Systematic versus on-demand early palliative care: A randomised clinical trial assessing quality of care and treatment aggressiveness near the end of life

Patterns of acute hospital and specialist palliative care use among people with non-curative upper gastrointestinal cancer

PURPOSE

Upper gastrointestinal (GI) cancers contribute to 16.7% of UK cancer deaths. These patients make high use of acute hospital services, but detail about palliative care use is lacking. We aimed to determine the patterns of use of acute hospital and hospital specialist palliative care services in patients with advanced non-curative upper GI cancer.

METHODS

We conducted a service evaluation of hospital use and palliative care for all patients with non-curative upper GI cancer seen in one large hospital, using routinely collected data (2019-2022). We report and characterise hospital admissions and palliative care within the study time period, using descriptive statistics, and multivariable Poisson regression to estimate the unadjusted and adjusted incidence rate ratio of hospital admissions.

RESULTS

The total with non-curative upper GI cancer was 960. 86.7% had at least one hospital admission, with 1239 admissions in total. Patients had a higher risk of admission to hospital if: aged ≤ 65 (IRR for 66-75 years 0.71, IRR 76-85 years 0.68; IRR > 85 years 0.53; p < 0.05), or lived in an area of lower socioeconomic status (IMD Deciles 1-5) (IRR 0.90; p < 0.05). Over the 4-year period, the rate of re-admission was higher in patients not referred to palliative care (rate 0.52 readmissions/patient versus rate 1.47 readmissions/patient).

CONCLUSION

People with advanced non-curative gastrointestinal cancer have frequent hospital admissions, especially if younger or from areas of lower socioeconomic status. There is clear association between specialist palliative care referral and reduced risk of hospitalisation. This evidence supports referral to specialist palliative care.

Effect of Education on Symptom Management and Control in Cancer Patients Receiving Palliative Care

OBJECTIVE

This study aims to investigate the effect of an educational intervention on cancer patients receiving palliative care and their caregivers concerning symptom management and family needs.

METHODS

This study involved 120 participants-60 cancer patients and their respective caregivers-divided into intervention and control groups. Over a 2-week period, the intervention group received a comprehensive educational program focusing on symptom management, while the control group did not receive any educational intervention. The Edmonton Symptom Assessment System (ESAS) and Palliative Performance Scale (PPS) were used to assess patients' symptoms, their intensity, and performance, while the Family Need Scale (FNS) was utilized to evaluate caregivers' needs. These assessments were conducted at the beginning and end of the study. Primary outcomes focused on symptom assessment using ESAS and PPS, along with evaluating caregivers' needs through FNS. Secondary outcomes involved assessing participant satisfaction with the intervention.

RESULTS

At the end of the study, comparing initial and second evaluations, both ESAS and PPS scores significantly increased in the intervention and control groups (p = .003, p = .002, respectively). Additionally, a statistically significant decrease in the severity of symptoms, except for lethargy/hypokinesis, was observed in the intervention group compared to the control group. The FNS scale indicated that family needs satisfaction was higher in the intervention group compared to the control group. The data obtained demonstrated that there was a reduction the pain, fatigue, depression, anxiety, drowsiness, and shortness of breath levels in the intervention group compared to the control group, but there was no significant difference other than these symptoms.

CONCLUSIONS

The educational intervention positively impacted symptom management and family needs. Optimizing symptom control would greatly benefit palliative care patients and their caregivers.

Palliative care integration and end-of-life care intensity for patients with NSCLC

BACKGROUND

Non-small cell lung cancer (NSCLC) without oncogenic driver mutations is considered to have a poor prognosis, although recent therapeutic progress. This study aims to assess the real-life integration of palliative care (PC) and the intensity of end-of-life (EOL) care for this population.

METHODS

This was an observational cohort study of decedent patients from metastatic NSCLC without oncogenic driver mutations over the period 01/2018 to 12/2022, treated in first line with immunotherapy +/- chemotherapy. We analysed PC integration and aggressiveness criteria of EOL care in the last month before death: systemic anti-cancer treatment administration, emergency room visits, intensive care unit admission, hospitalization, hospitalization duration > 14 days, and hospital death.

RESULTS

Among 149 patients, 75 (50 %) met the PC team at least once, and the median time from the first encounter to death was 2.3 months. In the last month before death, at least one criterion of aggressive EOL care was present for 97 patients (70 %). For patients with PC use < 30 days and for patients with PC use < 90 days before death, there were significant changes: increase in the frequency of systemic anti-cancer treatment (respectively 51.1 % vs 20 %; p < 0.001 and 58.7 % vs 6.2 %; p < 0.001); decrease in hospitalization lasting > 14 days (respectively 30 % vs 7 %; p = 0.001 and 36 % vs 6.2 %; p = 0.018) and in death hospitalisation (respectively 66 % and 18 %; p < 0.001 and 58.7 % and 10.3 %; p < 0.001). After adjusting for the factors tested, patients with no PC or late PC use in the last month before death or in the last three month before death, the odds ratio (OR) remained significantly greater than 1 (respectively OR = 3.97 [1.70; 9.98]; p = 0.001 and OR = 23.1 [5.21-177.0], p < 0.0001).

CONCLUSION

PC is still insufficiently integrated for patients with NSCL cancer. Cancer centres should monitor key indicators such as PC use and aggressiveness criteria of EOL care.

Guidelines for the diagnosis and treatment of cutaneous squamous cell carcinoma: a GRADE approach for evidence evaluation and recommendations by the Italian Association of Medical Oncology

Cutaneous squamous cell carcinoma (CSCC) accounts for ∼20%-25% of all skin tumors. Its precise incidence is often challenging to determine due to limited statistics and its incorporation with mucosal forms. While most cases have a favorable prognosis, challenges arise in patients presenting with locally advanced or metastatic forms, mainly appearing in immunocompromised patients, solid organ transplantation recipients, or those facing social difficulties. Traditionally, chemotherapy and targeted therapy were the mainstays for advanced cases, but recent approvals of immunotherapeutic agents like cemiplimab and pembrolizumab have revolutionized treatment options. These guidelines, developed by the Italian Association of Medical Oncologists (AIOM) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach, aim to guide clinicians in diagnosing, treating, and monitoring patients with CSCC, covering key aspects from primitive tumors to advanced stages, selected by a panel of experts selected by AIOM and other national scientific societies. The incorporation of these guidelines into clinical practice is expected to enhance patient care and address the evolving landscape of CSCC management.

Integrating Palliative Care Into the Management of Genitourinary Malignancies

Palliative care (PC) plays a critical role in managing the difficulties associated with genitourinary malignancies. Its primary aim is to improve the overall health of patients, provide support to both patients and their caregivers, and help individuals to navigate the complex decisions about treatment and end-of-life care. PC takes a holistic approach to patient care, recognizing that genitourinary malignancies affect multiple aspects of a person's life. By addressing physical, emotional, social, and spiritual needs, PC aims to provide comprehensive support that is consistent with the patient's values and preferences. The goal is to optimize comfort, minimize distress, and enhance the patient's quality of life throughout the course of the illness. PC is not a one-off intervention, but an ongoing source of support. This article aims to provide a thorough overview of the critical elements involved in addressing the challenges posed by genitourinary cancers, emphasizing the importance of palliative interventions. We will highlight the multifaceted aspects of care and explore strategies to optimize the overall well-being of patients throughout the course of treatment for genitourinary malignancies.

Can an Integrated Palliative and Oncology Co-rounding Model Reduce Aggressive Care at the End of Life? Secondary Analysis of an Open-label Stepped-wedge Cluster-randomized Trial

BACKGROUND

Clinical trial evidence on the effect of palliative care models in reducing aggressive end-of-life care is inconclusive. We previously reported on an integrated inpatient palliative care and medical oncology co-rounding model that significantly reduced hospital bed-days and postulate additional effect on reducing care aggressiveness.

OBJECTIVES

To compare the effect of a co-rounding model vs usual care in reducing receipt of aggressive treatment at end-of-life.

METHODS

Secondary analysis of an open-label stepped-wedge cluster-randomized trial comparing two integrated palliative care models within the inpatient oncology setting. The co-rounding model involved pooling specialist palliative care and oncology into one team with daily review of admission issues, while usual care constituted discretionary specialist palliative care referrals by the oncology team. We compared odds of receiving aggressive care at end-of-life: acute healthcare utilization in last 30 days of life, death in hospital, and cancer treatment in last 14 days of life between patients in two trial arms.

RESULTS

2145 patients were included in the analysis, and 1803 patients died by 4th April 2021. Median overall survival was 4.90 (4.07 - 5.72) months in co-rounding and 3.75 (3.22 - 4.21) months in usual care, with no difference in survival (P = .12). We found no significant differences between both models with respect to receipt of aggressive care at end-of-life. (Odds Ratio .67 - 1.27; all P > .05).

CONCLUSION

The co-rounding model within an inpatient setting did not reduce aggressiveness of care at end-of-life. This could be due in part to the overall focus on resolving episodic admission issues.

PALLiative care in ONcology (PALLiON): A cluster-randomised trial investigating the effect of palliative care on the use of anticancer treatment at the end of life

BACKGROUND

Effects on anticancer therapy following the integration of palliative care and oncology are rarely investigated. Thus, its potential effect is unknown.

AIM

To investigate the effects of the complex intervention PALLiON versus usual care on end-of-life anticancer therapy.

DESIGN

Cluster-randomised controlled trial (RCT), registered at ClinicalTrials.gov (No. NCT01362816). The complex intervention consisted of a physician education program enhancing theoretical, clinical and communication skills, a patient-centred care pathway and patient symptom reporting prior to all consultations. Primary outcome was overall use, start and cessation of anticancer therapy in the last 3 months before death. Secondary outcomes were patient-reported outcomes. Mixed effects logistic regression models and Cox proportional hazard were used.

SETTING

A total of 12 Norwegian hospitals (03/2017-02/2021).

PARTICIPANTS

Patients ⩾18 years, advanced stage solid tumour, starting last line of anticancer therapy, estimated life expectancy ⩽12 months.

RESULTS

A total of 616 (93%) patients were included (intervention: 309/control:307); 63% males, median age 69, 77% had gastrointestinal cancers. Median survival time from inclusion was 8 (IQR 3-14) and 7 months (IQR 3-12), and days between anticancer therapy start and death were 204 (90-378) and 168 (69-351) (intervention/control). Overall, 78 patients (13%) received anticancer therapy in the last month (intervention: 33 [11%]/control: 45 [15%]). No differences were found in patient-reported outcomes.

CONCLUSION

We found no significant differences in the probability of receiving end-of-life anticancer therapy. The intervention did not have the desired effect. It was probably too general and too focussed on communication skills to exert a substantial influence on conventional clinical practice.

Characterization of patients with brain metastases referred to palliative care

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thirteen Nonpharmacological Interventions for Increasing the Quality of Life in Patients with Advanced Cancer: A Network Meta-analysis

BACKGROUND

A variety of nonpharmacological interventions that improve the quality of life of patients with advanced cancer have been difficult for medical staff to select through randomized controlled trials or traditional meta-analyses. Thus, a network meta-analysis is necessary.

OBJECTIVE

This study used network meta-analysis to analyze the effect of 13 different nonpharmacological interventions on improving the living quality of patients with advanced cancer.

METHODS

Five English databases were searched up to January 2019. The search strategy only included terms relating to or describing the intervention.

RESULTS

The study included 13 different nonpharmacological interventions. The overall efficacy was summarized through a holistic study of quality of life. The study found that the combined effect sizes of 13 nonpharmacological interventions crossed the invalid line (weighted mean difference, -13 [95% confidence interval, -33 to 8.5] to 1.7 [95% confidence interval, -18 to 22]), indicating that none of the intervention was significantly different from each other. By evaluating the heterogeneity of this outcome, no significant evidence of heterogeneity ( P > .05) was observed. Probability ranking according to the surface under the cumulative ranking curve showed that there was a great possibility for the CanWalk intervention and structured multidisciplinary intervention to improve outcomes for cancer patients.

CONCLUSIONS

Thirteen nonpharmacological interventions did not significantly impact quality of life. Regarding the probability rank, CanWalk intervention may be the most promising way that advanced cancer patients can help themselves to a better life. Because of the limitations of the current studies, the conclusion needs further evidence.

IMPLICATIONS FOR PRACTICE

Nurses should consider recommending moderate physical activity for patients with advanced cancer.

What is an "early palliative care" intervention? A scoping review of controlled studies in oncology

INTRODUCTION

Early palliative care (EPC) has been advocated to improve cancer patients' health. However, EPC differs with regard to its elements and target groups. It is not known which parts of EPC contribute to effectiveness for which patient group. This scoping review provides a structured analysis of EPC interventions and outcome measures.

DESIGN

We searched EMBASE, MEDLINE, CINAHL, and CENTRAL up to February 2022. We included randomized controlled trials (RCT), nonrandomized trials, cohort studies (CS), and controlled before-after studies of EPC in adult patients in English, Dutch, and German language. Interventions had to be self-labeled as EPC. Screening and data extraction were performed by two raters. A structured analysis incorporating the TIDieR checklist was performed to describe the elements of the interventions.

RESULTS

We screened 2651 articles, resulting in 40 articles being included: 34 studies were RCT and six studies were CS with a mean sample size of 208 patients. Patients with pancreatic (n = 10) and lung cancer (n = 9) were most often included. Studies reported different reference points for the onset of EPC such as time after diagnosis of incurable cancer (n = 18) or prognosis (n = 9). Thirteen studies provided information about elements of EPC and eight studies about the control intervention. Most frequent elements of EPC were symptom management (n = 28), case management (n = 16), and advance care planning (ACP; n = 15). Most frequently reported outcome measures were health-related quality of life (n = 26), symptom intensity (n = 6), resource use, and the patient's mood (n = 4 each).

CONCLUSION

The elicited heterogeneity of ECP in combination with deficits of reporting are considerable barriers that should be addressed to further develop effective EPC interventions for different groups of cancer patients.

Intersection of Palliative Care and Hospice Use Among Patients With Advanced Lung Cancer

Background: Hospice and palliative care (PC) are important components of lung cancer care and independently provide benefits to patients and their families. Objective: To better understand the relationship between hospice and PC and factors that influence this relationship. Methods: A retrospective cohort study of patients diagnosed with advanced lung cancer (stage IIIB/IV) within the U.S. Veterans Health Administration (VA) from 2007 to 2013 with follow-up through 2017 (n = 22,907). Mixed logistic regression models with a random effect for site, adjustment for patient variables, and propensity score weighting were used to examine whether the association between PC and hospice use varied by U.S. region and PC team characteristics. Results: Overall, 57% of patients with lung cancer received PC, 69% received hospice, and 16% received neither. Of those who received hospice, 60% were already enrolled in PC. Patients who received PC had higher odds of hospice enrollment than patients who did not receive PC (adjusted odds ratio = 3.25, 95% confidence interval: 2.43-4.36). There were regional differences among patients who received PC; the predicted probability of hospice enrollment was 85% and 73% in the Southeast and Northeast, respectively. PC team and facility characteristics influenced hospice use in addition to PC; teams with the shortest duration of existence, with formal team training, and at lower hospital complexity were more likely to use hospice (all p < 0.05). Conclusions: Among patients with advanced lung cancer, PC was associated with hospice enrollment. However, this relationship varied by geographic region, and PC team and facility characteristics. Our findings suggest that regional PC resource availability may contribute to substitution effects between PC and hospice for end-of-life care.

Impact of early vs late palliative care referrals on healthcare utilization in patients with pancreatic cancer

PURPOSE

The purpose of this study was to examine the impact of early versus late palliative care referral (PCR) following pancreatic cancer diagnosis.

METHODS

Patients diagnosed with PDAC who received a PCR between 2014 and 2020 at a major academic institution were identified. PCR was classified as early (< 30 days) or late (≥ 30 days) based on time from definitive diagnosis. Data were obtained on number of emergency department (ED) visits, intensive care unit (ICU) admissions, and hospital admissions.

RESULTS

Among 1458 patients with PDAC, 419 (28.7%) received PCR, among which 67.3% (n = 282) received a late PCR. Of those who received PCR, the majority were White (85%) and male (54.8%), with a median age of 62 years at time of diagnosis. Patients who received an early PCR more commonly presented with stage 4 disease at diagnosis (early: n = 91, 69% vs. late: n = 132, 47%), whereas patients who received a late PCR more commonly presented with stage 1, 2, or 3 disease (early: n = 40, 30.5% vs. late: n = 150, 53.2%) (p < 0.001). Patients who received early PCR had fewer median ED visits (1 vs. 2, p < 0.001) and hospital admissions (1 vs. 2, p < 0.001) compared with patients who received late PCR. However, after performing recurrent-event Cox-proportional hazards models, the timing of PCR did not impact hospital admission (HR 0.88, 95% CI 0.68, 1.14; p = 0.3).

CONCLUSION

Timing of PCR for patients with PDAC was not associated with healthcare utilization. Further prospective trials are needed to study the patient-centered impact of early integration of palliative care services into multidisciplinary pancreatic cancer teams.

Aggressiveness of Cancer Care at End of Life in Patients with Metastatic Breast Cancer in Jordan

Background

Contrary to Western societies, more than 15% of patients with breast cancer in Jordan are diagnosed with stage IV disease. In this study, we evaluate the value of early palliative care integration in the end-of-life care of such patients.

Methods

All consecutive adult patients who died between 2014 to 2018, while under the care of our institution, with a confirmed diagnosis of breast cancer at the time of death, irrespective of place of death, were retrospectively reviewed.

Results

During the study period, a total of 433 patients, median age 51.6 years, were included in the analysis. Among the whole group, 102 (23.6%) were referred to palliative care service early (≥30 days prior to death), 182 (42.0%) had late referral (<30 days from death), while 149 (34.4%) were never referred and were followed up by their medical oncologists. During the last 30 days prior to death, patients who were never referred to palliative care were more likely to visit the Emergency Room (ER) more than once (OR 1.89, 95% CI 1.20-2.99, p = 0.006), more likely to be admitted to the hospital more than once (OR 2.27, 95% CI 1.38-3.73, p = 0.001), and more likely to be admitted to the intensive care unit (ICU) (OR 3.07, 95% CI 1.48-6.38, p = 0.0027). Fewer patients in the "no referral" group died with advance directives compared to those who had early or late referral; 60.8%, 75.0% and 82.5%, respectively, p = 0.0003. Survival of patients followed by medical oncologist was not better than those referred to palliative care, either late or early; median survival was 19.0, 19.1 and 23.8 months, respectively (p = 0.2338).

Conclusion

Findings suggest that earlier palliative care referral is associated with less aggressive end-of-life care, leading to less frequent ER visits, hospital and ICU admissions during the last month of life, and does not compromise survival.

The effect of palliative outpatient units on resource use for cancer patients in Finland

BACKGROUND

As cancer incidences are increasing, the means to provide effective palliative care (PC) are called for. There is evidence, that PC may prevent futile treatment at the end of life (EOL) thus implicating that PC decreases resource use at the EOL, however, the effects of outpatient PC units remain largely unknown. We surveyed the national use of Finnish tertiary care PC units and their effects on resource use at the EOL in real-life environments.

PATIENTS AND METHODS

Cancer patients treated in the departments of Oncology at all five Finnish university hospitals in 2013 and deceased by 31 December 2014 were identified; of the 6010 patients 2007 were randomly selected for the study cohort. The oncologic therapies received and the resource usage of emergency services and hospital wards were collected from the hospitals' medical records.

RESULTS

A PC unit was visited by 37% of the patients a median 112 days before death. A decision to terminate all life-prolonging cancer treatments was more often made for patients visiting the PC unit (90% vs. 66%, respectively). A visit to a PC unit was associated with significantly fewer visits to emergency departments (ED) and hospitalization during the last 90 days of life; the mean difference in ED visits decreased by 0.48 (SD 0.33 - 0.62, p < 0.001), and the mean inpatient days by 7.1 (SD 5.93 - 8.25, p < 0.001). A PC visit unit was independently associated with decreased acute hospital resource use during the last 30 and 90 days before death in multivariable analyses.

CONCLUSION

Cancer patients' contact with a PC unit was significantly associated with the reduced use of acute hospital services at the EOL, however; only one-third of the patients visited a PC unit. Thus, systematic PC unit referral practices for patients with advanced cancer are called for.

Factors associated with suffering from dying in patients with cancer: a cross-sectional analytical study among bereaved caregivers

BACKGROUND

In Colombia, cancer incidence is increasing, as is the demand for end-of-life care. Understanding how patients who die from cancer experience this phase will allow the identification of factors associated with greater suffering and actions to improve end-of-life care. We aimed to explore associations between the level of suffering of patients who died from cancer and were cared for in three Colombian hospitals with patient, tumor, treatment, and care characteristics and provided information.

METHODS

Data on the last week of life and level of suffering were collected through proxies: Bereaved caregivers of patients who died from cancer in three participating Colombian hospitals. Bereaved caregivers participated in a phone interview and answered a series of questions regarding the last week of the patient's life. An ordinal logistic regression model explored the relationship between the level of suffering reported by bereaved caregivers with the patient's demographic and clinical characteristics, the bereaved caregivers, and the care received. Multivariate analyses were adjusted for place of death, treatments to prolong of life, prolongation of life during the dying process, suffering due to prolongation of life, type of cancer, age, if patient had partner, rural/urban residence of patient, importance of religion for the caregiver, caregivers´ relationship with the patient, and co-living with the patient.

RESULTS

A total of 174 interviews were included. Median age of the deceased patients was 64 years (IQR 52-72 years), and 93 patients were women (53.4%). Most caregivers had rated the level of suffering of their relative as "moderately to extremely" (n = 139, 80%). In multivariate analyses, factors associated with a higher level of suffering were: unclear information about the treatment and the process before death Odds Ratio (OR) 2.26 (90% CI 1.21-4.19), outpatient palliative care versus home care OR 3.05 (90% CI 1.05-8.88), procedures inconsistent with the patient's wishes OR 2.92 (90% CI 1.28-6.70), and a younger age (18-44 years) at death versus the oldest age group (75-93 years) OR 3.80 (90% CI 1.33-10.84, p = 0.04).

CONCLUSION

End-of-life care for cancer patients should be aligned as much as possible with patients´ wishes, needs, and capacities. A better dialogue between doctors, family members, and patients is necessary to achieve this.

Patient & Caregiver Experiences: Qualitative Study Comparison Before and After Implementation of Early Palliative Care for Advanced Colorectal Cancer

BACKGROUND

The Palliative Care Early and Systematic (PaCES) program implemented an early palliative care pathway for advanced colorectal cancer patients in January 2019, to increase specialist palliative care consultation and palliative homecare referrals more than three months before death. This study aimed to understand the experience of patients with advanced colorectal cancer and family caregivers who received early palliative care supports from a specialist palliative care nurse and compared those experiences with participants who experienced standard oncology care prior to implementation of early palliative care.

METHODS

This was a qualitative and patient-oriented study. We conducted semi-structured telephone interviews with two cohorts of patients with advanced colorectal cancer before and after implementation of an early palliative care pathway. We conducted a thematic analysis of the transcripts guided by a Person-Centred Care Framework.

RESULTS

Seven patients living with advanced colorectal cancer and five family caregivers who received early palliative care supports expressed that visits from their early palliative care nurse was helpful, improved their understanding of palliative care, and improved their care. Four main themes shaped their experience of early palliative care: care coordination, perception of palliative care & advance care planning, coping with advanced cancer, and patient and family engagement. These findings were compared with experiences of 15 patients and seven caregivers prior to pathway implementation.

CONCLUSION

An early palliative care pathway can improve advanced cancer care, and improve understanding and acceptance of early palliative care. This work was conducted in the context of colorectal cancer but may have relevance for the care of other advanced cancers.

The impact of clinical trial enrollment on specialty palliative care utilization in pediatric patients with high-grade gliomas

BACKGROUND

Palliative care (PC) provides numerous benefits for children with cancer. Pediatric patients with high-grade glioma (HGG) are particularly well suited for early PC involvement given their high symptom burden and poor prognosis. However, studies continue to reveal that children with cancer, including HGG, have delayed PC involvement. We hypothesized that clinical trial enrollment may lead to a lack of or delay in PC involvement in this population.

PROCEDURE

For each patient in our cohort of 43 pediatric patients with HGG, demographic, diagnostic, therapeutic, clinical trial enrollment, and PC information were collected. Statistical analysis was performed comparing PC characteristics between patients who did and did not enroll in a clinical trial.

RESULTS

Seventy-two percent of patients had at least one visit with a PC provider. Fifty-six percent of patients enrolled in a clinical trial with HGG-directed therapy. Seventy-one percent of patients who enrolled in a clinical trial received specialty PC compared to 74% of non-trial participants (p = 1.000). Patients who enrolled in clinical trials received PC earlier in their disease course measured in days before death (mean = 177 days) compared to those who did not enroll (mean = 113 days, p = .180), though not statistically significant.

CONCLUSIONS

The prevalence of clinical trial enrollment is high in patients with HGG and will likely increase as the genomic/epigenomic landscape of these tumors is better understood. As such, our data reassuringly suggest that trial participation does not interfere with the receipt of specialty PC in this population.

A complex communication skills training program for physicians providing advanced cancer care - content development and barriers and solutions for implementation

Background: Early integration of oncology and patient-centered palliative care is the recommended clinical practice model for patients with advanced cancer. General and specific communication skills are necessary to achieve integrated patient-centered care, but require organized training to be adequately mastered. Challenges and barriers on several levels, i.e. organizational, professional and individual may, however, hamper implementation. The development, implementation, and evaluation of such an educational program focusing on communication skills contain many steps, considerations and lessons learned, which are described in this article.Methods: A multi-professional faculty developed, implemented, and evaluated an educational program through a 5-step approach. The program was part of a Norwegian cluster-randomized controlled trial aiming to test the effect of early integration of oncology and palliative care for patients with advanced cancer.Results: The result is the PALLiON educational program; a multi-faceted, evidence-based, and learner-centered program with a specific focus on physicians' communication skills. Four modules were developed: lectures, discussion groups, skills training, and coaching. These were implemented at the six intervention hospitals using different teaching strategies. Evaluation in a subgroup of participants showed a positive appraisal of the group discussions and skills training.Conclusion:We present our experiences and reflections regarding implementation and lessons learned, which should be considered in future developments and implementations; (1) Include experienced faculty with various backgrounds, (2) Be both evidence-based and learner-centered, (3) Choose teaching strategies wisely, (4) Expect resistance and skepticism, (5) Team up with management and gatekeepers, (6) Expect time to fly, and (7) Plan thorough assessment of the evaluation and effect.Trial registration: ClinicalTrials.gov identifier: NCT03088202.

Radiotherapy and palliative care outpatient clinic: a new healthcare integrated model in Italy

BACKGROUND

On the basis of substantial evidence demonstrate that palliative care combined with standard care improves patient, caregiver, and society outcomes, we have developed a new healthcare model called radiotherapy and palliative care (RaP) outpatient clinic were a radiation oncologist and a palliative care physician make a joint evaluation of advanced cancer patients.

METHODS

We performed a monocentric observational cohort study on advanced cancer patients referred for evaluation at the RaP outpatient clinic. Measures of quality of care were carried out.

RESULTS

Between April 2016 and April 2018, 287 joint evaluations were performed and 260 patients were evaluated. The primary tumor was lung in 31.9% of cases. One hundred fifty (52.3%) evaluations resulted in an indication for palliative radiotherapy treatment. In 57.6% of cases was used a single dose fraction of radiotherapy (8 Gy). All the irradiated cohort completed the palliative radiotherapy treatment. An 8% of irradiated patients received the palliative radiotherapy treatment in the last 30 days of life. A total of 80% of RaP patients received palliative care assistance until the end of life.

CONCLUSION

At the first descriptive analysis, the radiotherapy and palliative care model seem to respond to the need of multidisciplinary approach in order to obtain an improvement on quality of care for advanced cancer patients.

Should Outpatient Palliative Care Clinics in Cancer Centers be Stand Alone or Embedded?

Outpatient palliative care facilitates timely symptom management, psychosocial care and care planning. A growing number of cancer centers have either stand-alone or embedded outpatient palliative care clinics. In this "Controversies in Palliative Care" article, three groups of thought leaders independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. One group advocates for stand-alone clinics, another for embedded, and the third group tries to find a balance. In the absence of evidence that directly compares the two models, factors such as cancer center size, palliative care team composition, clinic space availability, and financial considerations may drive the decision-making process at each institution. Stand-alone clinics may be more appropriate for larger academic cancer centers or palliative care programs with a more comprehensive interdisciplinary team, while embedded clinics may be more suited for smaller palliative care programs or community oncology programs to stimulate referrals. As outpatient clinic models continue to evolve, investigators need to document the referral and patient outcomes to inform practice.

[Examining the use of palliative systemic treatments near end-of-life for patients with metastatic cancer at a French cancer institute]

BACKGROUND AND OBJECTIVES

Appropriate use of palliative systemic treatments near end-of-life is crucial to reduce aggressiveness of cancer care. The study's objective is to evaluate cancer quality-of-care near end-of-life in our cancer institute.

METHODS

From a retrospective cohort, we included all adults with metastatic solid cancers who died in 2019. The use of palliative systemic treatments close to death was measured from quality-of-care indicators described by Earle and al. The integration of supportive care into standard oncology care was also evaluated. All the information were collected from electronic records.

RESULTS

Of the 452 patients, 6.2% received systemic treatment in the last 14 days of life and 8.4% started a new systemic treatment in the last 30 days of life. Eighty six percent met a supportive care physician. This intervention was significantly less frequent in the TS_≤14 group than in the TS_>30 group (71.4 % vs 89.5 % p=0.021). The main reasons for first contact were pain (35 %), early palliative care (29 %) and then exclusive palliative care (17.5 %).

CONCLUSION

Our institute offers a good quality of end-of-life care for patients with metastatic solid cancers. However, improvements should be done regarding prognostic estimation and integration of palliative care.

Impact of Early Palliative Care to Improve Quality of Life of Advanced Cancer Patients: A Meta-Analysis of Randomised Controlled Trials

Palliative care is often started late in patients with life-threatening conditions, particularly in patients with advanced cancer. However, with the emergence of the early palliative care (EPC) paradigm, their quality of life (QoL) may be better. Although several previous meta-analyses support the effectiveness of EPC in increasing QoL, essential issues related to the optimisation of EPC interventions are still needed. A systematic review and meta-analysis of randomised controlled trials (RCTs) were conducted to determine the effectiveness of EPC on the QoL of patients with advanced cancer. PubMed, ProQuest, MEDLINE through EBSCOhost and Cochrane Library and clinicaltrials.gov (register website) were searched for RCTs published before May 2022. Data synthesis used the Review Manager 5.4 to generate pooled estimates of effect size. A total of 12 empirical trials met the eligibility criteria and were included in this study. The results showed that EPC intervention had a significant effect (standard mean difference = 0.16, 95% confidence interval: 0.04, 0.28, Z = 2.68, P < 0.05). However, the secondary outcomes showed including mood (mean difference = -0.90, 95% CI: -2.32, 0.51, P > 0.05) and symptom controls (MD = -1.49, 95% CI: -3.81, 0.81, P > 0.05) had no significant effect. EPC is effective in improving the QoL of patients with advanced cancer. However, other outcomes still need to be reviewed, because the review of QoL is not enough to generalise the benchmarks for the effectiveness and optimisation of EPC interventions. Another notable aspect is to consider the most effective and efficient duration for starting and ending EPC interventions.

Palliative medicine favourably influences end-of-life cancer care intensity: a large retrospective database study

OBJECTIVES

Hospice and home palliative care have been associated to a reduction of aggressive treatments in the end-of-life, but data in the Italian context are scanty. Therefore, we aim to investigate the role of palliative care on indicators of end-of-life intensity of care among patients with cancer in Lombardy, the largest Italian region.

METHODS

Within a retrospective study using the healthcare utilisation databases of Lombardy, Italy, we selected all residents who died in 2019 with a diagnosis of cancer. We considered as exposure variables admission to palliative care and time at palliative care admission, and as indicators of aggressive care hospitalisations, diagnostic/therapeutic procedures, in-hospital death, emergency department visits and chemotherapy over a time window of 30 days before death; chemotherapy in the last 14 days was also considered.

RESULTS

Our cohort included 26 539 individuals; of these, 14 320 (54%) were admitted to palliative care before death. Individuals who were admitted to palliative care had an odds ratio (OR) of 0.27 for one hospitalisation, 0.14 for ≥2 hospitalisations, 0.25 for hospital stay ≥12 days, 0.38 for minor diagnostic/therapeutic procedures, 0.18 for major diagnostic/therapeutic procedures, 0.02 for in-hospital death, 0.35 for one emergency department visit, 0.29 for ≥2 emergency department visits and 0.66 for chemotherapy use in the last 30 days; the OR was 0.56 for chemotherapy use in the last 14 days.

CONCLUSIONS

This large real-world analysis confirms and further support the importance of palliative care assistance for patients with cancer in the end- of- life; this is associated to a significant reduction in unnecessary treatments.

Development of the palliative care referral system: proposal of a tool for the referral of cancer patients to specialized palliative care

BACKGROUND

Early palliative care (PC) has shown beneficial effects for advanced cancer patients. However, it is still debated what criteria to use to identify patients for PC referral.

AIM

To document the initial steps of the development of the Palliative Care Referral System (PCRS), a tool to be used by oncologists in clinical practice.

METHODS

A multiprofessional working group developed the PCRS based on the results of a scoping literature review on PC referral criteria. PCRS criteria were evaluated by experts via a nominal group technique (NGT). Descriptive statistics were used to summarize expert scores on relevance, appropriateness and perceived feasibility of the criteria proposed. Quotations of participants during the discussion were also reported.

RESULTS

Sixteen studies, including PC referral criteria/tools, emerged from the scoping review. Severe symptoms, poor performance status, comorbidities and prognosis were the most commonly used criteria. The PCRS included nine major criteria and nine assessment methods; a scoring procedure was also proposed. Answers to the questionnaire during the NGT showed that five criteria reached full agreement on all items, while four did not, and were then discussed within the group. Participants agreed on the relevance of all criteria and on the appropriateness of methods proposed to assess most of them, while issues were raised about potential feasibility of the overall assessment of the PCRS in clinical practice.

CONCLUSION

The PCRS has been developed as an help for oncologists to timely identify patients for specialized PC referral. Since feasibility emerged as the main concern, implementation strategies have to be tested in subsequent studies.

Outpatient palliative care referral system (PCRS) for patients with advanced cancer: an impact evaluation protocol

INTRODUCTION

Early palliative care (PC) in the clinical pathway of advanced cancer patients improves symptom control, quality of life and has a positive impact on overall quality of care. At present, standardised criteria for appropriate referral for early PC in oncology care are lacking. The aim of this project is to develop a set of standardised referral criteria and procedures to implement appropriate early PC for advanced cancer patients (the palliative care referral system, PCRS) and test its impact on user perception of quality of care received, on patient quality of life and on the use of healthcare resources.

SETTING

Selected oncology clinics and PC outpatient clinic.

METHODS AND ANALYSIS

A scoping literature review and an expert consultation through a nominal group technique will be used to revise existing referral tools and to develop a new one, the PCRS. 25 patients will be enrolled in a pilot study to assess feasibility of the implementation of PCRS; 10 interviews with patients and healthcare professionals will be carried out to evaluate applicability.A pretest-post-test quasiexperimental study involving 150 patients before implementation of the PCRS and 150 patients after implementation will be carried out.Patient satisfaction with care received, quality of life and use of resources, and caregiver satisfaction with care will also be assessed to explore the impact of the intervention.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the Institutional Review board of the Fondazione IRCCS Istituto Nazionale Tumori; approval reference INT201/19.Results will be disseminated through open access publications and through scientific communication presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04936568.

Simultaneous care in oncology: Assessment of benefit in relation to symptoms, sex, and age in 753 patients

BACKGROUND

Early activation of palliative care for patients with advanced cancer is central in the treatment trajectory. At the Veneto Institute of Oncology, a simultaneous-care outpatient clinic (SCOC) has been active since 2014, where patients are evaluated by an oncologist together with a palliative care team. Recently, we reported on consecutive patients admitted at SCOC from 2018 to 2021 in terms of appropriateness, process, and outcome indicators. Here, we report further analysis in the same group of 753 patients, evaluating other parameters and the correlation between symptom intensity, gender, age, and survival.

METHODS

SCOC data were retrieved from a prospectively maintained database.

RESULTS

Among the patients, 42.2% were women, and the median age was 68 years, with 46.7% of patients aged ≥70 years. The most prevalent disease type was gastrointestinal cancer (75.2%), and 90.9% of the patients had metastatic disease. The median score for the distress thermometer was 4; the vast majority of the patients (98.6%) reported physical problems, and 69.4% presented emotional issues. Younger women demonstrated a significantly greater median distress than other patients (p=0.0018). Almost all symptoms had a higher prevalence on the 0-3 Edmonton Symptom Assessment Scale (ESAS) score, except for fatigue. About 43.8% of the patients received systemic anticancer treatment (SAT) in the last 60 days of life, 15.0% of whom received SAT in the last month and 3.1% in the last 2 weeks. For some symptoms, women frequently had more ESAS >3. Pain and nausea were significantly less reported by older patients compared with younger adults. Men had a lower risk of having MUST score ≥ 2 (p=0.0311). Men and older patients showed a lower prognosis awareness (p=0.0011 and p=0.0049, respectively). Older patients received less SAT within the last 30 days of life (p=0.0006) and had death risk decreased by 20.0%.

CONCLUSION

Our study identified two subgroups of patients with advanced cancer who require special attention and support due to important symptoms' burden detected by Patient Reported Outcome Measures tests: women and younger adults. These categories of patients require special attention and should be provided early access at SCOC. The role of an oncologist remains crucial to intercept all patients in need of early palliative care and balancing trade-offs of anticancer treatment in advanced metastatic disease.

A Retrospective, Single-Center Analysis of Specialized Palliative Care Services for Patients with Advanced Small-Cell Lung Cancer

Simple Summary

Patients with advanced small-cell lung cancer (SCLC) have a considerable symptom burden and may require extensive care. A crucial element of treatment for these patients is the integration of specialized palliative care (SPC). Timely integration of SPC for patients with advanced non-small cell lung cancer (NSCLC) improved quality of life and prolonged survival in large prospective trials. This study provides retrospective data for patients with SCLC with, and without SPC. The results and conclusions indicate that patients with advanced SCLC should participate in a consultation with a SPC team in a timely manner to ensure a benefit of SPC for this patient group.

Abstract

Timely integration of specialized palliative care (SPC) has been shown to improve cancer patients’ quality of life (QoL) and reduced the use of medical services. To evaluate the level of integration of SPC services for patients with advanced small-cell lung cancer (SCLC), we retrospectively analyzed medical records of patients from 2019 to 2021. Regarding the timing of referral to SPC services, we defined four cutoffs for early referral according to the current literature: (a) SPC provided ≤ 60 days after diagnosis; (b) SPC provided ≥ 60 days before death; (c) SPC provided ≥ 30 days before death; and (d) SPC provided ≥ 130 days before death. One hundred and forty-three patients (94.1%) were found to have locally advanced (stage III) or metastatic (stage IV) disease. Sixty-eight were not referred to SPC services (47.6%), whereas 75 patients received SPC (52.4%). We found a significantly higher number of referrals to SPC services for patients with higher ECOG (Eastern Cooperative Oncology Group) (i.e., ECOG ≥ 2) (p = 0.010) and patients with stage IV disease (p ≤ 0.001). The median overall survival (OS) for SCLC stage III/IV patients (n = 143) who did not receive SPC treatment was 17 months (95% CI 8.5–25.5), while those who did receive SPC treatment had a median OS of 8 months (95% CI 6.2–9.8) (p = 0.014). However, when we evaluated patients receiving SPC treatment in a timely manner before death as suggested by the different cutoffs indicated in the literature, they lived significantly longer when referred at a minimum of ≥60 or ≥130 days before death. Based on our findings, we suggest that patients with advanced SCLC should participate in a consultation with a SPC team in a timely manner to ensure a benefit of SPC for this patient group.

Early integration of palliative care for patients with haematological malignancies

Early palliative care (EPC) significantly improves quality of life, symptoms, and satisfaction with care for patients with advanced cancer. International organizations have recognized and promoted the role of palliative care as a distinct specialty, advocating its involvement throughout the cancer trajectory. Although patients with haematologic malignancies (HMs) have a comparable symptom burden to patients with solid tumours, they face multiple barriers to EPC integration. In this review, we discuss these barriers, present updated evidence from clinical trials of EPC in HMs and propose models to support EPC integration into care for patients with HMs.

Palliative and Supportive Care for Individuals with Pancreatic Adenocarcinoma

Individuals with pancreatic adenocarcinoma experience a complex constellation of palliative and supportive care needs. Notably, when caring for patients with pancreatic adenocarcinoma, clinicians must carefully assess and address these individuals' palliative and supportive care needs, as these can have important implications related to their treatment experience and care outcomes. Importantly, prior research has consistently demonstrated the benefits of palliative and supportive care interventions for patients with cancer to help address symptom burden, illness understanding, coping mechanisms, and informed decision making. However, much of this research did not specifically tailor the interventions to the unique concerns of a pancreatic cancer population. Thus, an urgent need exists to design and conduct rigorous research with the goal of enhancing care delivery and outcomes for the highly symptomatic population of individuals with pancreatic adenocarcinoma.

Impact of palliative care on quality of life in advanced cancer: A meta-analysis of randomised controlled trials

INTRODUCTION

This study aimed to examine the impact of palliative care on the life quality of adults with advanced cancer.

METHODS

After a comprehensive and regular search using [MeSH] keywords in some important databases, 25 published randomised controlled trials (RCTs) involving 5160 adults with advanced cancer were selected and examined through meta-analysis.

RESULTS

Analysis of 36 reports in 1-3 months follow-up, and 19 reports in 4-7 months follow-up, showed that compared to usual care (g = 0.25; 95%CI: 0.1 to 0.41), palliative care had a significant impact on quality of life (QOL) (g = 0.1; 95%CI: 0.019 to 0.18) of advanced cancer patients. Also, based on the analysis of 15 reports on outpatients (g = 0.27; 95%CI: 0.04 to 0.4), 10 reports of early (g = 0.27; 95%CI: 0.029 to 0.52), and 8 reports of end-of-life (g = 0.24; 95%CI: 0.06 to 0.47) palliative care in 4-7 months follow-up, a significant impact on life quality was shown. However, in four reports, the impact of palliative care on health related quality of life in ≥10 months follow-up (g = 0.19; 95%CI: -0.03 to 0.42) was not significant.

CONCLUSION

Systematic QOL assessment with valid tool in palliative care setting would establish quality assurance and could further develop the application of this pretty new discipline in oncology care worldwide.

Lesson Learned From Hospital Palliative Care Service in a Cancer Research Center in Italy: Results of 5 Years of Experience

Background

International studies have documented that over a third of all hospital beds are occupied by patients with palliative care needs in their last year of life. Experiences of Palliative Care Services that take place prevalently or exclusively in hospital settings are very few in Italy.

Objective

Describe clinical, educational and research activities performed by a hospital PCS and discussing opportunities and critical issues encountered in an Italian Cancer Center.

Method

Retrospective data regarding adults with advanced stage diseases referred from January 2015 to December 2019.

Results

Clinical activity - The PCS performed 2422 initial consultations with an average of 484 initial consultations per year. A majority of patients had advanced cancer, from 85% to 72%, with an average of 2583 total consultations per year and an average of 4.63 consultations per patient. The penetrance has increased over time from 6.3% to 15.75%. Educational and research activity - Since 2015, PCS has provided training to health professionals (HPs) of different departments of our hospital. Most of the educational projects for HPs were part of research projects, for example the communication training program, management of pain and end-of-life symptoms and the training program for PC-based skills.

Conclusion

Our data suggests that a PCS able to provide palliative care to inpatients and outpatient and continuous training support to other hospital specialists can relatively quickly improve the level of its penetrance in hospital activities.

Towards a novel approach guiding the decision-making process for anticancer treatment in patients with advanced cancer: framework for systemic anticancer treatment with palliative intent

Background

Weighing risks and benefits is currently the primary criterion for decisions regarding systemic anticancer treatment (SACT) in far advanced cancer patients, also in the modern immunotherapy- and molecular-targeted driven oncology. Decision aids rarely include substantially key concepts of early integrated palliative care (PC) and communication science. We compiled decisional factors (DFs) important for guiding the use of SACT with palliative intent (SACT-PI) and explored these DFs regarding their applicability in routine clinical care.

Patients and methods

Clinician (participants: n = 28) and patient (n = 15) focus groups were conducted in an integrated oncology and PC setting. Thematic analysis was used to identify DFs. A Delphi survey of clinicians ranked the importance of DFs in routine decision-making. DFs were aligned with elements of the typical decision-making process, resulting in an eight-step guide for making SACT-PI decisions in clinical practice.

Results

Eight focus groups revealed 55 DFs relating to established topics like providing information and risk–benefit analysis, as well as to PC topics like patients’ attitudes, beliefs, and hopes; patient–physician interaction; and physician attitudes. Agreement on the relative importance was reached for 34 (62%) of 55 DFs, assigned to five elements: patient/family, clinicians/system, patient-clinician-interaction, information/patient education, risk–benefit weighting/actual decision. These themes are embedded in a potential clinically useful SACT-PI Decision Framework, which includes eight steps: assess, educate, verify, reflect, discuss, weigh, pause, and decide.

Conclusions

The SACT-PI Decision Framework integrates subjective patient factors, interpersonal factors, and PC issues into decision-making. Our findings complement existing decision aids and prompt lists by framing DFs in the context of SACT-PI and enforce the decision ‘process’, not the decision act. Further research is needed to explore the relative importance of DFs in specific patient situations and test structured decision-making processes, such as our SACT-PI Decision Framework, against standard care.

•

Patient-centered decisions in advanced cancer care demand a stepwise decisional process, not a single decision act.

•

The decision process includes key palliative care domains, e.g. illness understanding, symptom control, or end-of-life preparation.

•

Patients’ attitudes, beliefs, hopes, patient–physician interaction, and physician attitudes demand structured observation.

•

The SACT-PI Decision Framework includes concrete steps: assess, educate, verify, reflect, discuss, weigh, pause, decide.

•

Interprofessionally working oncology clinicians may transform decision-making processes in oncology beyond decision aids.

Improving Palliative Care and Quality of Life in Pancreatic Cancer Patients

Background: Pancreatic cancer patients often present with complications, which can impact treatment tolerance. Thus, symptom management is a vital component of treatment in addition to traditional chemotherapeutics. Concurrent palliative care with an emphasis on aggressive symptom management may sustain both clinical and patient-centered outcomes during treatment. The purpose of this article is to explore the impact of a concurrent palliative care intervention in patients with pancreatic cancer treated on phase I clinical trials. Materials and Methods: This is a secondary analysis of a National Cancer Institute (NCI)-funded randomized trial of an advanced practice nurse driven palliative care intervention for solid tumor patients treated on phase I clinical trials. Only pancreatic cancer patients were included in the analysis. Patients received two educational sessions around the quality of life (QOL) domains and completed the Functional Assessment of Cancer Therapy-General (FACT-G), patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE), and the psychological distress thermometer at baseline, 4 and 12 weeks. Mixed model with repeated measures analysis was used to explore outcomes by study arm. Results: Of the 479 patients accrued to the study, 42 were diagnosed with pancreatic cancer (26 intervention, 16 usual care). A trend toward improvement in the physical, social, emotional, and functional FACT-G QOL subscales and psychological distress (baseline to 12 weeks) were observed for the intervention arm. Patients reported moderate severity in psychological and physical stress. Conclusions: In this secondary analysis, a nurse-led palliative care intervention may improve the QOL and psychological distress of pancreatic cancer patients. A phase III trial focused on patients with pancreatic cancer is needed to determine the effectiveness of the intervention.

Intensive end-of-life care in acute leukemia from a French national hospital database study (2017–2018)

Background

A better understanding of how the care of acute leukemia patients is managed in the last days of life would help clinicians and health policy makers improve the quality of end-of-life care. This study aimed: (i) to describe the intensity of end-of-life care among patients with acute leukemia who died in the hospital (2017–2018) and (ii) to identify the factors associated with the intensity of end-of-life care.

Methods

This was a retrospective cohort study of decedents based on data from the French national hospital database. The population included patients with acute leukemia who died during a hospital stay between 2017 and 2018, in a palliative care situation (code palliative care Z515 and-or being in a inpatient palliative care support bed during the 3 months preceding death). Intensity end-of-life care was assessed using two endpoints: High intensive end-of-life (HI-EOL: intensive care unit admission, emergency department admission, acute care hospitalization, intravenous chemotherapy) care and most invasive end-of-life (MI-EOL: orotracheal intubation, mechanical ventilation, artificial feeding, cardiopulmonary resuscitation, gastrostomy, or hemodialysis) care.

Results

A total of 3658 patients were included. In the last 30 days of life, 63 and 13% of the patients received HI-EOL care and MI-EOL care, respectively. Being younger, having comorbidities, being care managed in a specialized hospital, and a lower time in a palliative care structure were the main factors associated with HI-EOL.

Conclusions

A large majority of French young adults and adults with acute leukemia who died at the hospital experienced high intensity end-of-life care. Identification of factors associated with high-intensity end-of-life care, such as the access to palliative care and specialized cancer center care management, may help to improve end-of-life care quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00937-0.

When does early palliative care influence aggressive care at the end of life?

BACKGROUND

Early palliative care improves patient quality of life and influences cancer care. The time frame of early has not been established. Eight quality measures reflect aggressive care at the end of life. We retrospectively reviewed patients who died with cancer between January 1, 2018, through December 31, 2019, and compared the timing of palliative care consultation, advance directives (AD), and home palliative care with aggressive care at the end of life (ACEOL).

METHODS

Patients without ACEOL indicators were compared to patients with one or more than one indicator of ACEOL. The proportion of patients who received palliative care, completed AD, and the timing of palliative care and AD (less than 30 days, 30-90 days, and greater than 90 days prior to death) was compared for patients who had ACEOL versus those who did not. Chi-square analysis was used for categorical data, one-way ANOVA for continuous variables, and odds ratio (OR) with confidence intervals (CI) was reported as a measure of effect size. A p value ≤ 0.05 was considered significant.

RESULTS

1727 patients died, 46% were female, and the mean age was 69 (SD 11.91). Seventy-one percent had a palliative care consult, 26% completed AD, and 888 (51.4%) had at least one indicator of ACEOL. The most common indicator of ACEOL was new chemotherapy within 30 days of death, in 571 of 888 (64%) of patients experiencing ACEOL. ADs completed at any time reduced ACEOL (OR 0.80, 95%CI 0.64-0.99). Palliative care initiated at 30 days was associated with a greater risk of ACEOL (OR 5.32, 95% CI 3.94-7.18) and initiated between 30 and 90 days (OR 1.39, 95% CI 1.07-1.80) compared to no palliative care but was associated with reduced chemotherapy as an indicator of ACEOL when > 90 days (OR 0.46, 95% CI 0.38-0.57) before death.

DISCUSSION

Completed ADs were associated with reduced chemotherapy in the last 30 days of life and reduced ICU admissions. This may reflect goals of care and end-of-life discussions and transition of care to comfort measures. Palliative care paradoxically when initiated within 90 days before death was associated with greater ACEOL compared to no palliative care. This may be due to consultation late in the course of illness with a focus on crisis management in patients frequently utilizing the health care system. There is an associated reduction in the use of chemotherapy in the last 30 days of life if palliative care is consulted 90 days prior to death.

CONCLUSIONS

An initial palliative care consult greater than 90 days before death and ADs completed at any time during the disease trajectory was associated only with reduced chemotherapy in the last 30 days of life compared with no palliative care among the 7 ACEOL indicators. ADs were associated with reduced ICU admissions. Most palliative care consults occurred within 90 days of death and a palliative care consult within 90 days of death is not an optimal utilization of services.

How aging of the global population is changing oncology

Population aging is causing a demographic redistribution with implications for the future of healthcare. How will this affect oncology? First, there will be an overall rise in cancer affecting older adults, even though age-specific cancer incidences continue to fall due to better prevention. Second, there will be a wider spectrum of health functionality in this expanding cohort of older adults, with differences between “physiologically older” and “physiologically younger” patients becoming more important for optimal treatment selection. Third, greater teamwork with supportive care, geriatric, mental health and rehabilitation experts will come to enrich oncologic decision-making by making it less formulaic than it is at present. Success in this transition to a more nuanced professional mindset will depend in part on the development of user-friendly computational tools that can integrate a complex mix of quantitative and qualitative inputs from evidence-based medicine, functional and cognitive assessments, and the personal priorities of older adults.

Timely Palliative Care: Personalizing the Process of Referral

Timely palliative care is a systematic process to identify patients with high supportive care needs and to refer these individuals to specialist palliative care in a timely manner based on standardized referral criteria. It requires four components: (1) routine screening of supportive care needs at oncology clinics, (2) establishment of institution-specific consensual criteria for referral, (3) a system in place to trigger a referral when patients meet criteria, and (4) availability of outpatient palliative care resources to deliver personalized, timely patient-centered care aimed at improving patient and caregiver outcomes. In this review, we discuss the conceptual underpinnings, rationale, barriers and facilitators for timely palliative care referral. Timely palliative care provides a more rational use of the scarce palliative care resource and maximizes the impact on patients who are offered the intervention. Several sets of referral criteria have been proposed to date for outpatient palliative care referral. Studies examining the use of these referral criteria consistently found that timely palliative care can lead to a greater number of referrals and earlier palliative care access than routine referral. Implementation of timely palliative care at each institution requires oncology leadership support, adequate palliative care infrastructure, integration of electronic health record and customization of referral criteria.

The Effect of Palliative Invasive Interventions on Overall Survival in the Last 3 Months of Life in Metastatic Gastric Cancer

PURPOSE

Gastric cancer is one of the biologically aggressive and highly mortal cancers. In addition to limited treatment options, especially in advanced stages, palliative treatment methods are applied to increase patients' quality of life with gastric cancer. This study aims to discuss the effects of paracentesis, thoracentesis, tube thoracostomy, double J catheter nephrostomy, percutaneous transhepatic cholangiography (PTC), and abscess drainage catheter placement procedures applied in the last 3 months for problems requiring palliation, in the light of literature.

METHOD

The patient characteristics of the patients and, in addition, the history of any invasive intervention for palliative treatment in the last 3 months were questioned and recorded with the electronic medical record system. The effect of an invasive intervention on survival was examined. The data of patients with metastatic gastric cancer followed in the medical oncology clinic between February 2012 and May 2020 were reviewed retrospectively.

CONCLUSIONS

In this study, in which the effect of palliative invasive intervention (PIG) stories on survival in the last 3 months of life of patients diagnosed with metastatic gastric cancer was examined, no significant difference was found between those who underwent PIG and those who did not, in terms of overall survival. However, since PIG was not included in the design of our study, the effect of PIG in terms of quality of life, mood, motivation of patient relatives, and the cost is unknown.

RESULTS

In the final analysis, it was noted that 143 (94.1%) of the 152 patients included in the study died and 9 (5.9%) were still alive. Overall survival of all patients was reported as 12.9 months (95% CI, 10.9-14.9). The mean overall survival of 36 patients who underwent palliative invasive intervention (PIG) in the last 3 months was 13.0 months (95% CI, 9.1-17.0), and a similar 13.0 months (95% CI, 10.6-15.3) of 116 patients who did not undergo PIG no significant difference was found (p: 0.887).

Early specialized palliative care for patients with metastatic lung cancer receiving chemotherapy: a feasibility study of a nurse-led screening-triggered programme

BACKGROUND

Strategies to implement early specialized palliative care have not yet been established. The present study investigated the feasibility of a nurse-led, screening-triggered early specialized palliative care intervention programme and obtained data to design a randomized controlled trial.

METHODS

Patients with metastatic lung cancer undergoing first-line platinum-based chemotherapy were eligible. The intervention consisted of (1) a questionnaire-based screening programme and (2) advanced-level nurse counselling and care coordination with interdisciplinary team approach. The primary endpoint was the completion rate of the assessment questionnaire after the second course of first-line chemotherapy (T2). Secondary endpoints included changes in Functional Assessment of Cancer Therapy-Lung scores, depression and anxiety rates based on the Patient Health Questionnaire 9 and the Hospital Anxiety and Depression Scale, and the contents of specialized palliative care.

RESULTS

A total of 50 patients were enrolled between August 2012 and March 2014. Median age was 66 years (range, 40-78 year) and 84% were male. A total of 38 patients had stage IV non-small cell lung carcinoma and 12 had extensive disease small-cell lung carcinoma. The completion rate was 70% (95% confidence interval 56.0-81.0). The median duration between baseline and T2 was 53 days. Improvement from baseline were observed at T2 in Functional Assessment of Cancer Therapy-Lung scores (86.0 ± 18.1 vs 94.9 ± 18.2, P = 0.057), depression (16.0 vs 5.7%; P = 0.26) and anxiety (32.0 vs 22.9%; P = 0.65); however, these results were not statistically significant.

CONCLUSIONS

This early specialized palliative care intervention is feasible and could be useful in improving patients' quality of life. The present results justify the initiation of a randomized control trial.

Evolving pancreatic cancer treatment: From diagnosis to healthcare management

The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.

Effects of molecular targeting agents and immune-checkpoint inhibitors in patients with advanced cancer who are near the end of life

BACKGROUND

In recent years, the use of both molecular targeting agents (MTAs) and immune-checkpoint inhibitors (ICIs) tend to occupy important positions in systemic anticancer therapy (SACT). The objective of this study is to describe the predictors of SACT include both MTAs and ICIs near the end of life (EOL) and the effect on EOL care in patients with advanced cancer.

METHODS

We analyzed all patients who died of advanced cancer from August 2016 to August 2019, and we analyzed the survival time of patients who underwent anticancer agents excluded due to the loss of information about the last administration of SACT. The primary endpoint of this study was to identify predictors during the last administration of SACT near EOL.

RESULTS

In a multivariate analysis, the Eastern Cooperative Oncology Group performance status (ECOG-PS) (ORs 33.781) was significantly related factors within 14 days of death from the last administration of SACT. Age (ORs 0.412), ECOG-PS (ORs 11.533), primary cancer site of upper GI cancers (ORs 2.205), the number of comorbidities (ORs 0.207), MTAs (ORs 3.139), and ICIs (ORs 3.592) were significantly related factors within 30 days of death. The median survival time (MST) of patients with PS 3-4 was 29 days, while that of patients with both PS 0-2 was 76 days. The prevalence rate of delirium with MTAs was 17.5%, which was significantly lower than that of patients without it (31.8%). The prevalence rate of the mean dose of opioids in patients with ICIs was 97.9 mg/day, which was significantly higher than that of patients without it (44.9 mg/day).

CONCLUSIONS

Age, ECOG-PS, primary cancer site, the number of comorbidities, MTAs, and ICIs use were significant associated with SACT near EOL. Information on these factors may aid clinical decision making in referral to palliative care institutes.

Impact of Early Palliative Care on End-of-Life Outcomes in Hematologic Malignancies

Background: Patients with hematologic malignancies (HMs) receive more disease directed care at the end of life (EOL) and often die in the hospital. The impact of early palliative care (PC) consultation on EOL quality outcomes in HMs has not been well described. Objectives: In 2017 we embedded a PC specialist within our inpatient malignant hematology team at our hospital in Providence, Rhode Island to facilitate the use of early PC. We sought to determine if this practice was accompanied by a shift in EOL outcomes. Design/Setting: We conducted a retrospective review of patients diagnosed with acute myeloid leukemia (AML) at our institution in the two years before (Cohort A) and after (Cohort B) insertion of a PC specialist. We identified patients who received a PC consultation and whether it was early or late. We then examined EOL quality outcomes: hospitalizations and intensive care unit (ICU) admissions in the last 30 days of life, chemotherapy use in the last 14 days of life, use of hospice, and death out of hospital. Results: Among 139 AML patients, 46 in Cohort A and 93 in Cohort B, we identified 34 and 47 decedents in each cohort, respectively. There was no significant improvement in EOL outcomes between Cohort A and B or among patients receiving early PC (p > 0.05); however, PC in general across all cohorts was associated with significant increase in hospice use and fewer ICU admissions (p = 0.016 and 0.0043, respectively). Conclusion: Earlier PC consultation in AML was not significantly associated with improvement in EOL quality outcomes; however, PC use in general was with improvement in use of hospice and ICU utilization. Further studies are needed to more definitively examine the relationship between early PC and EOL outcomes in patients with HMs and to examine non EOL outcomes such as patient experience and quality-of-life measures.

Specialist palliative care teams and characteristics related to referral rate: a national cross-sectional survey among hospitals in the Netherlands

Background

Specialist palliative care teams (SPCTs) in hospitals improve quality of life and satisfaction with care for patients with advanced disease. However, referrals to SPCTs are often limited. To identify areas for improvement of SPCTs’ service penetration, we explored the characteristics and level of integration of palliative care programmes and SPCTs in Dutch hospitals and we assessed the relation between these characteristics and specialist palliative care referral rates.

Methods

We performed a secondary analysis of a national cross-sectional survey conducted among hospitals in the Netherlands from March through May 2018. For this survey, a previously developed online questionnaire, containing 6 consensus-based integration indicators, was sent to palliative care programme leaders in all 78 hospitals. For referral rate we calculated the number of annual inpatient referrals to the SPCT as a percentage of the number of total annual hospital admissions. Referral rate was dichotomized into high (≥ third quartile) and low (< third quartile). Characteristics of SPCTs with high and low referral rate were compared using univariate analyses. P-values < 0.05 were considered significant.

Results

In total, 63 hospitals (81%) participated in the survey, of which 62 had an operational SPCT. The palliative care programmes of these hospitals consisted of inpatient consultation services (94%), interdisciplinary staffing (61%), outpatient clinics (45%), dedicated acute care beds (21%) and community-based palliative care (27%). The median referral rate was 0.56% (IQR 0.23–1.0%), ranging from 0 to 3.7%. Comparing SPCTs with high referral rate (≥1%, n = 17) and low referral rate (< 1%, n = 45) showed significant differences for SPCTs’ years of existence, staffing, their level of education, participation in other departments’ team meetings, provision of education and conducting research. With regard to integration, significant differences were found for the presence of outpatient clinics and timing of referrals.

Conclusion

In the Netherlands, palliative care programmes and specialist palliative care teams in hospitals vary in their level of integration and development, with more mature teams showing higher referral rates. Appropriate staffing, dedicated outpatient clinics, education and research appear means to improve service penetration and timing of referral for patients with advanced diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00875-3.

The effect of an educational palliative care intervention on the quality of life of patients with incurable cancer and their caregivers

PURPOSE

The study aims to determine the effect of educational intervention provided to caregivers of hospitalized patients with terminal cancer theoretically, practically, and visually on their own and patients' quality of life.

METHODS

This quasi-experimental study was conducted at a palliative care unit in Turkey between January and June 2019. The study included 35 hospitalized patients with cancer and 35 caregivers. Caregivers were provided with educational intervention three times a week apart. The data were analyzed using descriptive statistics, Kolmogorov-Smirnov test, Friedman test, and iterative analysis of variance.

RESULTS

After the educational intervention, there was an increase in cancer patients' emotional function sub-scale and global health and decrease in their fatigue and nausea-vomiting symptoms (p<0.05). The mean scores of caregivers from role difficulty, pain, vitality, social function, emotional, and mental health sub-scales were high (positively) (p<0.001).

CONCLUSIONS

Educational intervention has a positive effect on caregiver burden and recovery in some quality of life sub-scales of both patients and caregivers.

Effect of Early Palliative Care on Quality of Life of Advanced Head and Neck Cancer Patients: A Phase III Trial

BACKGROUND

Early palliative care (EPC) is an important aspect of cancer management but, to our knowledge, has never been evaluated in patients with head and neck cancer. Hence, we performed this study to determine whether the addition of EPC to standard therapy leads to an improvement in the quality of life (QOL), decrease in symptom burden, and improvement in overall survival.

METHODS

Adult patients with squamous cell carcinoma of the head and neck region planned for palliative systemic therapy were allocated 1:1 to either standard systemic therapy without or with comprehensive EPC service referral. Patients were administered the revised Edmonton Symptom Assessment Scale and the Functional Assessment of Cancer Therapy for head and neck cancer (FACT-H&N) questionnaire at baseline and every 1 month thereafter for 3 months. The primary endpoint was a change in the QOL measured at 3 months after random assignment. All statistical tests were 2-sided.

RESULTS

Ninety patients were randomly assigned to each arm. There was no statistical difference in the change in the FACT-H&N total score (P = .94), FACT-H&N Trial Outcome Index (P = .95), FACT-general total (P = .84), and Edmonton Symptom Assessment Scale scores at 3 months between the 2 arms. The median overall survival was similar between the 2 arms (hazard ratio for death = 1.01, 95% confidence interval = 0.74 to 1.35). There were 5 in-hospital deaths in both arms (5.6% for both, P = .99).

CONCLUSIONS

In this phase III study, the integration of EPC in head and neck cancer patients did not lead to an improvement in the QOL or survival.

Palliative Care Unit at Home: Impact on Quality of Life in Cancer Patients at the End of Life in a Rural Environment

INTRODUCTION

Advanced cancer is accompanied by a substantial burden of symptoms, and palliative care (PC) plays an essential role, especially at the end of life (EOL). In fact, a comprehensive PC through Home Palliative Care Units (HPCU) has been associated with reducing potentially aggressive care at the EOL. We aim to study the impact of HPCU on the quality of assistance of cancer patients at Alcoy Health Department.

METHODS

A retrospective study was conducted including patients diagnosed with terminal cancer at the Medical Department of Hospital Virgen de los Lirios who died between January 2017 and December 2018. The Multivariate Cox regression model was used to assess the impact of HPCU assistance on the quality of life indicators.

RESULTS

388 patients were included. The median age was 71 years; 65% patients were male, and 68% presented with a 0-2 score on the ECOG scale. On the multivariate analysis, a lack of assistance by HPCU was associated with a higher risk of consulting in the emergency department (OR = 1.29, 95% CI: 1.02-1.67), of hospital admissions (OR = 4.72, 95% CI: 2.45-9.09), a higher probability of continuing active treatment (OR = 2.59, 95% CI: 1.44-4.67), and a greater probability of dying in hospital (OR = 6.52, 95% CI: 3.78-11.27).

CONCLUSIONS

Patients receiving HPCU assistance have a lower number of emergency room visits and hospital admissions, and are more likely to die at home. Taken together, these results support the relevance of HPCU providing a high quality attention of cancer patients.

Single early palliative care intervention added to usual oncology care for patients with advanced cancer: A randomized controlled trial (SENS Trial)

BACKGROUND

International oncology societies recommend early palliative care. Specific models to integrate early palliative care efficiently into clinical practice are debated. The authors designed a study to look at the quantitative and qualitative outcomes of an early palliative care intervention in oncological care to decrease stress and improve quality of life.

AIMS

To compare a single structured early palliative care intervention added to a usual oncology care in terms of distress and health-related quality of life at baseline compared to 6 months after enrollment.

DESIGN

This multicenter randomized controlled trial (NCT01983956) enrolled adult patients with advanced cancer. Participants were either randomly assigned to usual oncology care alone or usual care plus a structured early palliative care intervention.

SETTING/PARTICIPANTS

One hundred fifty adult patients with a variety of advanced cancer diagnoses were randomized. Seventy-four participants were in the intervention and 76 participants in the control group. The primary outcome was the change in patient distress assessed by the National Comprehensive Cancer Network distress thermometer at 6 months. Health-related quality of life, the secondary outcome, was assessed by the Functional Assessment of Cancer Therapy-General Questionnaire.

RESULTS

The results showed no significant effect of the early palliative care intervention neither on patient distress nor on health-related quality of life.

CONCLUSION

The addition of an early intervention to usual care for patients with advanced cancer did not improve distress or quality of life. Thus, patients may need more intensive early palliative care with continuous professional support to identify and address their palliative needs early.

Care plus study: a multi-site implementation of early palliative care in routine practice to improve health outcomes and reduce hospital admissions for people with advanced cancer: a study protocol

Background

Current international consensus is that ‘early’ referral to palliative care services improves cancer patient and family carer outcomes. In practice, however, these referrals are not routine. An approach which directly addresses identified barriers to early integration of palliative care is required. This protocol details a trial of a standardized model of early palliative care (Care Plus) introduced at key defined, disease-specific times or transition points in the illness for people with cancer. Introduced as a ‘whole of system’ practice change for identified advanced cancers, the key outcomes of interest are population health service use change.

The aims of the study are to examine the effect of Care Plus implementation on (1) acute hospitalisation days in the last 3 months of life; (2) timeliness of access to palliative care; (3) quality and (4) costs of end of life care; and (5) the acceptability of services for people with advanced cancer.

Methods

Multi-site stepped wedge implementation trial testing usual care (control) versus Care Plus (practice change). The design stipulates ‘control’ periods when usual care is observed, and the process of implementing Care Plus which includes phases of planning, engagement, practice change and evaluation. During the practice change phase, all patients with targeted advanced cancers reaching the transition point will, by default, receive Care Plus.

Health service utilization and unit costs before and after implementation will be collated from hospital records, and state and national health service administrative datasets. Qualitative data from patients, consumers and clinicians before and after practice change will be gathered through interviews and focus groups.

Discussion

The study outcomes will detail the impact and acceptability of the standardized integration of palliative care as a practice change, including recommendations for ongoing sustainability and broader implementation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN 12619001703190. Registered 04 December 2019.