Transition from curative to palliative care in cancer

Application of Deep Learning for Real-Time Ablation Zone Measurement in Ultrasound Imaging

BACKGROUND

The accurate delineation of ablation zones (AZs) is crucial for assessing radiofrequency ablation (RFA) therapy's efficacy. Manual measurement, the current standard, is subject to variability and potential inaccuracies.

AIM

This study aims to assess the effectiveness of Artificial Intelligence (AI) in automating AZ measurements in ultrasound images and compare its accuracy with manual measurements in ultrasound images.

METHODS

An in vitro study was conducted using chicken breast and liver samples subjected to bipolar RFA. Ultrasound images were captured every 15 s, with the AI model Mask2Former trained for AZ segmentation. The measurements were compared across all methods, focusing on short-axis (SA) metrics.

RESULTS

We performed 308 RFA procedures, generating 7275 ultrasound images across liver and chicken breast tissues. Manual and AI measurement comparisons for ablation zone diameters revealed no significant differences, with correlation coefficients exceeding 0.96 in both tissues (p < 0.001). Bland-Altman plots and a Deming regression analysis demonstrated a very close alignment between AI predictions and manual measurements, with the average difference between the two methods being -0.259 and -0.243 mm, for bovine liver and chicken breast tissue, respectively.

CONCLUSION

The study validates the Mask2Former model as a promising tool for automating AZ measurement in RFA research, offering a significant step towards reducing manual measurement variability.

Effect of ionizing radiation on the mechanical properties of current fluoride-releasing materials

OBJECTIVES

This study aimed to evaluate the effect of fractional radiation on the mechanical properties of fluoride-releasing materials.

MATERIALS AND METHODS

High-viscosity glass ionomer cement (F9), resin-modified glass ionomer cement (F2), glass hybrid restoration (EQ), and bioactive composite (AC) were divided into 3 subgroups: 0, 35, and 70 Gy fractional radiation doses. The specimens were subjected to surface roughness, Vickers microhardness, and compressive strength tests. The chemical components and morphology of the tested specimens were observed via energy dispersive spectroscopy and scanning electron microscopy. The data were analyzed using two-way ANOVA with Bonferroni post hoc analysis.

RESULTS

After exposure to fractional radiation, the surface roughness increased in all the groups. F9 had the highest surface roughness, while AC had the lowest surface roughness within the same radiation dose. The Vickers microhardness decreased in F9 and EQ. The AC had the highest compressive strength among all the groups, followed by F2. More cracks and voids were inspected, and no substantial differences in the chemical components were observed.

CONCLUSIONS

After fractional radiation, the surface roughness of all fluoride-releasing materials increased, while the Vickers microhardness of F9 and EQ decreased. However, the compressive strength increased only in F2 and AC.

End-of-Life Care in the Last Three Months before Death in Older Patients with Cancer in Belgium: A Large Retrospective Cohort Study Using Data Linkage

This study aims to describe end-of-life (EOL) care in older patients with cancer and investigate the association between geriatric assessment (GA) results and specialized palliative care (SPC) use. Older patients with a new cancer diagnosis (2009-2015) originally included in a previous multicentric study were selected if they died before the end of follow-up (2019). At the time of cancer diagnosis, patients underwent geriatric screening with Geriatric 8 (G8) followed by GA in case of a G8 score ≤14/17. These data were linked to the cancer registry and healthcare reimbursement data for follow-up. EOL care was assessed in the last three months before death, and associations were analyzed using logistic regression. A total of 3546 deceased older patients with cancer with a median age of 79 years at diagnosis were included. Breast, colon, and lung cancer were the most common diagnoses. In the last three months of life, 76.3% were hospitalized, 49.1% had an emergency department visit, and 43.5% received SPC. In total, 55.0% died in the hospital (38.5% in a non-palliative care unit and 16.4% in a palliative care unit). In multivariable analyses, functional and cognitive impairment at cancer diagnosis was associated with less SPC. Further research on optimizing EOL healthcare utilization and broadening access to SPC is needed.

Considerations for Fostering Palliative Care Awareness in Developing Contexts: Strategies From Locally Initiated Projects in India

CONTEXT

Lack of palliative care (PC) awareness is a barrier to its utilization in developing contexts.

OBJECTIVES

To identify and understand strategies that changed awareness of the concepts and value of palliative care in a multi-site quality improvement project in India.

METHODS

The Palliative Care - Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) evaluation team conducted 44 semi-structured interviews with clinician and organization stakeholders at seven geographically dispersed sites. We used inductive and deductive approaches in this secondary analysis to identify emerging themes.

RESULTS

We identified the following strategies to improve awareness of concepts and value of palliative care. Strategy 1: Educate medical trainees, staff, and the community about palliative care and its concepts. Sub-strategies: Participate in community events. Integrate PC concepts into early medical education. Standardize training for practitioners. Strategy 2: Design and disseminate India-specific research to reinforce awareness of the value of palliative care. Sub-strategies: Publish and use India-specific palliative care research. Strategy 3: Facilitate communication between providers and departments to improve awareness of palliative care services and its concepts. Sub-strategies: Create referral frameworks and network with providers referring to palliative care to change awareness of available services and palliative care concepts.

CONCLUSION

To increase palliative care utilization, program development can include community and provider-focused efforts on awareness of the concepts and value of palliative care. These three strategies held salience across sites representing diverse Indian geographic and cultural settings; as such, they may be applicable to other contexts.

The experiences of caregivers of patients living with cancer admitted to a hospice in South Africa

BACKGROUND

Caregivers share cancer experiences with patients, but little is known about their own experiences in the end-of-life phase, the most difficult phase in the caregiving journey.

AIMS

To describe the experiences of caregivers of cancer patients admitted to a hospice in South Africa.

METHODS

A qualitative design was used; 22 (n=22) participants were purposively selected and in-depth interviews were conducted. Analysis of the data was by qualitative content analysis.

FINDINGS

A total of three themes arose from the data: emotional responses towards the caregiver role, personal cost of caregiving and spiritual issues relating to caregiving.

CONCLUSION

Caring for cancer patients during the last phase of life was not easy. Responsibilities overwhelmed the participants and they were emotionally exhausted. They lacked knowledge of how to care and experienced a heavy financial burden. Despite the challenges that they faced, faith and religious practices served as a coping mechanism and kept some going.

Patient-Caregiver Treatment Preference Discordance and Its Association With Caregiving Burden and Esteem

Background and Objectives

Many patient–caregiver dyads report conflicting treatment decisions regarding preferences for life extension treatments and symptom management. It is possible that this discordance will lead to negative psychological outcomes including lowered caregiving esteem and increased caregiver burden. However, the relationships between treatment discordance among dyads and caregiver psychological outcomes are not well studied among advanced cancer patients—a gap this study aims to fill.

Research Design and Methods

Outcome variables included caregiver burden and caregiving esteem, measured via a modified 4-domain Caregiver Reaction Assessment Scale. The main independent variable was patient–caregiver treatment preference discordance, examined using questions adapted from an existing protocol. Analyses were conducted using multivariable regressions.

Results

A convenience sample of 285 patient–caregiver dyads were recruited from outpatient clinics at 2 tertiary hospitals in Singapore. The majority (60%) of patient–caregiver dyads reported discordant treatment preferences. Discordance in this study arose because caregivers wanted a balance between life extension and symptom management while patients preferred life-extending treatment. In multivariable analyses, discordance predicted caregiver burden arising from impact on caregiver schedule and health (β = 0.16, p = .07) and lack of family support (β = 0.13, p = .04).

Discussion and Implications

Theoretically, this study provided a more nuanced understanding of how dyad discordance may worsen the burdens felt by caregivers, and which aspects of their lives (i.e., burden due to impact of caregiver schedule and health and lack of family support) are most affected. Our findings can aid in establishing therapeutic interventions targeted toward improving communication skills and encouraging end-of-life discussions among patients, caregivers, and their health care providers. The importance of establishing and improving therapy programs specifically targeted toward caregivers was also underlined.

Use of symptom-focused oncological cancer therapies in hospices: a retrospective analysis

Background

There is controversy regarding the practical implementation of symptom-focused oncological cancer therapies to hospice residents. In this study, we aim to analyse the use and indication of supportive-oncological cancer therapies in hospices.

Methods

We conducted a retrospective survey of all residents of two hospice centres in the government district of Lower Bavaria, Germany. Hospice 1 (H1) was a member of an oncological–palliative medical network, and hospice 2 (H2) was independently organized. The evaluation period was the first 40 months after the opening of the respective hospice care centre. Demographical and epidemiological data as well as indications and type of supportive-oncological cancer therapies were recorded. A descriptive analysis and statistical tests were performed.

Results

Of the 706 residents, 645 had an underlying malignant disease. The average age was 72 years and the mean residence time was 28 days. The most frequent cancer types were gastrointestinal cancers, gynaecological cancers and bronchial carcinomas. Overall 39 residents (33 in H1 and 6 in H2, p < 0.01) received symptom-focused oncological cancer therapy. The average age of these residents was 68 years, and the mean residence time was 55 days. The most common therapeutic indications were dyspnoea and pain. The most common symptom-focused oncological cancer therapies were bisphosphonates, transfusions (erythrocyte- and platelet- concentrates), radiotherapy and anti-proliferative drugs (chemotherapy, anti-hormonal- and targeted- therapies). Patients with therapy lived significantly longer than patients without therapy (p < 0.01).

Conclusions

Symptom-focused oncological cancer therapies can be implemented in hospices; however, their implementation seems to require certain structural and organizational prerequisites as well as careful patient selection. As a palliative medical approach, the focus is to ameliorate the symptoms and not prolong life. Symptom-focused oncology treatment could be a further and important part for the therapy of hospice patients in the future.

Ethical and social implications of approaching death prediction in humans - when the biology of ageing meets existential issues

BACKGROUND

The discovery of biomarkers of ageing has led to the development of predictors of impending natural death and has paved the way for personalised estimation of the risk of death in the general population. This study intends to identify the ethical resources available to approach the idea of a long-lasting dying process and consider the perspective of death prediction. The reflection on human mortality is necessary but not sufficient to face this issue. Knowledge about death anticipation in clinical contexts allows for a better understanding of it. Still, the very notion of prediction and its implications must be clarified. This study outlines in a prospective way issues that call for further investigation in the various fields concerned: ethical, psychological, medical and social.

METHODS

The study is based on an interdisciplinary approach, a combination of philosophy, clinical psychology, medicine, demography, biology and actuarial science.

RESULTS

The present study proposes an understanding of death prediction based on its distinction with the relationship to human mortality and death anticipation, and on the analogy with the implications of genetic testing performed in pre-symptomatic stages of a disease. It leads to the identification of a multi-layered issue, including the individual and personal relationship to death prediction, the potential medical uses of biomarkers of ageing, the social and economic implications of the latter, especially in regard to the way longevity risk is perceived.

CONCLUSIONS

The present study work strives to propose a first sketch of what the implications of death prediction as such could be - from an individual, medical and social point of view. Both with anti-ageing medicine and the transhumanist quest for immortality, research on biomarkers of ageing brings back to the forefront crucial ethical matters: should we, as human beings, keep ignoring certain things, primarily the moment of our death, be it an estimation of it? If such knowledge was available, who should be informed about it and how such information should be given? Is it a knowledge that could be socially shared?

The efficacy of Life Review Therapy combined with Memory Specificity Training (LRT-MST) targeting cancer patients in palliative care: A randomized controlled trial

Background

The aim of this study was to evaluate the efficacy of an intervention combining Life Review Therapy (LRT) and Memory Specificity Training (MST) (LRT-MST) to improve ego-integrity and despair among cancer patients in palliative care.

Methods

In this multicentre randomized controlled trial, cancer patients in palliative care were randomized to the intervention group (LRT-MST; n = 55) or waiting-list control group (n = 52). LRT-MST is a 4-session home-based psychological intervention that aims to retrieve specific positive memories, to re-evaluate life events and to reconstruct the story of a patient’s life, including the diagnosis of incurable cancer. Outcome measures were ego-integrity and despair (NEIS), psychological distress, anxiety and depression (HADS), quality of life (EORTC QLQ-C15-PAL), and specificity of the autobiographical memory (AMT). NEIS, HADS and EORTC QLQ-C15-PAL were assessed at baseline (T0), 1 month later (post-treatment; T1), and at 1 month follow-up (T2). AMT was assessed at T0 and T1. Linear mixed models (intention to treat) were used to assess group differences in changes over time. Independent samples t-tests were used to assess group differences at T0, T1, and T2, and effect sizes (ES) were calculated at T1 and T2.

Results

The course of ego-integrity (not despair) improved significantly over time (p = .007) in the intervention group compared to the waiting-list control group, with moderate, but insignificant, effect sizes at T1 (ES = .42) and T2 (ES = .48). Compliance rate was 69% and total dropout rate was 28%, both primarily related to disease progression and death.

Conclusions

LRT-MST seems effective among cancer patients in palliative care to improve the course of ego-integrity.

Validity and reliability of the Palliative Care Transition Measure for Caregivers (PCTM-C)

OBJECTIVE

Patients suffering from advanced disease face different care transitions. The transition from acute to palliative care is challenging and may lead to the discontinuity of care. Family caregivers become important sources of information, as patients begin to experience difficulties in coping with emotional transition events. The Care Transition Measure was developed to evaluate care transitions as experienced by the elderly. It has never been used in palliative care. The aim of this study was to test the validity and reliability of a modified version of the Palliative Care Transition Measure, specifically the Palliative Care Transition Measure for Caregivers (PCTM-C).

METHOD

The study included two main phases. Phase I focused on the construction of a modified version of the Palliative Care Transition Measure through two focus groups and by computing the content validity index. Phase II focused on testing the psychometric properties of the PCTM-C on 272 family caregivers through confirmatory factor analysis.

RESULT

The content validity index for each of the items was higher than 0.80, whereas that for the scale was 0.95. The model tested with confirmatory factor analysis fitted the data well and confirmed that the transition measures referred to communication, integrated care and a trusting-relationship, and therefore the core dimensions of continuity according to existing conceptual models. The internal consistency was high (Cronbach's alpha = 0.94).

SIGNIFICANCE OF RESULTS

The PCTM-C proved to be a suitable measure of the quality of such transitions. It may be used in clinical practice as a continuity quality indicator and has the potential to guide interventions to enhance family caregivers' experience of care continuity.

The Smurf transition: new insights on ageing from end-of-life studies in animal models

PURPOSE OF REVIEW

Over the past 5 years, many articles were published concerning the prediction of high risk of mortality in apparently healthy adults, echoing the first description in 2011 of the Smurf phenotype, a harbinger of natural death in drosophila.

RECENT FINDINGS

These recent findings suggest that the end-of-life is molecularly and physiologically highly stereotyped, evolutionarily conserved and predictable.

SUMMARY

Taken altogether, these results from independent teams using multiple organisms including humans draw the lines of future directions in ageing research. The ability to identify and study individuals about to die of natural causes with no apparent diseases is a game-changer in this field. In addition, the public health applications are potentially of tremendous impact in our ageing societies and raise important ethical questions.

Quality of life and burden in family caregivers of patients with advanced cancer in active treatment settings and hospice care: A comparative study

The aim of this study was to evaluate caregiver burden and quality of life (QoL) in active treatment settings and hospice care for 76 family caregivers of advanced cancer patients, using the Medical Outcomes Study Short Form and the Caregiver Burden Inventory. Compared to the active group, the hospice group reported significantly lower QoL scores in mental component summary score and higher scores in general health subscale and in physical component summary score. Future research needs to further investigate the complexities of caregivers' needs, especially in the emotional and mental domains, and offer effective, clinically proven interventions.

Challenges in home-based palliative care in Norway: a qualitative study of spouses' experiences

INTRODUCTION

Issues around patients' preferred place of care and death are taking greater precedence of late. However, little is known about patients' and carers' experiences of palliative care in the home setting. This study explored carers' views of what determines the quality of home care at the end of life.

METHODS

The study made use of systems theory, the purpose of which is to obtain a broad understanding of a phenomenon by looking at the relations between its individual elements. Seven carers (spouses) of people who died having received home-based palliative care in three different municipalities in Norway were interviewed.

RESULTS

None of the participants had planned to give or receive palliative care in the home. However, they did not regret that the home had been the place of care. Factors deemed important to acheiving the best possible home-based palliative care included around-the-clock help, holistic care, and affirmation of the significance of the carer's role.

CONCLUSION

Health professionals should be more forthcoming in discussing the benefits and challenges of home-based palliative care and make greater acknowledgment of the carer's role. Treatment plans may be helpful in acheiving these goals.

Evaluating the attendance of medical staff and room occupancy during palliative radiotherapy

INTRODUCTION

Attendance of staff and use of resources during treatment have an impact on costs. For palliative radiotherapy, no reliable data are available on the subject. Therefore, the measurement of selected variables (staff absorbance and room occupancy) based on daily palliative irradiation was the aim of our prospective study. The analysis is part of a larger study conducted by the German Society of Radiation Oncology (DEGRO).

PATIENTS, MATERIAL, AND METHODS

A total of 172 palliative radiation treatments were followed up prospectively between October 2009 and March 2010. The study was performed at two experienced radiotherapy departments (Herne and Bielefeld) and evaluated the attendance of medical personnel and room occupancy related to the selected steps of the treatment procedure: treatment planning and daily application of radiation dose.

RESULTS

Computed tomography for treatment planning engaged the unit for 19 min (range: 17-22 min). The localization of target volume required on average 28 min of a technician's working time. The mean attendance of the entire staff (radiation oncologist, physicist, technician) for treatment planning was 159 min, while the total room occupancy was 140 min. Depending on the type of treatment, the overall duration of a radiotherapy session varied on average between 8 and 18 min. The staff was absorbed by the first treatment session (including portal imaging) for 8-27 min. Mean room occupancy was 18 min (range: 6-65 min). The longest medical staff attendance was observed during an initial irradiation session (mean: 11 min). Radiotherapy sessions with weekly performed field verifications occupied the rooms slightly longer (mean: 10 min, range: 4-25 min) than daily radiotherapy sessions (mean: 9 min, range: 3-29 min). We observed that the patients' symptoms, their condition, and their social environment confounded the time schedule.

CONCLUSIONS

Target localization, treatment planning, and performance of palliative radiotherapy absorb resources to an extent comparable to nonpalliative treatment. Because of unexpected events, the time schedule before and during radiotherapy may reveal strong interindividual variability.

Curative to palliative care-transition and communication issues: surgeons perspective

Transition of a cancer patient from curative to palliative stage is one of the most difficult and challenging phases of cancer care both from patient and physician point of view. Most of the time the treating surgeons are expected to facilitate this transition but due to a number of reasons surgeons often fail to fulfill this crucial responsibility. This article highlights the various issues involved in the transition phase from a surgeons perspective.

An Exploratory Analysis of Levels of Evidence for Articles Published in Indian Journal of Palliative Care in the years 2010-2011

CONTEXT

Indian Journal of Palliative Care (IJPC) provides a comprehensive multidisciplinary evidence base for an evidence-informed clinical decision making.

AIMS

To analyze the levels of evidence of articles published in IJPC in the years 2010-2011.

SETTINGS AND DESIGN

Systematic review of palliative care journals.

MATERIALS AND METHODS

Systematic review of articles was done and was scored according to Center for Evidence-Based Medicine levels of evidence into any of the five grades. The articles were categorized based upon article type, number of authors, study approach, age focus, population focus, disease focus, goals of care, domains of care, models of care, and year of publication.

STATISTICAL ANALYSIS USED

All descriptive analysis was done using frequencies and percentiles, and association between all categorical variables was done using Chi-square test at 95% confidence interval (CI) using Statistical Package for Social Sciences (SPSS) version 16 for Windows (SPSS Inc, Chicago, IL).

RESULTS

There was a greater prevalence of low level evidence (level 4: n = 46, 51%; level 5: n = 35, 39%) among the 90 selected articles, and article type (original articles with higher level of evidence, P = 0.000), article approach (analytical studies with higher level of evidence, P = 0.000), domains of palliative care (practice-related studies with higher level of evidence, P = 0.000) and models of care (biological or psychosocial model with higher level of evidence, P = 0.044) had a significant association with the grade of levels of evidence. Association with other factors was not statistically significant (P < 0.05).

CONCLUSIONS

The levels of research evidence for palliative care provided by articles published in IJPC were predominantly level 4 and level 5, and there is scope for more high quality evidence to inform palliative care decisions in the developing countries.

What are patients' priorities when facing the end of life? A critical review

This critical review aimed to investigate what patients' priorities are when facing the end of life, in order to gain further understanding of this issue. Academic databases were searched using key terms, and through a method of elimination and deduction using specific inclusion/exclusion criteria, suitable research studies were found. These articles were then assessed for their quality, and specific data was extracted from the final selection using appropriate information-gathering tools. In these final four articles the methodological processes used to explore terminally ill patients' needs were generally appropriate, although there was a lack of reflexivity (researcher reflection on the experience). Useful narrative themes were produced from all four papers for further discussion. The patients had similar priorities across all four articles, which were related to understanding and accepting their changing health status, the need to hold on to some normality in life, the need to feel supported by friends and family and to know they will be taken care of after the death, and the need to have good and trusting relationships with health professionals.