Systematic symptom screening in patients with advanced cancer treated in certified oncology centers: results of the prospective multicenter German KeSBa project

Assessment and monitoring by Integrated Palliative care Outcome Scale: an observational study on cancer patients at home

PURPOSE

Integrated Palliative care Outcome Scale (IPOS) is a specific tool for assessing needs in palliative care, recording and monitoring physical symptoms, emotional concerns, and communication and practical issues. This study aimed to evaluate if the IPOS tool was able to assess the impact of at-home palliative care program on physical symptoms and psychosocial problems in advanced cancer patients.

METHODS

This observational prospective longitudinal mixed-method study included advanced cancer patients assisted at home. IPOS questionnaire (patient version-7-day recall) was administered at the entry, after 2 and 4 weeks. A qualitative thematic analysis (TA) of the first open-ended question was performed. Change over time in IPOS scores was analyzed by Friedman's test for repeated measures.

RESULTS

Among the 60 patients included (29 men, 31 women; 68.2 ± 14.0 years), 47 completed the 4-week observation period. TA indicated that the 3 main themes running through the three surveys (at the entry, day 14, and day 28) relate patients' concerns about symptoms and side effects of treatments, family members, the evolution of the disease, and the daily issues. Repeated measures test demonstrated that patients entering with medium-high IPOS total score (n = 27) showed a significant decrease in IPOS total score (p = 0.003), physical symptoms (p = 0.002), and communication and practice (p = 0.028) subscales after 2 and 4 weeks.

CONCLUSION

Patients entering in home care with higher burden of symptoms and psychosocial problems reported significant decrease in IPOS scores. In these patients, IPOS was responsive to change showing substantial clinical improvements after the activation of home assistance.

Effectiveness of ePRO-based symptom management for cancer patients: a systematic review and meta-analysis of randomized controlled studies

PURPOSE

To systematically synthesize the evidence on the effectiveness of electronic patient-reported outcome (ePRO)-based symptom management on readmission rate, quality of life, symptom burden, anxiety, depression, and mortality in adult cancer patients.

METHOD

A systematic review and meta-analysis were conducted according to the PRISMA guideline in PubMed, Web of Science, EMBASE, the Cochrane Library, CINAHL, and Scopus for studies of randomized controlled trials reporting ePRO-based symptom management from January 1st, 2018, to May 31st, 2023. Two reviewers independently assessed risk-of-bias using Cochrane Risk-of-Bias version 2 and extracted the data. Subgroup analysis was conducted to identify the source of heterogeneity. Sensitivity analysis was performed by using the leave-one-out method. The study protocol was registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) (DOI: https://doi.org/10.37766/inplasy2023.6.0010 ).

RESULTS

A total of 10 studies were included in our review, comprising a total of 5321 participants. The results showed ePRO-based symptom management can improve quality of life (QOL) (SMD = 4.42, 95% CI 0.14 to 8.69, P = 0.04) in cancer patients. No significant differences in the impact on the improvement of readmission rate (RR = 0.89, 95% CI 0.77 to 1.04, P = 0.15), symptom burden (SMD = 1.23, 95% CI - 1.34 to 3.79, P = 0.35), anxiety (SMD =  - 0.00, 95% CI - 0.34 to 0.34, P = 0.99), depression (SMD = 0.03, 95% CI - 0.17 to 0.24, P = 0.74), and mortality (RR = 0.59, 95% CI 0.19 to 1.83, P = 0.36) between the two groups. In the subgroup analysis, readmission rates more than 30 days were significantly lower in the intervention group compared to the control group (relative rate (RR) = 0.85, 95% CI 0.72 to 0.99, P = 0.03). Also, the intervention group's QOL significantly improved compared to the control group when assessed within 1 month after the intervention (SMD = 4.35, 95% CI 3.75 to 4.94, P < 0.00001). In the sensitivity analysis, it was found that the results for readmission rates and quality of life (QOL) were unstable, indicating that further research is needed in the future.

CONCLUSION

Cancer patients often have different symptoms. Symptom management in cancer patients is an emerging topic. However, due to the limited numbers of included studies, the long-term effect of ePRO-based symptom management still needed to be validated.

REGISTRATION DETAILS

inplasy (DOI: https://doi.org/10.37766/inplasy2023.6.0010 ).

Patient Reported Outcome Measurement (PROM) under real-life conditions of non-curable cancer outpatients with the Integrated Palliative Outcome Scale (IPOS) and NCCN-Distress Thermometer - A mixed methods study

Objective

Prospective cohort study to test the real-life feasibility of longitudinal patient-reported outcome measurement PROM (Integrated Palliative Outcome Scale IPOS, and NCCN Distress Thermometer DT) required for outpatients with non-curable lung or prostate cancer in comprehensive cancer centers.

Methods

Assessment with paper-based IPOS and DT was observed for 15 months. We analyzed response to patients' distress (requests for supportive and palliative services) following PROM. Focus groups to comprehensively explore the user experience of patients, informal caregivers and health care professionals (HCP) supplemented the analysis.

Results

Ninety-seven percent (125/129) of the patients received a questionnaire once, but quarterly assessment as recommended by certification committees was achieved only in 50% and 31% of prostate and lung cancer patients. Although both instruments were well accepted, only IPOS showed a high content validity, because some patients had difficulties in understanding the DT. Patients felt comfortable with completing the PROM, and HCP found PROM helped to structure the patient encounter. Due to organizational deficiencies in the handling of the instruments and operationalization of reactions to identified distress, the referrals to supportive and palliative services were rare.

Conclusion

To facilitate consequences from PROM it should be a standardized intervention rather than assessment alone.

Innovation

The patient perspective improves the implementation of PROM under real-life clinical conditions.

Systematic development of a patient-reported ONCOlogical-ROUTinE-Screening (ONCO-ROUTES) procedure at the University Cancer Center Regensburg

PURPOSE

The evaluation of treatment success and progression in oncology patient-reported outcomes (PROs) is playing an increasingly important role. Meanwhile, PROs are a component of the certification requirements of the German Cancer Society for oncology centers. PROs are used to provide supportive therapy. There is currently no instrument that fully covers the requirements. At the University Hospital Regensburg (UKR), a digital ONCOlogical-ROUTinE-Screening (ONCO-ROUTES) procedure was developed in order to assess the need for supportive therapy in a standardized way and to provide patients with supportive interventions tailored to their needs.

METHODS

On the basis of current requirements and guidelines, the development of ONCO-ROUTES was supported by experts in focus groups and interviews, and digitalization was carried out in connection with the IT infrastructure.

RESULTS

A Needs-based, Quality-of-life (QoL) and Symptoms Screening (NQS2) tool already established in the routine at the UKR was further developed into ONCO-ROUTES, which is made up of the domains therapy phase, nutrition, tobacco use, alcohol use, quality of life, general condition/functional status, physical activity, psychooncology, social services, and further support needs. By linking the digitized questionnaire to the hospital information system, the results are available for immediate use in routine operations and thus for the referral of patients for further supportive therapy.

CONCLUSION

The digital PRO application ONCO-ROUTES is designed to involve patients in monitoring additional supportive needs and thus, improves supportive interdisciplinary treatment.

Determining the cut-off value for the Minimal Documentation System (MIDOS2) screening tool to initiate specialized palliative care based on patient's subjective need for palliative support and symptom burden in inpatients with advanced cancer

PURPOSE

The Minimal Documentation System (MIDOS2) is recommended as a systematic screening tool for assessing symptom burden and patient needs in advanced cancer patients. Given the absence of an optimal weighting of individual symptoms and a corresponding cut-off value, this study aims to determine a threshold based on inpatient's subjective need for palliative support. Additionally, we investigate the correlation between symptom burden and subjective need for palliative support collected through a patient-reported outcome measure (PROM) with survival duration of less or more than one year.

METHODS

Inpatients diagnosed with advanced solid cancer completed an electronic PROM, which included the MIDOS2 questionnaire among other tools. Differences in symptom burden were analysed between patients expressing subjective need for palliative support and those with survival of less or more than one year using ANOVA, Mann-Whitney-U Test, logistic regression, Pearson and Spearman correlation tests. Cut-off analyses were performed using a ROC curve. Youden-Index, sensitivity, and specificity measures were used as well.

RESULTS

Between April 2020 and March 2021, 265 inpatients were included in the study. Using a ROC curve, the MIDOS2 analysis resulted in an Area under the curve (AUC) of 0.732, a corresponding cut-off value of eight points, a sensitivity of 76.36% and a specificity of 62.98% in assessing the subjective need for palliative support. The MIDOS2, with double weighting of the significant symptoms, showed a cut-off value of 14 points, achieving a sensitivity of 78.18% and a specificity of 72.38%. A total of 55 patients (20.8%) expressed a need for support from the palliative care team. This need was independent of the oncological tumour entity and increased among patients with a survival of less than one year. These patients reported significantly poorer physical (p < 0.001) or mental (p < 0.001) condition. Additionally, they reported higher intensities of pain (p = 0.002), depressive symptoms (p < 0.001), weakness (p < 0.001), anxiety (p < 0.001), and tiredness (p < 0.001).

CONCLUSION

Using the established MIDOS2 cut-off value with an adjusted double weighting in our study, a large proportion of inpatients may be accurately referred to SPC based on their subjective need for palliative support. Additionally, subjective reports of poor general, mental, and physical condition, as well as pain, depressive symptoms, weakness, anxiety, and tiredness, increase the subjective need for palliative support, particularly in patients with a survival prognosis of less than one year.

Advanced Practice Nursing and CAR-T Cell Therapy: Opportunities, Challenges and Future Directions

OBJECTIVES

Chimeric antigen receptor (CAR)-T cell therapy is a new treatment for patients with myeloma and other B cell malignancies where advanced practice nurses (APN) can make a great contribution. The aim of this review is to identify key aspects of current literature relevant to APNs working with this population.

METHODS

Discussion of selected peer-reviewed literature and best practice guidelines found through electronic database searches (CINAHL, MEDLINE).

RESULTS

Although few APN roles in CAR-T cell therapy have been published to date, recent research suggests that the APN is central to the care of these patients. They are essential for continuity of care and navigation through the treatment process, providing an important and consistent point of contact for patients' and carers' anxieties and uncertainties. APNs play a central role in symptom management, as they constantly incorporate new experience and scientific findings into the refinement of existing protocols. The continuum of care extends far beyond the inpatient stay and addresses symptoms that may persist long after cytokine release syndrome and neurotoxicity have resolved. The APN may therefore make a relevant contribution to patients' health-related quality of life, given its likely correlation with the dynamics and intensity of treatment-related symptoms. The APN also takes on a leadership role in the treatment team.

CONCLUSIONS

APNs use all core competencies to sustainably support and empower patients and caregivers. This is achieved through counseling and education, in addition to identifying, developing, and implementing evidence-based symptom management. They play pivotal roles in introducing new CAR-T cell products, educating teams, and advancing their role through APN networks. Finally, APNs are integral members of multiprofessional teams, supporting colleagues in ethically challenging patient situations.

IMPLICATIONS FOR NURSING PRACTICE

APNs in the field of CAR-T cell therapy make an important contribution to the continuous care of patients, caregivers, and treatment teams.