Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care

Patients and family caregivers report high treatment expectations during palliative chemotherapy: a longitudinal prospective study

Background

When discussing treatment options and future care, it is important to understand the expectations of patients and family caregivers related to palliative chemotherapy and to identify patterns in patients’ quality of life. The study aims were to evaluate differences in treatment expectations and quality of life between patients with thoracic cancer (non-small-cell lung cancer, small-cell lung cancer and mesothelioma) who were < 70 and ≥ 70 years of age and receiving palliative chemotherapy and to assess family caregivers’ treatment expectations.

Methods

A prospective longitudinal study included patients with thoracic cancer receiving outpatient palliative chemotherapy at a university hospital in Denmark and their family caregivers. Patients’ treatment expectations and quality of life were assessed three times during treatment with a survey of treatment expectations and the Functional Assessment of Cancer Therapy – General questionnaire. Family caregivers’ treatment expectations were assessed once.

Results

A total of 48 patients and 36 family caregivers participated between 2018 and 2019. No statistically significant age-related differences in treatment expectations and quality of life were identified. 28% of patients aged < 70 years and 7% of those aged ≥70 years expected a cure. Among family caregivers, 36% expected a cure. Across both age groups, mean total quality of life scores significantly decreased from 73.2 at first palliative chemotherapy cycle to 70.5 at third cycle (p = 0.02). No meaningful changes were found in quality of life within either age group. A subgroup analysis found no significant between-group differences in quality of life. Mean physical well-being score for all patients decreased from 20.3 at first cycle to 18.4 at third cycle (p = 0.03) and mean emotional well-being score decreased from 15.4 at first cycle to 14.6 at third cycle (p = 0.04).

Conclusion

This study emphasizes the importance of initiating conversations about treatment expectations and paying attention to expectations that may differ by the age of the patient and between patients and family caregivers. Addressing treatment expectations among patients and family caregivers and monitoring quality of life among patients is important in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00731-4.

Inpatient palliative care utilization for patients with brain metastases

Introduction

Given the high symptom burden and complex clinical decision making associated with a diagnosis of brain metastases (BM), specialty palliative care (PC) can meaningfully improve patient quality of life. However, no prior study has formally evaluated patient-specific factors associated with PC consultation among BM patients.

Methods

We examined the rates of PC consults in a cohort of 1303 patients with BM admitted to three tertiary medical centers from October 2015 to December 2018. Patient demographics, surgical status, 30-day readmission, and death data were collected via retrospective chart review. PC utilization was assessed by identifying encounters for which an inpatient consult to PC was placed. Statistical analyses were performed to compare characteristics and outcomes between patients who did and did not receive PC consults.

Results

We analyzed 1303 patients admitted to the hospital with BM. The average overall rate of inpatient PC consultation was 19.6%. Rates of PC utilization differed significantly by patient race (17.5% in White/Caucasian vs 26.0% in Black/African American patients, P = .0014). Patients who received surgery during their admission had significantly lower rates of PC consultation (3.9% vs 22.4%, P < .0001). Patients who either died during their admission or were discharged to hospice had significantly higher rates of PC than those who were discharged home or to rehabilitation (P < .0001).

Conclusions

In our dataset, PC consultation rates varied by patient demographic, surgical status, discharging service, and practice setting. Further work is needed to identify the specific barriers to optimally utilizing specialty PC in this population.

Integrating Conservative kidney management Options and advance care Planning Education (COPE) into routine CKD care: a protocol for a pilot randomised controlled trial

INTRODUCTION

Predialysis education for patients with advanced chronic kidney disease (CKD) typically focuses narrowly on haemodialysis and peritoneal dialysis as future treatment options. However, patients who are older or seriously ill may not want to pursue dialysis and/or may not benefit from this treatment. Conservative kidney management, a reasonable alternative treatment, and advance care planning (ACP) are often left out of patient education and shared decision-making. In this study, we will pilot an educational intervention (Conservative Kidney Management Options and Advance Care Planning Education-COPE) to improve knowledge of conservative kidney management and ACP among patients with advanced CKD who are older and/or have poor functional status.

METHODS AND ANALYSIS

This is a single-centre pilot randomised controlled trial at an academic centre in Philadelphia, PA. Eligible patients will have: age ≥70 years and/or poor functional status (as defined by Karnofsky Performance Index Score <70), advanced CKD (estimated glomerular filtration rate<20 mL/min/1.73 m²), prefer to speak English during clinical encounters and self-report as black or white race. Enrolled patients will be randomised 1:1, with stratification by race, to receive enhanced usual care or usual care and in-person education about conservative kidney management and ACP (COPE). The primary outcome is change in knowledge of CKM and ACP. We will also explore intervention feasibility and acceptability, change in communication of preferences and differences in the intervention's effects on knowledge and communication of preferences by race. We will assess outcomes at baseline, immediately post-education and at 2 and 12 weeks.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board at the University of Pennsylvania. We will obtain written informed consent from all participants. The results from this work will be presented at academic conferences and disseminated through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

This trial is registered at ClinicalTrials.gov under NCT03229811.

Caregiver-Oncologist Prognostic Concordance, Caregiver Mastery, and Caregiver Psychological Health and Quality of Life

BACKGROUND

Caregivers of adults with cancer often report a different understanding of the patient's prognosis than the oncologist. We examine the associations of caregiver-oncologist prognostic concordance with caregiver depressive symptoms, distress, and quality of life (QoL). We also explore whether these relationships differed by caregiver environment mastery, an individual's sense of control, and effectiveness in managing life situations.

MATERIALS AND METHODS

We used data from a national geriatric assessment cluster-randomized trial (URCC 13070) that recruited patients aged 70 years and older with incurable cancer considering any line of cancer treatment at community oncology practices, their caregivers, and their oncologists. At enrollment, caregivers and oncologists estimated the patient's prognosis (0-6 months, 7-12 months, 1-2 years, 2-5 years, and >5 years; identical responses were concordant). Caregivers completed the Ryff's environmental mastery at enrollment. At 4-6 weeks, caregivers completed the Patient Health Questionnaire-2 (depressive symptoms), distress thermometer, and 12-Item Short-Form Health Survey (quality of life [QoL]). We used generalized estimating equations in models adjusted for covariates. We then assessed the moderation effect of caregiver mastery.

RESULTS

Of 411 caregiver-oncologist dyads (mean age = 66.5 years), 369 provided responses and 28% were concordant. Prognostic concordance was associated with greater caregiver depressive symptoms (β = 0.30; p = .04) but not distress or QoL. A significant moderation effect for caregiver depressive symptoms was found between concordance and mastery (p = .01). Specifically, among caregivers with low mastery (below median), concordance was associated with greater depressive symptoms (β = 0.68; p = .003).

CONCLUSIONS

Caregiver-oncologist prognostic concordance was associated with caregiver depressive symptoms. We found a novel moderating effect of caregiver mastery on the relationship between concordance and caregiver depressive symptoms.

IMPLICATIONS FOR PRACTICE

Caregiver-oncologist prognostic concordance is associated with greater caregiver depressive symptoms, particularly in those with low caregiver mastery. When discussing prognosis with caregivers, physicians should be aware that prognostic understanding may affect caregiver psychological health and should assess their depressive symptoms. In addition, while promoting accurate prognostic understanding, physicians should also identify strengths and build resilience among caregivers.

Epidemiology of Fear, Sadness, and Anger Expression in Palliative Care Conversations

CONTEXT

Advancing the science of serious illness communication requires methods for measuring characteristics of conversations in large studies. Understanding which characteristics predict clinically important outcomes can help prioritize attention to scalable measure development.

OBJECTIVES

To understand whether audibly recognizable expressions of distressing emotion during palliative care serious illness conversations are associated with ratings of patient experience or six-month enrollment in hospice.

METHODS

We audiorecorded initial palliative care consultations involving 231 hospitalized people with advanced cancer at two large academic medical centers. We coded conversations for expressions of fear, anger, and sadness. We examined the distribution of these expressions and their association with pre/post ratings of feeling heard and understood and six-month hospice enrollment after the consultation.

RESULTS

Nearly six in 10 conversations included at least one audible expression of distressing emotion (59%; 137 of 231). Among conversations with such an expression, fear was the most prevalent (72%; 98 of 137) followed by sadness (50%; 69 of 137) and anger (45%; 62 of 137). Anger expression was associated with more disease-focused end-of-life treatment preferences, pre/post consultation improvement in feeling heard and understood and lower six-month hospice enrollment. Fear was strongly associated with preconsultation patient ratings of shorter survival expectations. Sadness did not exhibit strong association with patient descriptors or outcomes.

CONCLUSION

Fear, anger, and sadness are commonly expressed in hospital-based palliative care consultations with people who have advanced cancer. Anger is an epidemiologically useful predictor of important clinical outcomes.

Frequency and Characteristics of First-Time Palliative Care Referrals During the Last Day of Life

CONTEXT

Palliative care referrals (PCRs) improve symptom management, provide psychosocial and spiritual support, clarify goals of care, and facilitate discharge planning. However, very late PCR can result in increased clinician distress and prevent patients and families from benefiting from the full spectrum of interdisciplinary care.

OBJECTIVES

To determine the frequency and predictors of PCR within 24 hours of death.

METHODS

Consecutive first-time inpatient PCR from September 1, 2013 to August 31, 2017 was identified to determine the frequency and predictors of referrals within 24 hours of death. We compared the clinical characteristics with a random sample of patients discharged alive or died more than 24 hours after first-time PCR as a control, stratified by year of consult in a 1:1 ratio.

RESULTS

Of 7322 first-time PCRs, 154 (2%) died within 24 hours of referral. These patients were older (P = 0.003) and had higher scores for depression (P = 0.0009), drowsiness (P = 0.02), and shortness of breath (P = 0.008) compared with a random sample of 153 patients discharged alive or died more than 24 hours after first-time PCR. Patients who received a PCR within 24 hours of death were more likely than the control group to have Eastern Cooperative Oncology Group 4 (95% vs. 25%, P < 0.0001), delirium (89% vs. 17%, P < 0.0001), do-not-resuscitate code status (81% vs. 18%, P < 0.0001), and hematologic malignancies (39% vs. 16%, P < 0.0001). In the multivariate analysis, depression (odds ratio [OR] 1.4; P = 0.005), do-not-resuscitate code status (OR 9.1; P = 0.003), and Eastern Cooperative Oncology Group 4 (OR 9.8; P = 0.003) were independently associated with first-time PCR within 24 hours of death.

CONCLUSION

Although only a small proportion of first-time PCR occurred in the last 24 hours of life, the patients had a significant amount of distress, indicating a missed opportunity for timely palliative care intervention. These sentinel events call for specific guidelines to better support patients, families, and clinicians during this difficult time. Further research is needed to understand how to minimize very late PCR.

How much time do we have? Longitudinal perception of prognosis in newly-diagnosed high grade glioma patients and caregivers compared to clinicians

PURPOSE

Discordant prognostic awareness (PA) can cause distress, impact goals of care and future planning, especially in patients with high grade glioma (pwHGG) who have limited survival. We aimed to evaluate the feasibility of assessing PA of pwHGG, caregivers and clinicians using a single question and to evaluate these responses for discord, alignment and fluctuation over time.

METHODS

This is a sub-study of an IRB-approved pilot study evaluating early palliative care and longitudinal symptom monitoring via a smart-device tool in 16 pwHGG and their caregivers receiving treatment at the Mayo Clinic Arizona (United States). Eligible patients were ≥ 18 years, English-speaking, newly-diagnosed, and had a willing caregiver. Participants answered a multiple-choice question asking for an estimate of their own or their loved one's survival on a monthly basis.

RESULTS

All except one patient/caregiver dyad answered the question each time it was asked. The question did not appear to cause discomfort or increase conversations with clinicians around prognosis. PA of patients and caregivers fluctuated monthly, ranging from dismal to overtly optimistic, with a discordance frequency of 68%. Patients tended to be more optimistic than caregivers, and a higher QOL correlated to a more optimistic response. Clinicians' were more hopeful; their prediction tended to fluctuate less than those of patients and caregivers.

CONCLUSIONS

PA may be assessed in pwHGG and caregivers with a single, frank question. There is clear discordance between PA of patients, their caregivers and clinicians. Understanding fluctuates longitudinally through disease and treatment course. Additional studies on timing and ways of discussing prognosis in this population are needed.

CLINICAL TRIAL REGISTRATION

NCT04630379.

Patient Perceptions of Treatment Benefit and Toxicity in Advanced Cancer: A Prospective Cross-Sectional Study

PURPOSE

Prior studies show that many patients receiving palliative cancer therapies misperceive likelihood of cure. Patients' understanding of treatment benefits and risks beyond cure is unknown. We explore patient perceptions of palliative treatment in the novel therapeutic era.

METHODS

We surveyed patients with advanced solid cancers and their oncologists regarding benefits and risks of palliative therapies. We assessed perceived likelihood of tumor response, survival benefit, symptom palliation, and side effects. We used generalized estimating equations to calculate least squares means of misperception (patient-assessed minus physician-assessed likelihood of benefit), accounting for clustering by physician, and compared the degree of misperception by participant characteristics.

RESULTS

Of the 119 patients enrolled, median age was 65 years (range, 59-73 years), 55% were male, and 56% had prior treatment. Treatments included chemotherapy (60%), immunotherapy (24%), and targeted therapy (15%). Compared with their oncologists, patients overestimate curability (median misperception, 20%; interquartile range [IQR], 0 to 60), chances of tumor response (median, 20%; IQR, 0 to 40), symptom palliation (median, 10%; IQR, -10 to 30), and survival benefit (median, 20%; IQR, 0 to 40). Toxicity was relatively accurately estimated (median, 0.5%; IQR, -20 to 20). Immunotherapy was associated with higher risk of misperception of tumor response and toxicity. Misperceptions of tumor response and curability did not correlate (r = 0.13, P = .15).

CONCLUSION

Compared with their oncologists, patients overestimated chances of tumor response, symptom palliation, and survival benefit, but accurately perceived likelihood of toxicity. There was no strong correlation between perception of curability and other goals of therapy. Communication focused on treatment goals alongside risks may reduce misperceptions and facilitate informed choices by patients.

The Importance of Prognostication: Impact of Prognostic Predictions, Disclosures, Awareness, and Acceptance on Patient Outcomes

In the advanced cancer setting, patients, families, and clinicians are often confronted with an uncertain future regarding treatment outcomes and survival. Greater certainty on what to expect can enhance decision-making for many personal and healthcare issues. Although 70-90% of patients with advanced cancer desire open and honest prognostic disclosure, a small proportion do not want to know. Approximately half of patients with advanced cancer have an inaccurate understanding of their illness, which could negatively impact their decision-making. In this review, we use a conceptual framework to highlight 5 key steps along the prognostic continuum, including (1) prognostic formulation, (2) prognostic disclosure, (3) prognostic awareness, (4) prognostic acceptance, and (5) prognosis-based decision-making. We shall summarize the impact of prognostic predictions, disclosure, awareness, and acceptance on various patient and caregiver outcomes, such as hope, trust, anxiety, depression, chemotherapy use, and care planning. Based on where the patient is at along the prognostic continuum, we propose 5 different subgroups (avoidance: "I don't want to know"; discordant, "I never wanted to know"; anxious, "I don't know what's happening"; concerned, "I don't like this"; acceptance, "I know how to plan ahead"). Although prognostication is not necessarily a linear process, recognizing where the patient is at cognitively and emotionally along the prognostic continuum may allow clinicians to provide personalized interventions, such as specialist palliative care and psychology referral, towards personalizing prognostic disclosure, enhancing prognostic awareness, increasing prognostic acceptance, and supporting decision-making and, ultimately, improving patient outcomes.

A Systematic Review on Barriers to Palliative Care in Oncology

The number of people with cancer and the need for palliative care among this population is increasing in the United States. Despite this growing need, several barriers exist to the utilization of palliative care in oncology. The purpose of this study was to synthesize the evidence on the barriers to palliative care utilization in an oncology population. A systematic review of literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, CINAHL, and Psych Info databases were used for the literature search. Articles were included if they: 1) focused on cancer, (2) examined and discussed barriers to palliative care, and c) were peer reviewed, published in English, and had an accessible full text. A total of 29 studies (8 quantitative, 18 qualitative, and 3 mixed-methods) were identified and synthesized for this review. The sample size of the included studies ranged from 10 participants to 313 participants. The barriers to palliative care were categorized into barriers related to the patient and family, b) barriers related to providers, and c) barriers related to the healthcare system or policy. The factors identified in this review provide guidance for intervention development to mitigate the existing barriers and facilitate the use palliative care in individuals with cancer.

Patient and caregiver agreement on prognosis estimates for older adults with advanced cancer

BACKGROUND

Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes.

METHODS

For this analysis, baseline data were obtained from a cluster-randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient-reported longer estimate, or caregiver-reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient-caregiver prognostic estimates. Independent variables were selected using the purposeful selection method.

RESULTS

Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P = .001), and caregivers reported greater distress (β = 0.12; P = .03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P = .005) and had lower perceived self-efficacy in interacting with physicians (β = -0.10; P = .008).

CONCLUSIONS

Several patient and caregiver factors were associated with patient-caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes.

The Effect of Disclosing Life Expectancy Information on Patients' Prognostic Understanding: Secondary Outcomes From a Multicenter Randomized Trial of a Palliative Chemotherapy Educational Intervention

CONTEXT

Many advanced patients with cancer have unrealistic prognostic expectations.

OBJECTIVES

We tested whether offering life expectancy (LE) statistics within palliative chemotherapy (PC) education promotes realistic expectations.

METHODS

In this multicenter trial, patients with advanced colorectal and pancreatic cancers initiating first or second line PC were randomized to usual care versus a PC educational tool with optional LE information. Surveys at two weeks and three months assessed patients' review of the LE module and their reactions; at three months, patients estimated their LE and reported occurrence of prognosis and end-of-life (EOL) discussions. Wilcoxon tests and proportional odds models evaluated between-arm differences in LE self-estimates, and how realistic those estimates were (based on cancer type and line of treatment).

RESULTS

From 2015 to 2017, 92 patients were randomized to the intervention and 94 to usual care. At baseline most patients (80.9%) wanted "a lot" or "as much information as possible" about the impact of chemotherapy on LE. Among patients randomized to the intervention, 52.0% reviewed the LE module by two weeks and 66.7% by three months-of whom 88.2% reported the information was important, 31.4% reported it was upsetting, and 3.9% regretted reviewing it. Overall, patients' LE self-estimates were very optimistic; 71.4% of patients with colorectal cancer estimated greater than five years; 50% pancreatic patients estimated greater than two years. The intervention had no effect on the length or realism of patients' LE self-estimates, or on the occurrence of prognostic or EOL discussions.

CONCLUSIONS

Offering LE information within a PC educational intervention had no effect on patients' prognostic expectations.

A Cross-Sectional Analysis of Ambulatory Oncology Experience by Treatment Intent

The Ambulatory Oncology Patient Satisfaction Survey (AOPSS) is a standardized instrument to assess the overall cancer patient experience. This study retrospectively investigated differences in care experiences and satisfaction among ambulatory oncology patients who self-identified as receiving outpatient therapies for curative intent or for symptom or disease control. This cross-sectional study analyzed data from the AOPSS collected between February and April 2019 within the provincial cancer program in Alberta, Canada. There were 2104 participants who returned the survey, representing a 52.7% response rate. This nationally validated survey gathers patient care experiences and satisfaction across six domains of person-centred care. Treatment intent was characterized by adding a new “goal of treatment” question. Statistical analysis was performed using Mann–Whitney U tests and analysis of covariance (ANCOVAs). Cancer patients’ treatment goals were found to be significantly associated with key patient characteristics like age, sex, tumour group, and the locations where they received care. Patients whose self-identified goal of treatment was to cure their cancer reported significantly higher levels of satisfaction and a more positive experience in five out of the six person-centred care domains. Results identify marked differences in satisfaction and experience between these two patient groups even though they both received care in the same ambulatory environments. A better understanding of the experience and satisfaction of non-curative cancer patients could allow for a more holistic and supportive approach to patient care. In addition, an early palliative approach to care is recommended for improved patient outcomes.

Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness

BACKGROUND

Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders.

PATIENTS AND METHODS

Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling.

RESULTS

At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036-4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989-89.786; P=.008). Both arms issued DNR orders close to death (median, 5-6 days before death).

CONCLUSIONS

Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.ClinicalTrial.gov Identification: NCT01912846.

Nurse-led, screening-triggered, early specialised palliative care intervention programme for patients with advanced lung cancer: study protocol for a multicentre randomised controlled trial

INTRODUCTION

It has been suggested that palliative care integrated into standard cancer treatment from the early phase of the disease can improve the quality of life of patients with cancer. In this paper, we present the protocol for a multicentre randomised controlled trial to examine the effectiveness of a nurse-led, screening-triggered, early specialised palliative care intervention programme for patients with advanced lung cancer.

METHODS AND ANALYSIS

A total of 206 patients will be randomised (1:1) to the intervention group or the control group (usual care). The intervention, triggered with a brief self-administered screening tool, comprises comprehensive need assessments, counselling and service coordination by advanced-level nurses. The primary outcome is the Trial Outcome Index of the Functional Assessment of Cancer Therapy (FACT) at 12 weeks. The secondary outcomes include participants' quality of life (FACT-Lung), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), illness perception (Prognosis and Treatment Perceptions Questionnaire), medical service use and survival. A mixed-method approach is expected to provide an insight about how this intervention works.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of the National Cancer Center Japan (approval number: 2016-235). The findings will be disseminated through peer-reviewed publications and conference presentations and will be reflected on to the national healthcare policy.

TRIAL REGISTRATION NUMBER

UMIN000025491.

Physicians' clinical prediction of survival in head and neck cancer patients in the palliative phase

BACKGROUND

The prognosis of patients with incurable head and neck cancer (HNC) is a relevant topic. The mean survival of these patients is 5 months but may vary from weeks to more than 3 years. Discussing the prognosis early in the disease trajectory enables patients to make well-considered end-of-life choices, and contributes to a better quality of life and death. However, physicians often are reluctant to discuss prognosis, partly because of the concern to be inaccurate. This study investigated the accuracy of physicians' clinical prediction of survival of palliative HNC patients.

METHODS

This study was part of a prospective cohort study in a tertiary cancer center. Patients with incurable HNC diagnosed between 2008 and 2011 (n = 191), and their treating physician were included. Analyses were conducted between July 2018 and February 2019. Patients' survival was clinically predicted by their physician ≤3 weeks after disclosure of the palliative diagnosis. The clinical prediction of survival in weeks (CPS) was based on physicians' clinical assessment of the patient during the outpatient visits. More than 25% difference between the actual survival (AS) and the CPS was regarded as a prediction error. In addition, when the difference between the AS and CPS was 2 weeks or less, this was always considered as correct.

RESULTS

In 59% (n = 112) of cases survival was overestimated. These patients lived shorter than predicted by their physician (median AS 6 weeks, median CPS 20 weeks). In 18% (n = 35) of the cases survival was correctly predicted. The remaining 23% was underestimated (median AS 35 weeks, median CPS 20 weeks). Besides the differences in AS and CPS, no other significant differences were found between the three groups. There was worse accuracy when predicting survival closer to death: out of the 66 patients who survived 6 weeks or shorter, survival was correctly predicted in only eight (12%).

CONCLUSION

Physicians tend to overestimate the survival of palliative HNC patients. This optimism can result in suboptimal use of palliative and end-of-life care. The future development of a prognostic model that provides more accurate estimates, could help physicians with personalized prognostic counseling.

Optimiser les soins palliatifs précoces aux patients atteints d’un cancer hématologique recevant une greffe de cellules souches : rôle de l’infirmière praticienne

La greffe de cellules souches hématopoïétiques (GCSH) est une approche thérapeutique intensive des hémopathies malignes qui s’accompagne d’un important risque de morbidité et de mortalité. Malgré la lueur d’espoir qu’elle apporte aux patients, les traitements sont longs et pénibles, tant du point de vue physique que psychosocial. Habituellement, la greffe de cellules souches hématopoïétiques a une visée curative qui laisse peu de place à un partenariat éventuel avec les services de soins palliatifs et, lorsque ces derniers sont proposés, il est souvent trop tard pour en tirer un bénéfice notable. Il faudrait donc systématiser le recours aux soins palliatifs pour les patients atteints d’hémopathie maligne qui reçoivent une GCSH; cependant, il demeure difficile de trouver la meilleure voie pour établir un tel partenariat. Les infirmières praticiennes, qui sont de plus en plus nombreuses, possèdent les connaissances et les compétences requises pour combler les lacunes dans la prestation de soins palliatifs aux patients recevant une GCSH. L’algorithme de soins palliatifs précoces dispensés par les infirmières praticiennes aux patients recevant une GCSH (dit NEST en anglais, pour « Nurse-Practitioner-Delivered Early Palliative Care for Stem Cell Transplant ») vise justement à faire le pont entre les services palliatifs et les équipes d’hématologie et de greffe afin d’offrir aux patients les meilleurs soins possible.

Expectations and perception of cancer treatment goals in previously untreated patients. The EXPECT trial

Purpose

Misconceptions regarding activity and toxicity of therapeutic interventions are common among cancer patients. There is little knowledge about the factors that contribute to a more realistic perception by patients.

Methods

This pilot study was designed as a prospective questionnaire survey and included 101 therapy-naïve patients treated at the Division of Oncology, Medical University of Vienna. After obtaining written informed consent, patients’ expectations about treatment aims, side effects and the satisfaction with their oncologic consultation were interrogated before the first treatment cycle by questionnaires.

Results

Of 101 patients, 53 (53%) were female and 67/101 (66%) were treated with curative attempt in an adjuvant or neo-adjuvant setting. The most common diagnoses were lung cancer (31%) and breast cancer (30%). Although 92% of patients were satisfied with the information given by their oncologist, palliative patients were more likely to declare that not everything was explained in an intelligible manner (p = 0.01). Patients with a first language other than German stated more often that their physician did not listen carefully enough (p = 0.02). Of 30 patients, 26 (87%) receiving chemotherapy with palliative intent believed that their disease was curable. Concerning adverse events, female patients anticipated more frequently hair loss (p = 0.003) and changes in taste (p = 0.001) compared to men. Patients under curative treatment were more likely to expect weight loss (p = 0.02) and lack of appetite (p = 0.01) compared to patients with palliative treatment intent.

Conclusion

In conclusion, cancer patients were satisfied with the patient-doctor communication. This prospective study aggregated patients’ concerns on side effects and the perception of therapeutic goals in therapy-naïve patients. Of note, the majority of patients treated in the palliative setting expected their treatment to cure the disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-020-05826-x.

Development, Validation, and Evaluation of a Simple Machine Learning Model to Predict Cirrhosis Mortality

Importance

Machine-learning algorithms offer better predictive accuracy than traditional prognostic models but are too complex and opaque for clinical use.

Objective

To compare different machine learning methods in predicting overall mortality in cirrhosis and to use machine learning to select easily scored clinical variables for a novel cirrhosis prognostic model.

Design, Setting, and Participants

This prognostic study used a retrospective cohort of adult patients with cirrhosis or its complications seen in 130 hospitals and affiliated ambulatory clinics in the integrated, national Veterans Affairs health care system from October 1, 2011, to September 30, 2015. Patients were followed up through December 31, 2018. Data were analyzed from October 1, 2017, to May 31, 2020.

Exposures

Potential predictors included demographic characteristics; liver disease etiology, severity, and complications; use of health care resources; comorbid conditions; and comprehensive laboratory and medication data. Patients were randomly selected for model development (66.7%) and validation (33.3%). Three different statistical and machine learning methods were evaluated: gradient descent boosting, logistic regression with least absolute shrinkage and selection operator (LASSO) regularization, and logistic regression with LASSO constrained to select no more than 10 predictors (partial pathway model). Predictor inclusion and model performance were evaluated in a 5-fold cross-validation. Last, the predictors identified in the most parsimonious (the partial path) model were refit using maximum-likelihood estimation (Cirrhosis Mortality Model [CiMM]), and its predictive performance was compared with that of the widely used Model for End Stage Liver Disease with sodium (MELD-Na) score.

Main Outcomes and Measures

All-cause mortality.

Results

Of the 107 939 patients with cirrhosis (mean [SD] age, 62.7 [9.6] years; 96.6% male; 66.3% white, 18.4% African American), the annual mortality rate ranged from 8.8% to 15.3%. In total, 32.7% of patients died within 3 years, and 46.2% died within 5 years after the index date. Models predicting 1-year mortality had good discrimination for the gradient descent boosting (area under the receiver operating characteristics curve [AUC], 0.81; 95% CI, 0.80-0.82), logistic regression with LASSO regularization (AUC, 0.78; 95% CI, 0.77-0.79), and the partial path logistic model (AUC, 0.78; 95% CI, 0.76-0.78). All models showed good calibration. The final CiMM model with machine learning-derived clinical variables offered significantly better discrimination than the MELD-Na score, with AUCs of 0.78 (95% CI, 0.77-0.79) vs 0.67 (95% CI, 0.66-0.68) for 1-year mortality, respectively (DeLong z = 17.00; P < .001).

Conclusions and Relevance

In this study, simple machine learning techniques performed as well as the more advanced ensemble gradient boosting. Using the clinical variables identified from simple machine learning in a cirrhosis mortality model produced a new score more transparent than machine learning and more predictive than the MELD-Na score.

Late decisions about treatment limitation in patients with cancer: empirical analysis of end-of-life practices in a haematology and oncology unit at a German university hospital

Background

Decisions to limit treatment (DLTs) are important to protect patients from overtreatment but constitute one of the most ethically challenging situations in oncology practice. In the Ethics Policy for Advance Care Planning and Limiting Treatment study (EPAL), we examined how often DLT preceded a patient’s death and how early they were determined before (T1) and after (T2) the implementation of an intrainstitutional ethics policy on DLT.

Methods

This prospective quantitative study recruited 1.134 patients with haematological/oncological neoplasia in a period of 2×6 months at the University Hospital of Munich, Germany. Information on admissions, discharges, diagnosis, age, DLT, date and place of death, and time span between the initial determination of a DLT and the death of a patient was recorded using a standardised form.

Results

Overall, for 21% (n=236) of the 1.134 patients, a DLT was made. After implementation of the policy, the proportion decreased (26% T1/16% T2). However, the decisions were more comprehensive, including more often the combination of ‘Do not resuscitate’ and ‘no intense care unit’ (44% T1/64% T2). The median time between the determination of a DLT and the patient’s death was similarly short with 6 days at a regular ward (each T1/T2) and 10.5/9 (T1/T2) days at a palliative care unit. For patients with solid tumours, the DLTs were made earlier at both regular and palliative care units than for the deceased with haematological neoplasia.

Conclusion

Our results show that an ethics policy on DLT could sensitise for treatment limitations in terms of frequency and extension but had no significant impact on timing of DLT. Since patients with haematological malignancies tend to undergo intensive therapy more often during their last days than patients with solid tumours, special attention needs to be paid to this group. To support timely discussions, we recommend the concept of advance care planning.

A Palliative Care Intervention for Patients on Phase 1 Studies

Background: Phase 1 clinical trials remain vital for oncology care. Patients on these trials require supportive care for quality-of-life (QOL) concerns. Objective: To test a Palliative Care Intervention (PCI) for patients with solid tumors enrolled in Phase I therapeutic trials with a priori hypothesis that psychological distress, QOL, satisfaction, symptoms, and resource utilization would be improved in the PCI group. Design: This unblinded randomized trial compared the PCI with usual care in patients accrued to Phase I Clinical Trials. Subjects (n = 479) were followed for 24 weeks, with 12 weeks as the primary outcome. Setting: Two Comprehensive Cancer Centers in the United States. Subjects: A consecutive sample, 21 years or older, English fluency, with solid tumors initiating a Phase 1 trial. Measurements: Psychological Distress (Distress Thermometer), QOL total and subscales (FACT-G), satisfaction (FAM-CARE), survival, and resource utilization (chart audit). Results: PCI subjects showed improved Psychological Distress (-0.47, p = 0.015) and Emotional Well-Being (0.81, p = 0.045), with differences on variables of QOL and distress between sites. High rates of symptom-management admissions (41.3%) and low rates of Advance Directive completion (39.0%), and hospice enrollment (30.7%), despite a median survival in both groups of 10.1 months from initiating a Phase 1 study. Conclusions: A nurse-delivered PCI can improve some QOL outcomes and distress for patients participating in Phase 1 trials. Greater integration of PC is needed to provide quality care to these patients and to support transitions from treatment to supportive care, especially at the end of life. ClinicalTrials.gov Identifier: NCT01612598.

Palliative care needs and utilisation of different specialist services in the last days of life for people with lung cancer

OBJECTIVES

To (a) compare palliative care needs of lung cancer patients on their final admission to community-based and inpatient palliative care services; and (b) explore whether and how these care needs affect their utilisation of different palliative care services in the last days of life.

METHODS

Descriptive study involving 17,816 lung cancer patients who received the last episode of palliative care from specialist services and died between 1 January 2013 and 31 December 2018.

RESULTS

Both groups of patients admitted to community-based and inpatient palliative care services generally experienced relatively low levels of symptom distress, but high levels of functional impairment and dependency. "Unstable" versus "stable" palliative care phase (Odds ratio = 11.66; 95% Confidence Interval: 9.55-14.24), poorer functional outcomes and severe levels of distress from many symptoms predicted greater likelihood of use of inpatient versus community-based palliative care.

CONCLUSIONS

Most inpatient palliative care admissions are not associated with high levels of symptom severity. To extend the period of home care and rate of home death for people with lung cancer, additional investment is required to improve their access to sufficiently skilled palliative care staff, multi-disciplinary teams and 24-hour home support in community settings.

The Pitfalls of Utilizing "Goals of Care" as a Clinical Buzz Phrase: A Case Study and Proposed Solution

Assistance with discussing goals of care is one of the most common reasons clinicians seek out palliative care consultation. In practice though, the phrase "goals of care" is often utilized as a buzz phrase that lacks a shared understanding of its clinical relevance. We present a case example in which breakdowns in communication occurred between a patient and clinicians due to misunderstandings of the meaning of the phrase "goals of care." Subsequently, we review the literature to propose a unified definition of "goals of care" in hopes to minimize differences in what this phrase implies in clinical practice. We also seek to introduce a standardized process for establishing goals of care that may offer a more reliable and measurable method to promote goal-concordant care.

Impact of Prognostic Nutritional Index on Terminal Cancer Patients

BACKGROUND

In terminal cancer patients (TCPs), one of the most important things is to define the survival to help the main responsible physicians, patients, and main caregivers make decisions, set goals, and work across the end-of-life strategies.

PATIENTS AND METHODS

We retrospectively reviewed the medical files of TCPs, who died during September 2011 and December 2017, to recognize the correlation between prognostic nutritional indices (PNIs) and survival in those subtypes of patients. The receiver operating characteristic (ROC) curve was used to identify the cutoff value of PNI.

RESULTS

A total of 858 TCPs were eligible and included, the median age was 62 years (range: 18-107). The most common primary cancer sites were colorectal cancer in 151 patients (17.6%), hepatobiliary in 129 (15%), lung cancer in 115 (13.4%), breast cancer in 114 (13.3%), and genitourinary in 80 (9.3%). The mean value of PNI for all cancer types was 32.9 ± 6.7. The values showed different levels across cancer types. For patients who lived >2 weeks, PNI was 36.7 compared with that who died within 2 weeks was 29.3, which was a statistically significant (P < 0.001). By the ROC curve, the cutoff value of PNI was 32.3 and area under the curve was 0.888. The sensitivity, specificity, positive predictive value, and negative predictive value were 91.28% (95% confidence interval [CI]: 88.2-93.8), 71.09% (95% CI: 66.5-75.4), 76.5% (95% CI: 73.7-79.2), and 88.8% (95% CI: 85.3-91.5), respectively.

CONCLUSION

The PNI is an easy and an applicable biomarker to estimate life expectancy in TCPs.

Optimizing the delivery of early palliative care for hematology patients receiving a stem cell transplant: A role for a Nurse Practitioner

A hematopoietic stem cell transplant (HSCT) is an intense treatment approach for patients with a hematologic malignancy and brings a significant risk for morbidity and mortality. HSCT brings hope of cure for patients; however, treatments are lengthy and burdensome from both a physical and psychosocial perspective. As the culture of HSCT has traditionally been cure-oriented, it leaves little room for a potential partnership with palliative care services, and when palliative care services are introduced, it is often too late for significant benefit. The need to standardize palliative care involvement for patients with hematologic malignancies receiving a HSCT has become necessary, yet there are challenges with the best way to create such a partnership. Nurse practitioners are a steadily growing professional body possessing the knowledge and skill necessary to fill the gap in palliative care delivery for HSCT patients. The proposed Nurse Practitioner Early Palliative Care for HSCT patients (NEST) algorithm will seek to provide a pathway in which to foster a partnership between hematology/HSCT teams and palliative services to yield the best care possible for patients.

Prognostic Awareness in Caregivers of Patients with Incurable Cancer

Background: Little is known about how patients with incurable cancer and caregivers differ in their prognostic awareness, and the relationship between caregiver prognostic awareness and their psychological distress. Objective: To investigate prognostic awareness in caregivers of patients with incurable cancer and prognostic discordance in patient-caregiver dyads and its association with psychological distress. Design: This is a cross-sectional study. Setting/Subjects: In total, subjects were 390 caregivers of adults with incurable lung, gastrointestinal, and brain cancers at a cancer center in the northeastern United States. Measurements: The Prognosis and Treatment Perceptions Questionnaire was used to assess prognostic awareness and Hospital Anxiety and Depression Scale to assess psychological distress. Results: In total, 39.7% (n = 147/370) and 17.3% (n = 64/370) caregivers reported clinically significant anxiety and depression symptoms. And 53.7% of caregivers reported the patients' cancer as "curable" and 44.1% reported the cancer was "not terminal." Caregivers' report of curability was not associated with their anxiety (odds ratio [OR] = 0.99, p = 0.93) or depression (OR = 1.05, p = 0.32) symptoms. Among 42.5% (124/292) and 26.0% (76/292) of dyads (n = 292), both patients and their caregivers agreed in their perception of the cancer as curable and incurable, respectively. In 19.9% of dyads (n = 58), patients reported their cancer as curable, while their caregivers reported it as incurable. In 11.6% of dyads (n = 34), patients reported the cancer as incurable while caregivers reported it as curable. Conclusions: More than half of caregivers have misperceptions about the patients' likelihood of cure, and one-third of patient-caregiver dyads have discordant perceptions. Supportive care interventions may facilitate conversations and enhance prognostic understanding in patients with incurable cancer and their caregivers.

The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers

BACKGROUND

Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously.

OBJECTIVES

To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families.

SEARCH METHODS

We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available.

MAIN RESULTS

We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I² = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I² = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I² = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I² = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I² = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision.

AUTHORS' CONCLUSIONS

Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.

Retrospective analysis of the prevalence of specialised palliative care services for patients with metastatic breast cancer

Background

Patients with metastatic breast cancer (MBC) have a considerable symptom burden and may require extensive care for a long period of time. Palliative care (PC) has the potential to improve their quality of care and reduce their use of medical services. However, the role of specialised PC (SPC) in patients with MBC remains unclear.

Patients and methods

We performed a retrospective analysis of the medical records of patients diagnosed with breast cancer (BC) from 2008 to 2018 at an university-based referral centre to examine the extent of early and late integration of SPC services for patients with MBC. A descriptive analysis of the patients was also established.

Results

In all, 932 patients were diagnosed with BC from 2008 to 2018; 225 of these patients had or developed metastases related to their BC. In addition, 132 patients received SPC (58.7%) and 93 patients did not receive SPC (41.3%). The median probability of overall survival (OS) for patients who did not receive SPC services was 3.6 years (95% CI 2.0 to 5.1) and 1.8 years (95% CI 1.3 to 2.3) (p<0.0001) for patients who did receive SPC. In multivariate analysis, referral to SPC services was independently associated with OS (HR 1.60, 95% CI 1.16 to 2.22, p=0.004).

Conclusion

Patients who received SPC lived significantly shorter amounts of time than patients not referred for SPC services at our hospital. We concluded that the referral to SPC services was often too late and should be implemented earlier in the course of the disease. We suggest that patients with MBC should participate in a consultation by a SPC team ≤60 days after the start of systemic palliative anticancer therapy in addition to endocrine treatment. Larger prospective studies are needed to evaluate the benefit of the early integration of SPC services for patients with MBC.

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer

BACKGROUND

Integration of specialist palliative care into routine oncologic care improves patients' quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of "palliative care" and "hospice care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.

MATERIALS AND METHODS

We reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of "palliative care" and "hospice care," the definitions for these terms if available, and the recommended timing for these services.

RESULTS

We identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care.

CONCLUSION

"Palliative care" was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

IMPLICATIONS FOR PRACTICE

Integration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

Referral Criteria to Palliative Care for Patients With Heart Failure: A Systematic Review

BACKGROUND

Patients with heart failure have significant symptom burden, care needs, and often a progressive course to end-stage disease. Palliative care referrals may be helpful but it is currently unclear when patients should be referred and by whom. We conducted a systematic review of the literature to examine referral criteria for palliative care among patients with heart failure.

METHODS

We searched Ovid, MEDLINE, Ovid Embase, and PubMed databases for articles in the English language from the inception of databases to January 17, 2019 related to palliative care referral in patients with heart failure. Two investigators independently reviewed each citation for inclusion and then extracted the referral criteria. Referral criteria were then categorized thematically.

RESULTS

Of the 1199 citations in our initial search, 102 articles were included in the final sample. We identified 18 categories of referral criteria, including 7 needs-based criteria and 10 disease-based criteria. The most commonly discussed criterion was physical or emotional symptoms (n=51 [50%]), followed by cardiac stage (n=46 [45%]), hospital utilization (n=38 [37%]), prognosis (n=37 [36%]), and advanced cardiac therapies (n=36 [35%]). Under cardiac stage, 31 (30%) articles suggested New York Heart Association functional class ≥III and 12 (12%) recommended New York Heart Association class ≥IV as cutoffs for referral. Prognosis of ≤1 year was mentioned in 21 (21%) articles as a potential trigger; few other criteria had specific cutoffs.

CONCLUSIONS

This systematic review highlighted the lack of consensus regarding referral criteria for the involvement of palliative care in patients with heart failure. Further research is needed to identify appropriate and timely triggers for palliative care referral.

Prognostic awareness in advanced cancer: an integrative literature review

Individuals with advanced cancer who have accurate prognostic awareness are reported to make more informed decisions about their plan of care. Despite this, it is reported that individuals do not always have accurate prognostic awareness with the rationale for this discordance unclear. The primary aim of the integrative literature review was to identify if there is concordance between actual prognosis and accurate prognostic awareness in individuals with advanced cancer. The secondary aim was to identify the rationale for any discordance between actual prognosis and prognostic awareness in individuals with advanced cancer. This is an integrative literature review using a systematic approach. Literature searches were undertaken in March 2018 in four databases; CINAHL, MEDLINE, PsycINFO and Cochrane Library. Searches were limited to between 2008 and 2018 and those written in the English language. Database searches were supplemented with papers from reference lists of included papers and grey literature. Two reviewers independently completed the literature search and independently reviewed the papers. Fourteen eligible research papers were identified. The majority of individuals with advanced cancer in the included studies did not have accurate prognostic awareness. When identified, the rationale for discordance relates to the individual not being communicated accurate prognostic information, not being able to recall prognostic conversations or prognosis being discussed in vague terms. As individuals with advanced cancer with accurate prognostic awareness make more informed decisions at a crucial time in their life trajectory, it is imperative that healthcare professionals are equipped to effectively deliver accurate prognostic information, ensuring understanding is assessed.

Patients' understanding of oncology clinical endpoints: A literature review

OBJECTIVES

Oncology clinical trials use a variety of clinical endpoints. Patients' understanding of the differences between clinical endpoints is important because misperceptions of treatment efficacy may affect treatment decisions. The objective of this literature review is to find and synthesize available empirical publications assessing patients' understanding of common oncology clinical endpoints.

METHODS

We conducted a literature search of 5 databases and 3 conferences, limiting the search to articles and abstracts published in English through September 2018. We reviewed the titles and abstracts for inclusion, then reviewed full texts to determine if they reported empirical research studies focused on (1) clinical endpoints, (2) oncology, and (3) patient understanding. The original search identified 497publications, of which 13 met the inclusion criteria.

RESULTS

Available literature yields little information on this topic.The few publications that do exist suggest that healthcare professionals and cancer patients generally do not discuss clinical endpoint concepts and that patients can be confused about the purpose of a treatment based on misperceptions about endpoints.

CONCLUSIONS

Research is needed on how to discuss oncology clinical endpoints with patients.

PRACTICE IMPLICATIONS

Patient-friendly definitions of clinical endpoints may help healthcare providers communicate important information about treatments to patients.

Patients' Understanding of Oncology Clinical Endpoints: Environmental Scan and Focus Groups

BACKGROUND

Understanding treatment options is important for patients with cancer and their caregivers. This may be difficult, however, because oncology treatments are often approved based on complex clinical endpoints. The study aimed to explore lay understanding of oncology clinical endpoints by assessing the definitions of clinical endpoints available online and gathering qualitative focus group data on cancer survivors' and the general public's understanding of clinical endpoints.

METHODS

We conducted an environmental scan to find Web sites accessible by a general audience that defined three clinical endpoints: overall survival, progression-free survival, and response rate. Next, we conducted a series of eight focus groups across the U.S. with cancer survivors (n = 36) and general population adults (n = 36).

RESULTS

We found several online resources defining each endpoint; however, many of the definitions we identified used technical language that may not be easily understood by patients and caregivers. Few focus group participants were familiar with the technical terms for these endpoints. When presented with the endpoint terms and definitions, participants had misconceptions about treatment efficacy. Specifically, they tended to expect that all endpoints were a variation on living longer.

CONCLUSION

The results point to the need for more patient-friendly definitions of clinical endpoints developed with input from the general public and from patients with cancer.

IMPLICATIONS FOR PRACTICE

As the number of oncology prescription drug approvals and the advertising of those drugs to consumers increase, it is timely and critical to understand how to discuss treatment benefits with patients. Patient-friendly definitions of common clinical endpoints, such as overall survival and progression-free survival, would help health care providers describe treatment benefits to patients. This research provides evidence regarding patients' understanding of these endpoints and suggests definitions for additional research. This represents a first step in creating evidence-based patient-friendly language to describe clinical endpoints.

Barriers and benefits of model development for integration of palliative care for cancer patients in a developing country: A qualitative study

AIM

The aim of the study was to identify barriers and benefits in establishing a model for integration of palliative care of cancer patients in daily clinical practice in tertiary health institutions.

METHODS

This was a qualitative design study using in-depth interviews with four stakeholders and focus group discussions with 19 nurse managers using purposive sampling to select the participants, utilizing interpretive paradigm method. Need was ascertained for a model that would guide nursing care for cancer patients.

RESULTS

Barriers identified in relation to integrating palliative care in daily clinical practice included lack of hospital policies about palliative care activities, cultural influences, denial or rejection of diagnosis by patients, inappropriate attitude of health care workers, patients failing to keep check-up appointments and financial implications of setting up a dedicated palliative care team. Benefits of the model were twofold: hospital outcomes and patients/family outcomes.

CONCLUSIONS

Quality care for cancer patients/families calls for the adoption of clearly set out principles of palliative care as an integral component of daily practice. Challenges to implementation of palliative care services in hospitals can be overcome by establishing workable policies and allocating adequate funds for palliative care activities.

Conducting Goals-of-Care Discussions Takes Less Time Than Imagined

PURPOSE

To describe the length of encounter during visits where goals-of-care (GoC) discussions were expected to take place.

METHODS

Oncologists from community, academic, municipal, and rural hospitals were randomly assigned to receive a coaching model of communication skills to facilitate GoC discussions with patients with newly diagnosed advanced solid-tumor cancer with a prognosis of < 2 years. Patients were surveyed after the first restaging visit regarding the quality of the GoC discussion on a scale of 0-10 (0 = worst; 10 = best), with ≥ 8 indicating a high-quality GoC discussion. Visits were audiotaped, and total encounter time was measured.

RESULTS

The median face-to-face time oncologists spent during a GoC discussion was 15 minutes (range, 10-20 minutes). Among the different hospital types, there was no significant difference in encounter time. There was no difference in the length of the encounter whether a high-quality GoC discussion took place or not (15 v 14 minutes; P = .9). If there was imaging evidence of cancer progression, the median encounter time was 18 minutes compared with 13 minutes for no progression (P = .03). In a multivariate model, oncologist productivity, patient age, and Medicare coverage affected duration of the encounter.

CONCLUSION

Oncologists can complete high-quality GoC discussions in 15 minutes. These data refute the common misperception that discussing such matters with patients with advanced cancer requires significant time.

External validation of life expectancy prognostic models in patients evaluated for palliative radiotherapy at the end-of-life

BACKGROUND

The TEACHH and Chow models were developed to predict life expectancy (LE) in patients evaluated for palliative radiotherapy (PRT). We sought to validate the TEACHH and Chow models in patients who died within 90 days of PRT consultation.

METHODS

A retrospective review was conducted on patients evaluated for PRT from 2017 to 2019 who died within 90 days of consultation. Data were collected for the TEACHH and Chow models; one point was assigned for each adverse factor. TEACHH model included: primary site of disease, ECOG performance status, age, prior palliative chemotherapy courses, hospitalization within the last 3 months, and presence of hepatic metastases; patients with 0-1, 2-4, and 5-6 adverse factors were categorized into groups (A, B, and C). The Chow model included non-breast primary, site of metastases other than bone only, and KPS; patients with 0-1, 2, or 3 adverse factors were categorized into groups (I, II, and III).

RESULTS

A total of 505 patients with a median overall survival of 2.1 months (IQR: 0.7-2.6) were identified. Based on the TEACHH model, 10 (2.0%), 387 (76.6%), and 108 (21.4%) patients were predicted to live >1 year, >3 months to ≤1 year, and ≤3 months, respectively. Utilizing the Chow model, 108 (21.4%), 250 (49.5%), and 147 (29.1%) patients were expected to live 15.0, 6.5, and 2.3 months, respectively.

CONCLUSION

Neither the TEACHH nor Chow model correctly predict prognosis in a patient population with a survival <3 months. A better predictive tool is required to identify patients with short LE.

The role of palliative care in the management of patients with lung cancer

Palliative care (PC) is the care of patients and their families with serious illness and is rapidly becoming an important part of the care of cancer patients. Patients with advanced lung cancer are a highly symptomatic population of patients and clearly experience benefits in quality of life and potentially benefits in overall survival when PC is incorporated early on after diagnosis. However, referrals to PC are still reliant on clinical judgment of patient prognosis and symptom burden. Moving forward, improving the integration of PC and lung cancer care will require more efficient real-time screening of patient symptoms, which may be accomplished through the use of patient-reported outcomes.

An Individualized, Interactive, and Advance Care Planning Intervention Promotes Transitions in Prognostic Awareness States Among Terminally Ill Cancer Patients in Their Last Six Months-A Secondary Analysis of a Randomized Controlled Trial

CONTEXT/OBJECTIVES

To examine whether an advance care planning intervention randomized controlled trial facilitates terminally ill cancer patients' transitions to accurate prognostic awareness (PA) and the time spent in the accurate PA state in patients' last six months.

METHODS

Participants (N = 460) were randomized 1:1 to experimental (interactive intervention tailored to participants' readiness for advance care planning/prognostic information) and control (symptom management education) arms with similar formats. PA was categorized into four states: 1) unknown and not wanting to know; 2) unknown but wanting to know; 3) inaccurate awareness; and 4) accurate awareness. Intervention effectiveness in the two outcomes was evaluated by intention-to-treat analysis with multistate Markov modeling (effect size ≥0.2 as minimal clinically important difference).

RESULTS

The final sample constituted 188 and 184 experimental arm and control arm participants who died and were repeatedly assessed, respectively. Experimental arm participants in States 1-3 had a higher probability of shifting to accurate PA (23.0%-35.4% vs. 15.2%-26.2%) than control arm participants, and all effect sizes met the minimal clinically important difference criterion (effect sizes 0.22-0.49). In their last six months, experimental arm participants spent more time in States 3 and 4 (0.18 vs. 0.08 and 2.94 vs. 2.38 months, respectively) but less time in States 1 and 2 (2.70 vs. 3.19 and 0.18 vs. 0.36 months, respectively) (effect sizes 0.11-0.19).

CONCLUSION

Our intervention meaningfully facilitated participants' transition toward accurate PA and more time spent in the accurate PA state (State 4). Our intervention can help health care professionals foster cancer patients' accurate PA earlier in the terminal illness trajectory to make informed end-of-life care decisions tailored to their readiness for prognostic information.

Associations of Caregiver-Oncologist Discordance in Prognostic Understanding With Caregiver-Reported Therapeutic Alliance and Anxiety

CONTEXT

Discordance in prognostic understanding between caregivers of adults with advanced cancer and the oncologist may shape caregivers' views of the oncologist and bereavement outcomes.

OBJECTIVES

We examined prospective associations of caregiver-oncologist discordance with caregiver-oncologist therapeutic alliance and caregiver anxiety after patient death.

METHODS

We conducted a secondary analysis of data collected in a cluster randomized controlled trial from August 2012 to June 2014 in Western New York and California. At enrollment, caregivers and oncologists used a seven-point scale to rate their beliefs about the patient's curability and living two years or more: 100%, about 90%, about 75%, about 50 of 50, about 25%, about 10%, and 0%. Discordance was defined as a difference of two points or more. Outcomes at seven months after patient death included caregiver-oncologist therapeutic alliance (The Human Connection scale, modified into five items) and caregiver anxiety (Generalized Anxiety Disorder-7). We conducted multivariable linear regression models to assess the independent associations of discordance with alliance and anxiety.

RESULTS

We included 97 caregivers (mean age 63) and 38 oncologists; 41% of caregiver-oncologist dyads had discordant beliefs about the patient's curability, and 63% of caregiver-oncologist dyads had discordant beliefs about living two years or more. On multivariate analysis, discordance in beliefs about curability was associated with lower anxiety (β = -2.20; SE 0.77; P = 0.005). Discordance in beliefs about length of life was associated with a weaker alliance (β = -5.87; SE = 2.56; P = 0.02).

CONCLUSION

A better understanding of how caregivers understand and come to terms with poor prognoses will guide interventions to improve cancer care delivery and outcomes of cancer treatment.

Palliative Radiation Therapy for Oncologic Emergencies in the Setting of COVID-19: Approaches to Balancing Risks and Benefits

Palliation of metastatic disease compromises a significant portion of radiation treatments in the United States. These patients present a unique challenge in resource-limited settings, as expeditious treatment is often required to prevent serious morbidity. In order to reduce the risk of infection with severe acute respiratory syndrome coronavirus-2 and maximize the benefit to patients, we present evidence-based recommendations for radiation in patients with oncologic emergencies. Radiation oncologists with expertise in the treatment of metastatic disease at a high-volume comprehensive cancer center reviewed the available evidence and recommended best practices for the treatment of common oncologic emergencies, with attention to balancing the risk of infection with severe acute respiratory syndrome coronavirus-2 and the potential morbidity of delaying treatment. Many prospective trials and national guidelines support the use of abbreviated courses of radiotherapy for patients with oncologic emergencies. As such, in the setting of the current coronavirus disease 2019 pandemic, the use of hypofractionated radiation therapy for patients requiring palliation for oncologic emergencies achieves desirable functional outcomes without compromising care.

Newly diagnosed patients with advanced non-small cell lung cancer: A clinical description of those with moderate to severe depressive symptoms

OBJECTIVES

The aims of this observational study were to 1) accrue newly diagnosed patients with advanced-stage non-small cell lung cancer (NSCLC) awaiting the start of first-line treatment and identify those with moderate to severe depressive symptoms and, 2) provide a clinical description of the multiple, co-occurring psychological and behavioral difficulties and physical symptoms that potentially exacerbate and maintain depressive symptoms.

MATERIALS AND METHODS

Patients with stage IV NSCLC (N = 186) were enrolled in an observational study (ClinicalTrials.gov Identifier: NCT03199651) and completed the American Society of Clinical Oncology-recommended screening measure for depression (Patient Health Questionnaire-9 [PHQ-9]). Individuals with none/mild (n = 119; 64 %), moderate (n = 52; 28 %), and severe (n = 15; 8 %) depressive symptoms were identified. Patients also completed measures of hopelessness, generalized anxiety disorder (GAD) symptoms, stress, illness perceptions, functional status, and symptoms.

RESULTS

Patients with severe depressive symptoms reported concomitant feelings of hopelessness (elevating risk for suicidal behavior), anxiety symptoms suggestive of GAD, and traumatic, cancer-specific stress. They perceived lung cancer as consequential for their lives and not controllable with treatment. Pain and multiple severe symptoms were present along with substantial functional impairment. Patients with moderate depressive symptoms had generally lower levels of disturbance, though still substantial. The most salient differences were low GAD symptom severity and fewer functional impairments for those with moderate symptoms.

CONCLUSIONS

Depressive symptoms of moderate to severe levels co-occur in a matrix of clinical levels of anxiety symptoms, traumatic stress, impaired functional status, and pain and other physical symptoms. All of the latter factors have been shown, individually and collectively, to contribute to the maintenance or exacerbation of depressive symptoms. As life-extending targeted and immunotherapy use expands, prompt identification of patients with moderate to severe depressive symptoms, referral for evaluation, and psychological/behavioral treatment are key to maximizing treatment outcomes and quality of life for individuals with advanced NSCLC.

Relationship Between Perceptions of Treatment Goals and Psychological Distress in Patients With Advanced Cancer

BACKGROUND

Studies have shown gaps in prognostic understanding among patients with cancer. However, few studies have explored patients' perceptions of their treatment goals versus how they perceive their oncologist's goals, and the association of these views with their psychological distress.

METHODS

We conducted a cross-sectional study of 559 patients with incurable lung, gastrointestinal, breast, and brain cancers. The Prognosis and Treatment Perception Questionnaire was used to assess patients' reports of their treatment goal and their oncologist's treatment goal, and the Hospital Anxiety and Depression Scale was used to assess patients' psychological symptoms.

RESULTS

We found that 61.7% of patients reported that both their treatment goal and their oncologist's treatment goal were noncurative, whereas 19.3% reported that both their goal and their oncologist's goal were to cure their cancer, 13.9% reported that their goal was to cure their cancer whereas their oncologist's goal was noncurative, and 5% reported that their goal was noncurative whereas their oncologist's goal was curative. Patients who reported both their goal and their oncologist's goal as noncurative had higher levels of depression (B=0.99; P=.021) and anxiety symptoms (B=1.01; P=.015) compared with those who reported that both their goal and their oncologist's goal was curative. Patients with discordant perceptions of their goal and their oncologist's goal reported higher anxiety symptoms (B=1.47; P=.004) compared with those who reported that both their goal and their oncologist's goal were curative.

CONCLUSIONS

One-fifth of patients with incurable cancer reported that both their treatment goal and their oncologist's goal were to cure their cancer. Patients who acknowledged the noncurative intent of their treatment and those who perceived that their treatment goal was discordant from that of their oncologist reported greater psychological distress.

What Goals Do Patients and Oncologists Have When Starting Medical Treatment for Metastatic Lung Cancer?

BACKGROUND

Metastatic lung cancer is an incurable disease that can be treated with systemic therapy. These treatments might prolong survival and reduce symptoms, but they may also cause serious adverse effects. We studied the treatment goals of patients with metastasized lung cancer and their oncologists before starting systemic therapy, concordance between patients' and oncologists' goals, and feasibility of these goals.

PATIENTS AND METHODS

This research was conducted between November 2016 and April 2018 in 1 academic and 5 nonacademic hospitals across the Netherlands. A total of 266 patients with metastatic lung cancer and their prescribing oncologists (n = 23) filled out a questionnaire about their treatment goals and the estimated feasibility of these goals before treatment was started. Additional interviews were conducted with patients and oncologists.

RESULTS

Patients and oncologists reported quality of life (respectively, 45% and 72%), life prolongation (45% and 55%), decrease in tumor size (39% and 66%), and cure (19% and 2%) as treatment goals. The interviews showed that the latter appeared to be often as motivation to stay alive. Concordances between patients' and oncologists' treatment goals were low (ranging from 24% to 33%). Patients had slightly higher feasibility scores than oncologists (6.8 vs. 5.8 on a 10-point scale). Educational level, age, religious views, and performance status of patients were associated with treatment goals.

CONCLUSION

Patients and oncologists set various goals for the treatment they receive/prescribe. Low concordance might exist because different goals are set or because the patient misunderstands something. Clear communication about treatment goals should be integrated into clinical care.

The health care cost of palliative care for cancer patients: a systematic review

OBJECTIVES

Several delivery models of palliative care are currently available: hospital-based, outpatient-based, home-based, nursing home-based, and hospice-based. Weighing the differences in costs of these delivery models helps to advise on the future direction of expanding palliative care services. The objective of this review is to identify and summarize the best available evidence in the US on cost associated with palliative care for patients diagnosed with cancer.

METHODS

The systematic review was carried out of studies conducted in the US between 2008 and 2018, searching PubMed, Medline, the Cochrane library, CINAHL, EconLit, the Social Science Citation Index, Embase, and Science Citation Index, using the following terms: palliative, cancer, carcinoma, cost, and reimbursement.

RESULTS

The initial search identified 748 articles, of which 16 met the inclusion criteria. Eight studies (50%) were inpatient-based, four (25%) were combined outpatient/inpatient, two (12.5%) reported only on home-based palliative services, and two (12.5%) were in multiple settings. Most included studies showed that palliative care reduced the cost of health care by $1285-$20,719 for inpatient palliative care, $1000-$5198 for outpatient and inpatient combined, $4258 for home-based, and $117-$400 per day for home/hospice, combined outpatient/inpatient palliative care.

CONCLUSION

Receiving palliative care after a cancer diagnosis was associated with lower costs for cancer patients, and remarkable differences exist in cost saving across different palliative care models.

Prognostication in Serious Illness

Prognostication is a vital aspect of decision making because it provides patients and families with information to establish realistic and achievable goals of care, is used in determining eligibility for certain benefits, and helps in targeting interventions to those likely to benefit. Prognostication consists of 3 components: clinicians use their clinical judgment or other tools to estimate the probability of an individual developing a particular outcome over a specific period of time; this prognostic estimate is communicated in accordance with the patient's information preferences; the prognostic estimate is interpreted by the patient or surrogate and used in clinical decision making.

Integrated Model for Patient-Centered Advanced Liver Disease Care

Advanced liver disease (AdvLD) is a high-risk common condition with a progressive, highly morbid, and often fatal course. Despite effective treatments, there are substantial shortfalls in access to and use of evidence-based supportive and palliative care for AdvLD. Although patient-centered, chronic illness models that integrate early supportive and palliative care with curative treatments hold promise, there are several knowledge gaps that hinder development of an integrated model for AdvLD. We review these evidence gaps. We also describe a conceptual framework for a patient-centered approach that explicates key elements needed to improve integrated care. An integrated model of AdvLD would allow clinicians, patients, and caregivers to work collaboratively to identify treatments and other healthcare that best align with patients' priorities.

The Effect of Prognostic Communication on Patient Outcomes in Palliative Cancer Care: a Systematic Review

BACKGROUND

While prognostic information is considered important for treatment decision-making, physicians struggle to communicate prognosis to advanced cancer patients. This systematic review aimed to offer up-to-date, evidence-based guidance on prognostic communication in palliative oncology.

METHODS

PubMed and PsycInfo were searched until September 2019 for literature on the association between prognostic disclosure (strategies) and patient outcomes in palliative cancer care, and its moderators. Methodological quality was reported.

RESULTS

Eighteen studies were included. Concerning prognostic disclosure, results revealed a positive association with patients' prognostic awareness. Findings showed no or positive associations between prognostic disclosure and the physician-patient relationship or the discussion of care preferences. Evidence for an association with the documentation of care preferences or physical outcomes was lacking. Findings on the emotional consequences of prognostic disclosure were multifaceted. Concerning disclosure strategies, affective communication seemingly reduced patients' physiological arousal and improved perceived physician's support. Affective and explicit communication showed no or beneficial effects on patients' psychological well-being and satisfaction. Communicating multiple survival scenarios improved prognostic understanding. Physicians displaying expertise, positivity and collaboration fostered hope. Evidence on demographic, clinical and personality factors moderating the effect of prognostic communication was weak.

CONCLUSION

If preferred by patients, physicians could disclose prognosis using sensible strategies. The combination of explicit and affective communication, multiple survival scenarios and expert, positive, collaborative behaviour likely benefits most patients. Still, more evidence is needed, and tailoring communication to individual patients is warranted.

IMPLICATIONS

Future research should examine the effect of prognostic communication on psychological well-being over time and treatment decision-making, and focus on individualising care.