death) during the last 30 days of life. Multivariable logistic regression was used to determine independent association between MDM discussion and palliative care referral.

RESULTS

MDM discussion did not independently impact palliative care referral. There was reduced likelihood of MDM presentation in patients with metastatic disease (P < 0.0001) and poorer performance status (P = 0.025), and higher likelihood of palliative care referral in these patients (both P < 0.001). MDM discussion reduced end-of-life intensive care unit (ICU) admission in patients with metastatic disease (P = 0.04). A palliative care referral-to-death interval of ≥30 days was associated with reduced hospitalisation at the end of life (P < 0.0001) and hospital deaths (P = 0.001).

CONCLUSION

Discussion at lung MDM did not increase palliative care referral, but did reduce ICU admission among metastatic patients at the end of life. Longer palliative care referral-to-death interval was associated with reduced aggressive end-of-life care. Further research is needed in these areas.

Impact of a specialised palliative care intervention in patients with advanced soft tissue sarcoma - a single-centre retrospective analysis

BACKGROUND

Soft tissue sarcomas (STS) account for less than 1% of all malignancies. Approximately 50% of the patients develop metastases with limited survival in the course of their disease. For those patients, palliative treatment aiming at symptom relief and improvement of quality of life is most important. However, data on symptom burden and palliative intervention are limited in STS patients.

AIM

Our study evaluates the effectiveness of a palliative care intervention on symptom relief and quality of life in STS patients.

DESIGN/SETTING

We retrospectively analysed 53 inpatient visits of 34 patients with advanced STS, admitted to our palliative care unit between 2012 and 2018. Symptom burden was measured with a standardised base assessment questionnaire at admission and discharge.

RESULTS

Median disease duration before admission was 24 months, 85% of patients had metastases. The predominant indication for admission was pain, weakness and fatigue. Palliative care intervention led to a significant reduction of pain: median NRS for acute pain was reduced from 3 to 1 (p < 0.001), pain within the last 24 h from 5 to 2 (p < 0.001) and of the median MIDOS symptom score: 18 to 13 (p < 0.001). Also, the median stress level, according to the distress thermometer, was reduced significantly: 7.5 to 5 (p = 0.027).

CONCLUSIONS

Our data underline that specialised palliative care intervention leads to significant symptom relief in patients with advanced STS. Further efforts should aim for an early integration of palliative care in these patients focusing primarily on the identification of subjects at high risk for severe symptomatic disease.

American Association of Clinical Endocrinology Disease State Clinical Review on the Evaluation and Management of Adrenocortical Carcinoma in an Adult: a Practical Approach

OBJECTIVE

The aim of this Disease State Clinical Review is to provide a practical approach to patients with newly diagnosed adrenocortical carcinoma, as well as to follow-up and management of patients with persistent or recurrent disease.

METHODS

This is a case-based clinical review. The provided recommendations are based on evidence available from randomized prospective clinical studies, cohort studies, cross-sectional and case-based studies, and expert opinions.

RESULTS

Adrenocortical carcinoma is a rare malignancy, often with poor outcomes. For any patient with an adrenal mass suspicious for adrenocortical carcinoma, the approach should include prompt evaluation with detailed history and physical exam, imaging, and biochemical adrenal hormone assessment. In addition to adrenal-focused imaging, patients should be evaluated with chest-abdomen-pelvis cross-sectional imaging to define the initial therapy plan. Patients with potentially resectable disease limited to the adrenal gland should undergo en bloc open surgery by an expert surgeon. For patients presenting with advanced or recurrent disease, a multidisciplinary approach considering curative repeat surgery, local control with surgery, radiation therapy or radiofrequency ablation, or systemic therapy with mitotane and/or cytotoxic chemotherapy is recommended.

CONCLUSION

As most health care providers will rarely encounter a patient with adrenocortical carcinoma, we recommend that patients with suspected adrenocortical carcinoma be evaluated by an expert multidisciplinary team which includes clinicians with expertise in adrenal tumors, including endocrinologists, oncologists, surgeons, radiation oncologists, pathologists, geneticists, and radiologists. We recommend that patients in remote locations be followed by the local health care provider in collaboration with a multidisciplinary team at an expert adrenal tumor program.

ABBREVIATIONS

ACC = adrenocortical carcinoma; ACTH = adrenocorticotropic hormone; BRACC = borderline resectable adrenocortical carcinoma; CT = computed tomography; DHEAS = dehydroepiandrosterone sulfate; EDP = etoposide, doxorubicin, cisplatin; FDG = ¹⁸F-fluorodeoxyglucose; FNA = fine-needle aspiration; HU = Hounsfield units; IVC = inferior vena cava; LFS = Li-Fraumeni syndrome; MEN1 = multiple endocrine neoplasia type 1; MRI = magnetic resonance imaging; OAC = oncocytic adrenocortical carcinoma; PC = palliative care; PET = positron emission tomography.

Challenges of Dental Hygienists in a Multidisciplinary Team Approach During Palliative Care for Patients With Advanced Cancer: A Nationwide Study

PURPOSE

Palliative care is constructed by various kinds of professionals. This study aimed to identify the challenges that dental hygienists (DHs) encountered when working with other professionals in a multidisciplinary team approach in palliative care for advanced cancer patients.

METHODS

We conducted the following two studies: (1) a questionnaire-based survey for DHs who belong to Japanese Society for Oral Care (JSOC) on oral care in palliative care settings (n = 1,290), and (2) surveys on education for DHs in universities. Items in this study included the following: 1) a cross-sectional analysis of the curriculum on palliative care at 10 universities and 2) a questionnaire-based survey on palliative care education at 1 of the 10 universities (n = 75).

RESULTS

(1) Seventy-three percent had experience in oral care in palliative care settings. The number of DHs with ≥20 years' experience was significantly higher than those with <10 years' experience (76% vs 66%, p = 0.042). Further, 92% received no formal palliative care education, and 94% perceived a lack of knowledge on palliative care. These data did not differ based on the years of experience. (2) (a) There was no specific curriculum on the subject of palliative care in 10 universities. Lectures on palliative care were provided at 3 universities. (b) Fifty-five percent of students attended lectures on palliative care. However, 88% of them experienced anxiety, and 78% perceived few classes on palliative care.

CONCLUSIONS

For DHs, to positively contribute to multidisciplinary palliative care team approach, it is important to establish pregraduate and postgraduate education systems.

Stakeholder engagement in research on quality of life and palliative care for brain tumors: a qualitative analysis of #BTSM and #HPM tweet chats

Background

Research is needed to inform palliative care models that address the full spectrum of quality of life (QoL) needs for brain tumor patients and care partners. Stakeholder engagement in research can inform research priorities; engagement via social media can complement stakeholder panels. The purpose of this paper is to describe the use of Twitter to complement in-person stakeholder engagement, and report emergent themes from qualitative analysis of tweet chats on QoL needs and palliative care opportunities for brain tumor patients.

Methods

The Brain Cancer Quality of Life Collaborative engaged brain tumor (#BTSM) and palliative medicine (#HPM) stakeholder communities via Twitter using tweet chats. The #BTSM chat focused on defining and communicating about QoL among brain tumor patients. The #HPM chat discussed communication about palliative care for those facing neurological conditions. Qualitative content analysis was used to identify tweet chat themes.

Results

Analysis showed QoL for brain tumor patients and care partners includes psychosocial, physical, and cognitive concerns. Distressing concerns included behavioral changes, grief over loss of identity, changes in relationships, depression, and anxiety. Patients appreciated when providers discussed QoL early in treatment, and emphasized the need for care partner support. Communication about QoL and palliative care rely on relationships to meet evolving patient needs.

Conclusions

In addition to providing neurological and symptom management, specialized palliative care for brain tumor patients may address unmet patient and care partner psychosocial and informational needs. Stakeholder engagement using Twitter proved useful for informing research priorities and understanding stakeholder perspectives on QoL and palliative care.

Challenges for cancer patients returning home during SARS-COV-19 pandemic after medical tourism - a consensus report by the emirates oncology task force

BACKGROUND

The COVID-19 pandemic has caused a global health crisis. Numerous cancer patients from non-Western countries, including the United Arab Emirates (UAE), seek cancer care outside their home countries and many are sponsored by their governments for treatment. Many patients interrupted their cancer treatment abruptly and so returned to their home countries with unique challenges. In this review we will discuss practical challenges and recommendations for all cancer patients returning to their home countries from treatment abroad.

METHOD

Experts from medical, surgical and other cancer subspecialties in the UAE were invited to form a taskforce to address challenges and propose recommendations for patients returning home from abroad after medical tourism during the SARS-COV-19 Pandemic.

RESULTS

The taskforce which consisted of experts from medical oncology, hematology, surgical oncology, radiation oncology, pathology, radiology and palliative care summarized the current challenges and suggested a practical approaches to address these specific challenges to improve the returning cancer patients care. Lack of medical documentation, pathology specimens and radiology images are one of the major limitations on the continuation of the cancer care for returning patients. Difference in approaches and treatment recommendations between the existing treating oncologists abroad and receiving oncologists in the UAE regarding the optimal management which can be addressed by early and empathic communications with patients and by engaging the previous treating oncologists in treatment planning based on the available resources and expertise in the UAE. Interruption of curative radiotherapy (RT) schedules which can potentially increase risk of treatment failure has been a major challenge, RT dose-compensation calculation should be considered in these circumstances.

CONCLUSION

The importance of a thorough clinical handover cannot be overstated and regulatory bodies are needed to prevent what can be considered unethical procedure towards returning cancer patients with lack of an effective handover. Clear communication is paramount to gain the trust of returning patients and their families. This pandemic may also serve as an opportunity to encourage patients to receive treatment locally in their home country. Future studies will be needed to address the steps to retain cancer patients in the UAE rather than seeking cancer treatment abroad.

Oncology Fellow-Led Quality Improvement Project to Improve Rates of Palliative Care Utilization in Patients With Advanced Cancer

PURPOSE

ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. First-year oncology fellows at our institution identified low rates of PC utilization in their longitudinal clinic as a metric needing improvement.

METHODS

A fellow-led multidisciplinary team aimed to increase PC utilization for patients with advanced cancer followed in he first-year fellows' clinic from a baseline of 11.5% (5 of 43 patients, July to December of 2018) to 30% over a 6-month period. Utilization was defined as evaluation in the outpatient PC clinic hosted in the cancer center. The team identified the following barriers to referral: orders difficult to find in the electronic medical record (EMR), multiple consulting mechanisms (EMR, by phone, or in person), EMR request not activating formal consult, no centralized scheduler to contact or confirm appointment, and poor awareness of team structure. Plan-Do-Study-Act (PDSA) cycles were implemented based on identified opportunities. Data were obtained from the EMR.

RESULTS

The first PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and disseminating process changes. PDSA cycles were implemented from January to June of 2019. Rates of PC use increased from 11.5% before the intervention to 48.4% (48 of 99 patients) after the intervention.

CONCLUSION

A multidisciplinary approach and classic quality improvement methodology improved PC use in patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional and leadership support. Straightforward EMR interventions and ancillary staff use are effective in addressing underreferrals.

Standards, Guidelines, and Quality Measures for Successful Specialty Palliative Care Integration Into Oncology: Current Approaches and Future Directions

Although robust evidence demonstrates that specialty palliative care integrated into oncology care improves patient and health system outcomes, few clinicians are familiar with the standards, guidelines, and quality measures related to integration. These types of guidance outline principles of best practice and provide a framework for assessing the fidelity of their implementation. Significant advances in the understanding of effective methods and procedures to guide integration of specialty palliative care into oncology have led to a proliferation of guidance documents around the world, with several areas of commonality but also some key differences. Commonalities originate from a shared vision for integration; differences arise from diverse roles of palliative care specialists within cancer care globally. In this review we discuss three of the most cited standards/guidelines, as well as quality measures related to integrated palliative and oncology care. We also recommend changes to the quality measurement framework for palliative care and a new way to match palliative care services to patients with advanced cancer on the basis of care complexity and patient needs, irrespective of prognosis.

Development and Use of the 'SENS'-Structure to Proactively Identify Care Needs in Early Palliative Care-An Innovative Approach

Anticipatory planning for end of life requires a common language for discussion among patients, families, and professionals. Studies show that early Palliative Care (PC) interventions based on a problem-oriented approach can improve quality of life, support decision-making, and optimize the timing of medical treatment and transition to hospice services. The aim of this quality-improvement project was to develop a pragmatic structure meeting all clinical settings and populations needs. Based on the Medical Research Council (MRC) framework, a literature review identifying approaches commonly used in PC was performed. In addition, more than 500 hospital-based interprofessional consultations were analyzed. Identified themes were structured and compared to published approaches. We evaluated the clinical usefulness of this structure with an online survey among professionals. The emerged 'SENS'-structure stands for: Symptoms patients suffer from; End-of-life decisions; Network around the patient delivering care; and Support for the carer. Evaluation among professionals has confirmed that the 'SENS'-structure covers all relevant areas for anticipatory planning in PC. 'SENS' is useful in guiding patient-centered PC conversations and pragmatic anticipatory planning, alongside the regular diagnosis-triggered approach in various settings. Following this approach, 'SENS' may facilitate systematic integration of PC in clinical practice. Depending on clearly defined outcomes, this needs to be confirmed by future randomized controlled studies.

Systematic Review: Depression and Anxiety Prevalence in Bladder Cancer Patients

Background:

Depression affects more than 300 million people of all ages worldwide. In patients with cancer the reported prevalence is up to 24%.

Objective:

To systematically review the literature to report the prevalence of depression and anxiety among patients with bladder cancer (BC).

Methods:

Web of Science, MEDLINE/PubMed, and The Cochrane Library were searched between January and March 2018 using the terms “bladder carcinoma OR bladder cancer AND depression OR anxiety”.

Results:

Thirteen studies encompassing 1659 patients with BC were included. Six studies assessed depression prior and after treatment at 1, 6 and 12 months. Three were conducted in the US, one each in Turkey, Sweden/Egypt and China. Four studies showed a reduction of depression after radical cystectomy (RC) at 1, 6 and 12 months, respectively. Contrary, two studies showed no significant difference in depression between baseline and follow-up. Four studies investigated anxiety; they reported a slight reduction in anxiety score compared to baseline. Seven additional studies reported the prevalence of depression and anxiety (five studies) among patients with BC at a specific time-point. Studies were conducted in Sweden (2), Italy, Greece, US, China and Spain. Pretreatment depression rates ranged from 5.7 to 23.1% and post-treatment from 4.7 to 78%. Post-treatment anxiety rates ranged from 12.5 to 71.3%.

Conclusions:

The prevalence of reported depression and anxiety among BC patients is high with large geographic heterogeneity. Gender and geriatric specific screening and management for anxiety and depression should be implemented to alleviate suffering.