Gallbladder cancer: current and future treatment options

Deep Vein Thrombosis as a Complication of Gemcitabine-Capecitabine Chemotherapy in Adenocarcinoma of Gallbladder

Gallbladder adenocarcinoma has a high mortality rate, with approximately 1.7% cancer-related deaths worldwide. Cancer-associated thrombosis (CAT), including deep vein thrombosis (DVT), can significantly increase the risk of mortality within cancer patients, especially in pancreatic, brain, and intra-abdominal cancers, as well as in advanced and metastatic cancers. In this case report, there was a 45-year-old male patient diagnosed with advanced gallbladder adenocarcinoma UICC stage IVB with a TNM stage of T2b, N0, M1 with liver metastases who experienced pain and swelling in both lower limbs after undergoing a VI-A cycle of chemotherapy with gemcitabine capecitabine. The risk of thrombosis was calculated using the modified Khorana-Vienna CAT scores, which increased during every chemotherapy session. In this case, the Khorana-Vienna CAT score was calculated during two latest cycle of chemotherapy that somewhat considered delayed as the patient had already shown hypercoagulopathy symptoms and developed a poorer prognosis. Early CAT scoring, ideally before starting chemotherapy session, potentially improves thrombosis prognosis. The patient's condition improved after administration of antithrombotic agents. Chemotherapy agents and other factors, including the cancer site and presence of metastatic cancer, influence the risk of CAT. Risk predictor scores are required to assess the risk of CAT and benefits of prophylactic treatment. Prophylactic therapy can be initiated in patients with high-risk CAT, calculated using the modified Khorana and Vienna CAT scores, to prevent thrombosis and improve patient outcomes.

Newer Biomarkers in Gallbladder Carcinoma: A Scoping Review

Biomarkers have the potential to play a crucial role in managing gallbladder cancer post-surgery. They can identify patients more likely to experience a recurrence, allowing oncologists to tailor a more intensive surveillance plan and consider additional therapies. Some biomarkers can even predict how well a patient will respond to specific chemotherapy or targeted treatments. By monitoring these biomarkers, clinicians can track how effective the ongoing treatment is and detect any signs of early recurrence. Various biomarkers, like tumor markers, genetic markers, and genomic and epigenetic markers, are being investigated. The goal is to find the most reliable and accurate biomarkers to enhance patient care and outcomes. Integrating biomarker data into treatment plans can help personalize therapy and make better informed decisions. By identifying which patients are likely to benefit from specific treatments, biomarkers have the potential to improve long-term survival rates significantly. This scoping review discusses newer biomarkers in gallbladder carcinoma; some of them are in clinical use, while most of them are used in research settings. This provides a broad insight to practicing clinicians about the present biomarkers and the futuristic biomarkers.

Efficacy of neoadjuvant therapy and lymph node dissection in advanced gallbladder cancer without distant metastases: a SEER database analysis

Purpose

To investigate the effectiveness of neoadjuvant therapy and lymph node dissection(LND) on overall survival (OS) in patients with stage III/IV gallbladder cancer without distant metastases.

Methods

Data from 101 patients who received neoadjuvant therapy followed by surgery combined with adjuvant chemotherapy, and 1412 patients who received direct surgical treatment followed by adjuvant chemotherapy, were collected from the SEER database from 2004 to 2020. Patients were divided into group A (neoadjuvant therapy) and group B (direct surgery) based on the treatment modality. A total of 202 cases were obtained after propensity score matching, with 101 cases in each group (A and B). Cox unifactorial and multifactorial analyses were performed to identify independent risk factors for patients with advanced cholecystic carcinoma, and the Kaplan-Meier method was used to analyze overall survival (OS). The Cox proportional hazards model was used to investigate the effect of different subgroups on OS in both patient groups. Further survival analyses were conducted to determine whether lymph node dissection(LND) was beneficial for patients receiving neoadjuvant therapy for gallbladder cancer.

Results

Cox univariate analysis showed that marital status, AJCC stage, number of LND, tumor size, and treatment modality were associated with OS (P<0.05). Cox multifactorial regression analysis indicated that AJCC stage, LND, tumor size, and treatment modality were independent risk factors for OS in patients with non-metastatic advanced gallbladder cancer (P<0.05). Survival curves demonstrated that the OS in group A was longer than in group B (median OS: 30 months vs. 14 months, P<0.001). Subgroup analysis indicated that neoadjuvant therapy had a consistent effect on the OS of patients with advanced gallbladder cancer, improving both survival time and outcomes. Survival curves indicated that lymph node dissection was not significant in group A patients (p>0.05) but was significant in group B (p<0.05).

Conclusion

Neoadjuvant therapy can improve the OS of patients with non-metastatic stage III/IV gallbladder cancer and is an independent risk factor affecting prognosis; however, the significance of lymph node dissection in these patients still needs further study.

Comparison of treatment models for single primary advanced gallbladder cancer

Purpose

Treatment for advanced gallbladder cancer (GBC) remains controversial, with various recommendations regarding the choice and combination of surgery and adjuvant therapy. The present article is targeting for the exploration of optimal treatment models for advanced GBC.

Methods

AJCC (American Joint Committee on Cancer, 8th edition) stage III and stage IV GBC, were defined as advanced GBC. Patients with advanced GBC were identified using the Surveillance, Epidemiology, and End Results (SEER) database and departmental cohort. Because of the most representative, only gallbladder adenocarcinoma (GBAC) patients were selected. Based on their surgical status (No, Non-radical and Radical surgery), chemotherapy status (Chemotherapy, No chemotherapy), and radiotherapy status (Radiotherapy, No radiotherapy), treatment models were categorized. For the purposes of evaluating the treatment outcomes of various treatment models and determining the risk element for cancer-specific survival (CSS), Cox regression analysis was applied. Kaplan-Meier curves were used before and after adjusting for covariates, with log-rank tests used to analyze discrepancies between curves. Immunotherapy was analyzed using clinical data from departmental cohort. Finally, to compensate for the limitations of the database, a review examines the progress in treatment models for advanced GBC.

Results

5,154 patients aged over 18 years with solitary primary advanced GBC were identified from the SEER database. In advanced GBC patients, the treatment model has emerged as a significant prognostic factor. "Radical surgery + Chemotherapy + Radiotherapy" models maximally improved the CSS of advanced GBC before and after adjusting for covariates, while "No surgery + No chemotherapy + No radiotherapy" model had the lowest CSS. The present conclusions were supported even after subgroup analysis by AJCC stage. The efficacy of immunotherapy was demonstrated in the departmental cohort analysis. Additionally, this article provides a comprehensive overview of recent advancements in various emerging treatment strategies.

Conclusion

Even when optimal treatment model cannot be pursued, providing comprehensive combinations of treatments to advanced GBC patients whenever possible is always beneficial for their survival.

Machine learning prediction of early recurrence after surgery for gallbladder cancer

BACKGROUND

Gallbladder cancer is often associated with poor prognosis, especially when patients experience early recurrence after surgery. Machine learning may improve prediction accuracy by analysing complex non-linear relationships. The aim of this study was to develop and evaluate a machine learning model to predict early recurrence risk after resection of gallbladder cancer.

METHODS

In this cross-sectional study, patients who underwent resection of gallbladder cancer with curative intent between 2001 and 2022 were identified using an international database. Patients were assigned randomly to a development and an evaluation cohort. Four machine learning models were trained to predict early recurrence (within 12 months) and compared using the area under the receiver operating curve (AUC).

RESULTS

Among 374 patients, 56 (15.0%) experienced early recurrence; most patients had T1 (51, 13.6%) or T2 (180, 48.1%) disease, and a subset had lymph node metastasis (120, 32.1%). In multivariable Cox analysis, resection margins (HR 2.34, 95% c.i. 1.55 to 3.80; P < 0.001), and greater AJCC T (HR 2.14, 1.41 to 3.25; P < 0.001) and N (HR 1.59, 1.05 to 2.42; P = 0.029) categories were independent predictors of early recurrence. The random forest model demonstrated the highest discrimination in the evaluation cohort (AUC 76.4, 95% c.i. 66.3 to 86.5), compared with XGBoost (AUC 74.4, 53.4 to 85.3), support vector machine (AUC 67.2, 54.4 to 80.0), and logistic regression (AUC 73.1, 60.6 to 85.7), as well as good accuracy after bootstrapping validation (AUC 75.3, 75.0 to 75.6). Patients classified as being at high versus low risk of early recurrence had much worse overall survival (36.1 versus 63.8% respectively; P < 0.001). An easy-to-use calculator was made available (https://catalano-giovanni.shinyapps.io/GallbladderER).

CONCLUSION

Machine learning-based prediction of early recurrence after resection of gallbladder cancer may help stratify patients, as well as help inform postoperative adjuvant therapy and surveillance strategies.

Novel multifactor predictive model for postoperative survival in gallbladder cancer: a multi-center study

BACKGROUND

Gallbladder cancer (GBC) is a highly aggressive malignancy, with limited survival profiles after curative surgeries. This study aimed to develop a practical model for predicting the postoperative overall survival (OS) in GBC patients.

METHODS

Patients from three hospitals were included. Two centers (N = 102 and 100) were adopted for model development and internal validation, and the third center (N = 85) was used for external testing. Univariate and stepwise multivariate Cox regression were used for feature selection. A nomogram for 1-, 3-, and 5-year postoperative survival rates was constructed accordingly. Performance assessment included Harrell's concordance index (C-index), receiver operating characteristic (ROC) curves and calibration curves. Kaplan-Meier curves were utilized to evaluate the risk stratification results of the nomogram. Decision curves were used to reflect the net benefit.

RESULTS

Eight factors, TNM stage, age-adjusted Charlson Comorbidity Index (aCCI), body mass index (BMI), R0 resection, blood platelet count, and serum levels of albumin, CA125, CA199 were incorporated in the nomogram. The time-dependent C-index consistently exceeded 0.70 from 6 months to 5 years, and time-dependent ROC revealed an area under the curve (AUC) of over 75% for 1-, 3-, and 5-year survival. The calibration curves, Kaplan-Meier curves and decision curves also indicated good prognostic performance and clinical benefit, surpassing traditional indicators TNM staging and CA199 levels. The reliability of results was further proved in the independent external testing set.

CONCLUSIONS

The novel nomogram exhibited good prognostic efficacy and robust generalizability in GBC patients, which might be a promising tool for aiding clinical decision-making.

Machine learning-based short-term DFS-associated characteristic factor screening and model construction for patients with gallbladder cancer after radical surgery

Gallbladder cancer (GBC) is a malignancy with a bleak prognosis, and radical surgery remains the primary treatment option. However, the high postoperative recurrence rate and the lack of individualized risk assessment tools limit the effectiveness of current treatment strategies. This study aims to identify risk factors affecting the short-term disease-free survival (DFS) of GBC patients using machine learning methods and to build a prediction model. A retrospective analysis was conducted on the clinical data from 328 GBC patients treated at the First Affiliated Hospital of Huzhou University from 2008 to 2021. Patients were randomly divided into a training set (n=230) and a validation set (n=98). Clinical data, laboratory indexes, and follow-up data were collected. Univariate Cox regression analysis identified age, tumor T-staging, lymph node metastasis, differentiation degree, and CA199 level as prognostic factors affecting DFS (all P<0.05). A prediction model constructed using the LASSO regression achieved AUCs of 0.827 and 0.801 for predicting 1-year and 3-year DFS, respectively. Notably, the XGBoost regression model showed higher prediction accuracy with AUCs of 0.922 and 0.947, respectively. The Delong test confirmed that the XGBoost model had significantly higher AUC values compared to the LASSO model (all P<0.001). In the validation set, the XGBoost model demonstrated AUCs of 0.764 and 0.761 for predicting 1-year and 3-year DFS, respectively. Overall, the XGBoost regression model demonstrates high accuracy and clinical value in predicting short-term DFS in GBC patients after radical surgery, offering a valuable tool for personalized treatment.

Synchronous Primary Gallbladder and Colon Adenocarcinoma: A Case Report and Systematic Literature Review

Synchronous primary malignancies, defined as two or more primary malignancies diagnosed simultaneously or within six months, are uncommon and present unique diagnostic and therapeutic challenges. Synchronous primary adenocarcinoma of the gallbladder and colon is particularly rare. We report a case of a 48-year-old female presenting with persistent right upper abdominal pain. Laboratory tests and imaging studies initially suggested xanthogranulomatous cholecystitis. However, subsequent laparoscopic cholecystectomy and pathological examination revealed a moderately differentiated adenocarcinoma of the gallbladder (pT2bN1M0). Further staging with CT and PET-CT scans identified a suspicious mass in the transverse colon, confirmed by colonoscopy and surgical resection as well-differentiated adenocarcinoma of the transverse colon (pT3N0M0). Immunohistochemistry and genetic profiling of both tumors indicated distinct primary origins without loss of mismatch repair (MMR) protein expression. The patient underwent additional liver resection, lymph node dissection, and right extended hemicolectomy. She is currently undergoing further staging and awaiting chemotherapy. A review of English-language literature revealed eight reported cases of synchronous primary gallbladder and colorectal cancer and a total of 13 with synchronous primary malignancy of other organs. Such cases are rare and diagnostically complex cases. Common factors contributing to multiple primary malignancies (MPM) include genetic predispositions, previous cancer treatments, and lifestyle factors such as smoking and alcohol consumption. This case underscores the importance of thorough investigation and prompt treatment in patients suspected of having MPM. Advances in diagnostic imaging and molecular profiling are crucial for early detection and tailored therapeutic strategies. Standardized guidelines for managing synchronous cancers are needed to improve patient outcomes.

The Role of Immunotherapy in the Treatment of Gynecologic Cancers: A Systematic Review

Gynecologic cancers remain a significant health burden worldwide. Immunotherapy has emerged as a promising treatment approach across various cancer types. To evaluate the efficacy and safety of immune checkpoint inhibitors, alone or in combination with other therapies, in the treatment of gynecologic cancers. We searched PubMed/MEDLINE, Cochrane Library, Embase, Web of Science, and ClinicalTrials.gov for clinical trials of immunotherapy in gynecologic cancers. Randomized controlled trials and prospective studies were included. MMAT tool was used to assess the quality of the studies. Risk of bias was assessed using appropriate tools for each study design. Seventeen studies met inclusion criteria, encompassing ovarian, endometrial, and cervical cancers. Immune checkpoint inhibitors, particularly in combination with standard therapies, demonstrated improved progression-free survival across multiple trials. Notable results include improved outcomes with pembrolizumab in endometrial and cervical cancers, and promising combinations of PARP inhibitors with checkpoint inhibitors in ovarian cancer. Safety profiles were generally consistent with known effects of immunotherapy. Immunotherapy shows significant promise in improving outcomes for patients with gynecologic cancers. Further research is needed to optimize patient selection and combination strategies.

Mechanisms of Ferroptosis-Related Genes in Gallbladder Cancer Based on Bioinformatics Analysis

Gallbladder Cancer (GBC) is a lethal malignancy with limited treatment options and poor prognosis. Recent studies have emphasized the role of ferroptosis, a regulated form of cell death, in various cancers, including GBC. We applied bioinformatics methodologies on four GBC datasets to identify differentially expressed genes (DEGs). An intersection of DEGs from the four datasets with ferroptosis and GBC-associated genes was done to identify key ferroptosis-related genes in GBC. GSVA pathway enrichment analysis and immune cell infiltration assessment were conducted to explore their functional roles and interactions. Seven ferroptosis-related genes, EZH2, MUC1, PVT1, GOT1, CDO1, LIFR, and TFAP2A, were identified to be related to GBC. These genes were associated with vital signaling pathways like the G2/M checkpoint and DNA repair and showed significant correlations with immune cell infiltration in GBC. Receiver Operating Characteristic (ROC) curve analysis revealed their high diagnostic potential, with Area Under the Curve (AUC) values ranging from 0.796 to 0.953. Our findings underscore the pivotal role of ferroptosis in GBC and the potential of ferroptosis-related genes as diagnostic biomarkers. This study lays a foundation for further research into ferroptosis-based therapeutic strategies for GBC.

Fatty Acid Binding Protein 1 is an Independent Prognostic Biomarker for Gallbladder Cancer with Direct Hepatic Invasion

Background: Direct liver invasion (DI) is a predominant pathway of gallbladder cancer (GBC) metastasis, but the molecular alterations associated with DI remain addressed. This study identified specific genes correlated with DI, which may offer a potential biomarker for the diagnosis and prognosis of advanced GBC. Methods: RNA samples from 3 patients with DI of GBC were used for RNA-seq analysis. Differentially expressed genes and metabolic pathways between primary tumor (T) and DI tissue was used to analyze aberrant gene expressions. Immunohistochemistry (IHC) of fatty acid binding protein 1 (FABP1) in 62 patients with DI was engaged to evaluate its association with clinicopathological characteristics and prognosis. IHC of CD3+ and CD8+ T cells was analyzed for their correlation with FABP1 expression, clinicopathological features and prognosis. Univariate and multivariate Cox hazards regression analyses were performed to identify independent prognostic factors for disease-free survival (DFS) and overall survival (OS). Results: FABP1 mRNA levels were significantly upregulated in DI region compared to T tissue. IHC results showed identical results with elevated FABP1 (p < 0.0001). Expression of FABP1 in DI region was significantly associated with lymph node metastasis (P = 0.028), reduced DFS (P = 0.013) and OS (P = 0.022); in contrast, its expression in T region was not associated with clinicopathological characteristics and prognosis (P > 0.05). The density of CD8+ T cells in DI region with higher FABP1 expression was significantly lower than that with lower FABP1 expression (p = 0.0084). Multivariate analysis unveiled those hepatic metastatic nodules (HR = 3.35, 95%CI: 1.37-8.15, P = 0.008) and FABP1 expression in DI region (HR = 2.01, 95%CI: 1.05-3.88, P = 0.036) were high risk factors for OS, and FABP1(HR = 2.05, 95%CI: 1.04-4.06, P = 0.039) was also a high risk factor for DFS. Conclusions: Elevated expression of FABP1 in DI region serves as a potential prognostic biomarker for advanced GBC with DI.

The role of kinesin family members in hepatobiliary carcinomas: from bench to bedside

As a major component of the digestive system malignancies, tumors originating from the hepatic and biliary ducts seriously endanger public health. The kinesins (KIFs) are molecular motors that enable the microtubule-dependent intracellular trafficking necessary for mitosis and meiosis. Normally, the stability of KIFs is essential to maintain cell proliferation and genetic homeostasis. However, aberrant KIFs activity may destroy this dynamic stability, leading to uncontrolled cell division and tumor initiation. In this work, we have made an integral summarization of the specific roles of KIFs in hepatocellular and biliary duct carcinogenesis, referring to aberrant signal transduction and the potential for prognostic evaluation. Additionally, current clinical applications of KIFs-targeted inhibitors have also been discussed, including their efficacy advantages, relationship with drug sensitivity or resistance, the feasibility of combination chemotherapy or other targeted agents, as well as the corresponding clinical trials. In conclusion, the abnormally activated KIFs participate in the regulation of tumor progression via a diverse range of mechanisms and are closely associated with tumor prognosis. Meanwhile, KIFs-aimed inhibitors also carry out a promising tumor-targeted therapeutic strategy that deserves to be further investigated in hepatobiliary carcinoma (HBC).

New trends in diagnosis and management of gallbladder carcinoma

Gallbladder (GB) carcinoma, although relatively rare, is the most common biliary tree cholangiocarcinoma with aggressiveness and poor prognosis. It is closely associated with cholelithiasis and long-standing large (> 3 cm) gallstones in up to 90% of cases. The other main predisposing factors for GB carcinoma include molecular factors such as mutated genes, GB wall calcification (porcelain) or mainly mucosal microcalcifications, and GB polyps ≥ 1 cm in size. Diagnosis is made by ultrasound, computed tomography (CT), and, more precisely, magnetic resonance imaging (MRI). Preoperative staging is of great importance in decision-making regarding therapeutic management. Preoperative staging is based on MRI findings, the leading technique for liver metastasis imaging, enhanced three-phase CT angiography, or magnetic resonance angiography for major vessel assessment. It is also necessary to use positron emission tomography (PET)-CT or 18F-FDG PET-MRI to more accurately detect metastases and any other occult deposits with active metabolic uptake. Staging laparoscopy may detect dissemination not otherwise found in 20%-28.6% of cases. Multimodality treatment is needed, including surgical resection, targeted therapy by biological agents according to molecular testing gene mapping, chemotherapy, radiation therapy, and immunotherapy. It is of great importance to understand the updated guidelines and current treatment options. The extent of surgical intervention depends on the disease stage, ranging from simple cholecystectomy (T1a) to extended resections and including extended cholecystectomy (T1b), with wide lymph node resection in every case or IV-V segmentectomy (T2), hepatic trisegmentectomy or major hepatectomy accompanied by hepaticojejunostomy Roux-Y, and adjacent organ resection if necessary (T3). Laparoscopic or robotic surgery shows fewer postoperative complications and equivalent oncological outcomes when compared to open surgery, but much attention must be paid to avoiding injuries. In addition to surgery, novel targeted treatment along with immunotherapy and recent improvements in radiotherapy and chemotherapy (neoadjuvant-adjuvant capecitabine, cisplatin, gemcitabine) have yielded promising results even in inoperable cases calling for palliation (T4). Thus, individualized treatment must be applied.

Identification of genes associated with gall bladder cell carcinogenesis: Implications in targeted therapy of gall bladder cancer

Gall bladder cancer (GBC) is becoming a very devastating form of hepatobiliary cancer in India. Every year new cases of GBC are quite high in India. Despite recent advanced multimodality treatment options, the survival of GBC patients is very low. If the disease is diagnosed at the advanced stage (with local nodal metastasis or distant metastasis) or surgical resection is inoperable, the prognosis of those patients is very poor. So, perspectives of targeted therapy are being taken. Targeted therapy includes hormone therapy, proteasome inhibitors, signal transduction and apoptosis inhibitors, angiogenesis inhibitors, and immunotherapeutic agents. One such signal transduction inhibitor is the specific short interfering RNA (siRNA) or short hairpin RNA (shRNA). For developing siRNA-mediated therapy shRNA, although several preclinical studies to evaluate the efficacy of these key molecules have been performed using gall bladder cells, many more clinical trials are required. To date, many such genes have been identified. This review will discuss the recently identified genes associated with GBC and those that have implications in its treatment by siRNA or shRNA.

Increased co-expression of PD1 and TIM3 is associated with poor prognosis and immune microenvironment heterogeneity in gallbladder cancer

BACKGROUND

The effectiveness of immune checkpoint inhibitors in treating gallbladder cancer (GBC) remains unsatisfactory. Recently, several new immune checkpoints have been identified. However, investigations exploring these immune checkpoints in GBC are limited. In this study, we aim to investigate the expression patterns and clinical implications of various immune checkpoints, and further characterize the spatial and quantitative heterogeneity of immune components in GBC.

METHODS

We employed single and multiplex immunohistochemistry to evaluate the expression of five immune checkpoint markers and four immune cell markers in the primary tumor core, hepatic invasion margin, and liver metastasis. Subsequently, we analyzed their interrelationships and their prognostic significance.

RESULTS

We observed a robust positive correlation between PD1/TIM3 expression in GBC (R = 0.614, P < 0.001). The co-expression of PD1/TIM3 exhibited a synergistic effect in predicting poor prognosis among postoperative GBC patients. Further analysis revealed that the prognostic significance of PD1/TIM3 was prominent in the subgroup with high infiltration of CD8 + T cells (P < 0.001). Multiplex immunohistochemistry reveals that PD1 + TIM3 + FOXP3 + cells constitute a significant proportion of FOXP3 + TILs in GBC tissue. Moreover, the co-high expression of PD1 and TIM3 is positively correlated with the accumulation of CD8 + TILs at the hepatic invasion margin. Lastly, our findings indicated reduced expression levels of immune checkpoints and diminished immune cell infiltration in liver metastases compared to primary tumors.

CONCLUSIONS

Increased co-expression of PD1/TIM3 is associated with poor prognosis in GBC patients and is related to the heterogeneity of immune microenvironment between GBC primary tumor and its hepatic invasion margin or liver metastases, which may be a potential target for future immunotherapy of GBC.

Effectivity of Palliative Care Bundle on Advanced Gallbladder Cancer: A Randomised Controlled Trial

Objectives

The main aim of this study was to develop, test, and compare palliative care bundles to improve functional recovery, resilience, and quality of life among advanced gallbladder cancer patient with their routine palliative care.

Material and Methods

This study was to test a palliative care bundle, a single-center, and two-arm randomised controlled trial done on a total of 116 participants (58 in each arm) from July 2019 to December 2021 at All India Institute of Medical Sciences, Rishikesh.

Results

By the end of 4th month, the recruitment rate was 96.7%, retention rate acceptance rate was 95%, and adherence rate was 85%. The palliative care bundle showed that a significant difference in trial outcome index score (P = 0.014*) indicates the effectiveness of the palliative care bundle related to improvement in physical mobility, resilience, and quality of life of patients and reduced caregiver burden. Reported barriers faced by participants were physical exhaustion (65%), psychological factors (25%), social factors (15%) and unfamiliar surroundings (5%). Caregivers reported barriers that their job (40%), physical fatigue related to the care of their patient (40%), their education (10%), and lack of support for their other family members (10%) were some reasons forcing them not to practice palliative care bundle.

Conclusion

The palliative care bundle did not interfere with the palliative treatment plan of any patients and significantly improved physical mobility, resilience, quality of life of patients, and reduced caregiver burden. Hence, a palliative care bundle can be considered in the palliative care of advanced cancer patients during their palliative treatment to provide holistic care.