Symptoms at presentation for treatment in patients with lung cancer: implications for the evaluation of palliative treatment. The Medical Research Council (MRC) Lung Cancer Working Party

An Integrative Medicine Educational Program for Radiation Oncology Patients: Patient-Reported Outcomes

Purpose

Complementary health approaches (CHAs) equip patients to self-manage radiation therapy (RT)-related symptoms and fulfill unmet needs, but few disclose CHA use to their radiation oncologist. An integrative medicine educational program (IMEP) was developed to assess its ability to improve patient self-efficacy for symptom management and CHA use disclosure.

Methods and Materials

The IMEP included 4 1-hour sessions covering topics of (1) meditation, (2) yoga, (3) massage therapy, and (4) nutrition. Individuals over age 18 years and actively receiving RT were administered presession and postsession surveys. The primary outcomes were intention to disclose CHA use and self-efficacy. Qualitative data were assessed with a thematic approach.

Results

Overall, 23 patients attended 1 or more sessions, yielding 43 completed surveys. Compared with 35.9% of participants who had disclosed CHA use before the session, 67.4% intended to disclose after the session. Of the 5 self-efficacy statements, there were significant improvements in "I have ownership over my health" (increase of 0.42; 95% CI, 0.07-0.77; P = .01), "I have tools to manage my disease on my own" (1.14; 95% CI, 0.42-1.87; P = .001), and "I have control over my cancer" (0.96; 95% CI, 0.39-1.53; P < .001). Barriers to involvement included transportation, timing relative to RT appointment, and poor performance status.

Conclusions

A radiation-specific IMEP resulted in a high rate of intention to disclose CHA use and improvements in patients' reported self-efficacy to manage radiation-related symptoms. However, substantial resources were needed to deliver the IMEP. Future work must focus on increasing accessibility through telehealth and flexible timing.

Promoting moderate-to-vigorous physical activities in patients with advanced lung cancer: preferences and social cognitive factors, and the mediating roles

PURPOSE

The purpose of this study is to assess the prevalence and preferences of moderate-to-vigorous physical activities (MVPA) in patients with advanced lung cancer, explore the social cognitive factors that were associated with MVPA and interest in PA counseling and program, and examine the mediating role of social cognitive factors.

METHODS

This was a cross-sectional study. Questionnaires on PA levels, PA counseling and programming preferences, and social cognitive variables (social support and self-efficacy) were administered to 105 patients with advanced lung cancer. Linear regression model was used to explore the social cognitive factors associated with MVPA, and logistic regression model was used to explore the factors associated with interest in PA counseling and program. Mediation analysis was used to examine the mediating role of self-efficacy on social support and MVPA.

RESULTS

Merely 30.5% of patients met the recommended level of MVPA; however, the majority of patients (89.5%) were interested in PA program. Social support (β = 0.60; p = 0.007) and self-efficacy (β = 1.06; p = 0.027) were positively associated with MVPA. Specifically, self-efficacy mediated the relationship between social support and MVPA (β = 0.63, p = 0.004).

CONCLUSION

The majority of the patients with advanced lung cancer did not meet the recommended level of MVPA; however, they are interested in receiving PA counseling and joining PA programs. Social support was key to promoting higher levels of MVPA, and the association was mediated by self-efficacy. The established mediating model provides insights into designing PA programs and targeting the mediating variable, self-efficacy, to enhance the level of MVPA.

The Effect of Thoracic Radiotherapy on the Quality of Life in Lung Cancer Patients

Introduction

This study aimed to investigate changes in respiratory symptoms and quality of life (QoL) in patients with locally advanced and metastatic lung cancer receiving thoracic radiotherapy (RT). We investigated the correlation between the level of symptom relief and tumor response.

Methods

Thirty-two patients were included in this study. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QoL) Questionnaire (QLQ)-C30 and EORTC QLQ-LC13 were used to investigate QoL changes. Assessments were performed on the first day of RT, on the last day of RT, routinely monthly follow-ups, and three months after RT.

Results

The median age of the patients was 62; 88% of the patients were male. For the symptom scale, fatigue and dyspnea provided significant improvement at the end of RT (p=0.000, p=0.047). No significant improvement was observed at the end of RT in pain and insomnia. While coughing showed substantial improvement at the end of RT (p=0.004), the maximum improvement was achieved during the third-month follow-up (p<0.001). No significant improvement was observed at the end of RT in hemoptysis, but a considerable improvement was observed during the third-month follow-up (p=0.008).

Conclusion

This study confirms that RT offered palliation of respiratory symptoms and improved QoL in a substantial proportion of patients with lung cancer.

Safety and Patient-Reported Outcomes of Atezolizumab Plus Chemotherapy With or Without Bevacizumab Versus Bevacizumab Plus Chemotherapy in Non-Small-Cell Lung Cancer

PURPOSE

Atezolizumab, bevacizumab, carboplatin, and paclitaxel (ABCP) demonstrated survival benefit versus bevacizumab, carboplatin, and paclitaxel (BCP) in chemotherapy-naïve nonsquamous non–small-cell lung cancer (NSCLC). We present safety and patient-reported outcomes (PROs) to provide additional information on the relative impact of adding atezolizumab to chemotherapy with and without bevacizumab in nonsquamous NSCLC.

METHODS

Patients were randomly assigned to receive atezolizumab, carboplatin, and paclitaxel (ACP), ABCP, or BCP. Coprimary end points were overall survival and investigator-assessed progression-free survival. The incidence, nature, and severity of adverse events (AEs) were assessed. PROs, a secondary end point, were evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-Core 30 and EORTC QLQ-Lung Cancer 13.

RESULTS

Overall, 400 (ACP), 393 (ABCP), and 394 (BCP) patients were safety evaluable (ie, intention-to-treat population that received one or more doses of any study treatment). More patients had grade 3/4 treatment-related AEs during the induction versus maintenance phase (ACP, 40.5% v 8.2%; ABCP, 48.6% v 21.2%; BCP, 44.7% v 11.1%). During induction, the incidence of serious AEs (SAEs) was 28.3%, 28.5%, and 26.4% in the ACP, ABCP, and BCP arms, respectively. During maintenance, SAE incidences were 20.0%, 26.3%, and 13.0%, respectively. Completion rates of the PRO questionnaires were > 88% at baseline and remained ≥ 70% throughout most study visits. Across arms, patients on average reported no clinically meaningful worsening of global health status or physical functioning scores through cycle 13. Patients across arms rated common symptoms with chemotherapy and immunotherapy similarly.

CONCLUSION

ABCP seems tolerable and manageable versus ACP and BCP in first-line nonsquamous NSCLC. Treatment tolerability differed between induction and maintenance phases across treatment arms. PROs reflect a minimal treatment burden (eg, health-related quality of life, symptoms) with each regimen.

Patterns of Symptom Distress in Adults Receiving Treatment for Lung Cancer

Knowledge of the patterns of symptom distress in adults receiving treatment for lung cancer is an important first step in developing interventions that can potentially lessen symptom distress. The purposes of this secondary analysis were to describe the changes in patterns of symptom distress over time in adults receiving treatment for lung cancer, and to examine the relationship of selected demographic and clinical characteristics to symptom distress. Complete data were available for 117 patients. The patterns of symptom distress in adults receiving treatment for lung cancer varied between treatment groups and over time. Symptom distress scores were moderate to high on entry into the study, indicating that symptom management in newly diagnosed lung cancer patients is essential and should begin early in the course of illness. Moreover, clinical interventions should be tailored to the type of treatment. Various demographic and clinical variables were weak and inconsistent predictors of symptom distress, underscoring the importance of examining the role of psychosocial factors in mediating symptom distress.

A Report of an Investigation of End-of-Life Care Practices in Health Care Facilities and the Influences on those Practices

In 1992, 82.2% of deaths in Alberta occurred in acute care hospitals or continuing care facilities. This paper outlines the end-of-life care of adult in patients who died that year in four such facilities (n=137). CPR was an infrequent end-of-life treatment modality (2.9%), in stark contrast to the extensive use of other medical technologies. Almost every inpatient (94.2%) died with one or more technologies in continuous operation. Although reasons were infrequently given, the desire to promote patient comfort was the most frequent influence on end-of-life technology use. The findings of this study raise issues for debate and further investigation. Chief among these issues is whether or not medical technologies promote comfort during the dying process.

Assessment of baseline symptom burden in treatment-naïve patients with lung cancer: an observational study

BACKGROUND

Patients with newly diagnosed lung cancer who have not yet begun treatment may already be experiencing major symptoms produced by their disease. Understanding the symptomatic effects of cancer treatment requires knowledge of pretreatment symptoms (both severity and interference with daily activities). We assessed pretreatment symptom severity, interference, and quality of life (QOL) in treatment-naïve patients with lung cancer and report factors that correlated with symptom severity.

METHODS

This was a retrospective analysis of data collected at initial intake. Symptoms/interference were rated on the MD Anderson Symptom Inventory (MDASI) between 30 days prediagnosis and 45 days postdiagnosis. We examined symptom severity by disease stage and differences in severity by histology. Linear regression analyses identified significant predictors of severe pain and dyspnea.

RESULTS

Of 460 eligible patients, 256 (62%) had adenocarcinoma, 30 (7%) had small cell carcinoma, and 100 (24%) had squamous cell carcinoma; > 30% reported moderate-to-severe (rated ≥ 5, 0-10 scale) pretreatment symptoms. The most-severe were fatigue, disturbed sleep, distress, pain, dyspnea, sadness, and drowsiness. Symptoms affected work, enjoyment of life, and general activity (interference) and physical well-being (QOL) the most. Patients with advanced disease (n = 289, 63%) had more-severe symptoms. Cancer stage was associated with pain severity; both histology and cancer stage were associated with severe dyspnea.

CONCLUSION

One third of lung cancer patients were symptomatic at initial presentation. Quantification of pretreatment symptom burden can inform patient-specific palliative therapy and differentiate disease-related symptoms from treatment-related toxicities. Poorly controlled symptoms could negatively affect treatment adherence and therapeutic outcomes.

Anticancer effects of curcumin on nude mice bearing lung cancer A549 cell subsets SP and NSP cells

Curcumin is a key polyphenolic curcuminoid extracted from the root of turmeric rhizome Curcuma longa Linn, which is a frequently used Chinese herb for the treatment of cancer. The aim of the present study was to investigate the mechanism of the inhibitory effects of curcumin on nude mice with lung cancer A549 cell subsets side population (SP) and non-SP (NSP) cells. BALB/c mice were subcutaneously injected with the tumor cells of A549 SP or NSP subsets consisting of 1×10⁹ cells/l (0.2 ml in total). After 16 days of inoculation with A549, the mice were intraperitoneally injected with curcumin (100 mg/kg, 0.2 ml) once every other day, eight times in total. A series of assays were performed to detect the effects of curcumin on: i) Tumor weight and size; ii) Notch and hypoxia inducible factor 1 (HIF-1) mRNA expression by quantitative polymerase chain reaction; and iii) vascular endothelial growth factor (VEGF) and nuclear factor-κB (NF-κB) by immunohistochemistry. It was determined that curcumin decreased the tumor weight and size, downregulated the expression of Notch and HIF-1 mRNA and suppressed the VEGF and NF-κB expression. These results indicated that curcumin inhibited lung cancer growth through the regulation of angiogenesis mediated by VEGF signaling.

Evaluation of health-related quality of life and symptoms in patients with advanced non-squamous non-small cell lung cancer treated with nivolumab or docetaxel in CheckMate 057

BACKGROUND

Nivolumab, a programmed death-1 inhibitor, prolonged overall survival and had a favourable safety profile versus docetaxel in previously treated patients with advanced non-squamous non-small cell lung cancer (NSCLC) in the phase III CheckMate 057 trial.

AIM

To evaluate health-related quality of life (HRQoL) using patient-reported outcomes.

METHODS

Disease-related symptoms and general health status were assessed using two validated patient-reported instruments, the Lung Cancer Symptom Scale (LCSS) and the European Quality of Life Five Dimensions (EQ-5D), respectively. The proportion of patients with disease-related symptom improvement at 12 weeks on the LCSS average symptom burden index (ASBI) was a secondary end-point. LCSS 3-item global index (3-IGI), EQ-5D utility index and EQ-5D visual analogue scale (VAS) scores were also determined. Mixed-effects model repeated measures (MMRM) and time to first deterioration analyses assessed longitudinal changes.

RESULTS

Mean baseline LCSS ASBI scores were similar in both arms. By week 12, rates of disease-related improvement (95% confidence interval) were similar between nivolumab (17.8% [13.6-22.7]) and docetaxel (19.7% [15.2-24.7]); however, numerical differences in LCSS ASBI mean change from baseline favoured nivolumab. Subsequently, LCSS ASBI scores improved with nivolumab and worsened with docetaxel, with statistically significant between-arm differences at weeks 12, 24, 30 and 42. HRQoL improvements with nivolumab versus docetaxel were also supported by the LCSS 3-IGI, EQ-5D VAS and MMRM analysis. Time to first HRQoL deterioration was longer with nivolumab than with docetaxel.

CONCLUSION

Nivolumab improved disease-related symptoms and overall health status versus docetaxel for second-line treatment of advanced non-squamous NSCLC.

CLINICAL TRIAL REGISTRATION

NCT01673867.

Implementation of optimized supportive care and hospital needs along the management of patients with advanced lung cancer

BACKGROUND

Supportive care in cancer (SCC) have been recommended to be integrated in the management of patients with lung cancer all along the course of the disease. We took advantage of a pilot program of early implementation of optimized SCC, to report the feasibility such program in patients with advanced lung cancer, and correlate patient characteristics and outcomes with the actual use of optimized SCC.

METHODS

This study is a retrospective analysis of all consecutive patients with lung cancer treated at our center between 2012 and 2016. Optimized SCC included the intervention of a nurse for the home-hospital network coordination, as well as socio-aesthetics, psychomotricity, art-therapy, adapted physical activity, and also establishment of at-home hospitalization.

RESULTS

309 patients were included. Median overall survival was 11.2 months. Unplanned hospitalizations occurred for 276 (89%) patients. The median duration of hospital stay was 19 days. Unplanned hospitalizations more frequently occurred within the first 3 months after the diagnosis of advanced cancer, and in the last 3 months before death. A short - less than 3 months - delay between diagnosis and unplanned hospitalization was associated with poor outcome. 272 (88%) patients received optimized SCC, within a median delay of 8 weeks after diagnosis. Intervention of the nurse for in- and out-patient network coordination was done for 143 (46%) patients, and at-home hospitalization was organized for 78 (25%) patients. The outcome of patients who received optimized SCC was numerically, but not significantly better (median overall survival of 11.8 vs. 6.9 months, p = 0.270).

CONCLUSION

Our study provides landmark data to support an early integration of optimized SCC for patients with advanced lung cancer, that includes multimodal supportive care interventions along the course of the disease. This highlights the role of multidisciplinary teams to optimize the management of patients with advanced lung cancer.

Coping Skills Practice and Symptom Change: A Secondary Analysis of a Pilot Telephone Symptom Management Intervention for Lung Cancer Patients and Their Family Caregivers

CONTEXT

Little research has explored coping skills practice in relation to symptom outcomes in psychosocial interventions for cancer patients and their family caregivers.

OBJECTIVES

To examine associations of coping skills practice to symptom change in a telephone symptom management (TSM) intervention delivered concurrently to lung cancer patients and their caregivers.

METHODS

This study was a secondary analysis of a randomized pilot trial. Data were examined from patient-caregiver dyads (n = 51 dyads) that were randomized to the TSM intervention. Guided by social cognitive theory, TSM involved four weekly sessions where dyads were taught coping skills including a mindfulness exercise, guided imagery, pursed lips breathing, cognitive restructuring, problem solving, emotion-focused coping, and assertive communication. Symptoms were assessed, including patients' and caregivers' psychological distress and patients' pain interference, fatigue interference, and distress related to breathlessness. Multiple regression analyses examined associations of coping skills practice during the intervention to symptoms at six weeks after the intervention.

RESULTS

For patients, greater practice of assertive communication was associated with less pain interference (β = -0.45, P = 0.02) and psychological distress (β = -0.36, P = 0.047); for caregivers, greater practice of guided imagery was associated with less psychological distress (β = -0.30, P = 0.01). Unexpectedly, for patients, greater practice of a mindfulness exercise was associated with higher pain (β = 0.47, P = 0.07) and fatigue interference (β = 0.49, P = 0.04); greater practice of problem solving was associated with higher distress related to breathlessness (β = 0.56, P = 0.01) and psychological distress (β = 0.36, P = 0.08).

CONCLUSION

Findings suggest that the effectiveness of TSM may have been reduced by competing effects of certain coping skills. Future interventions should consider focusing on assertive communication training for patients and guided imagery for caregivers.

Can early palliative care with anticancer treatment improve overall survival and patient-related outcomes in advanced lung cancer patients? A review of the literature

Purpose

Metastatic non-small-cell lung cancer (NSCLC), the leading cause of death from cancer worldwide, is a debilitating disease that results in a high burden of symptoms and poor quality of life; the estimated prognosis after the diagnosis has been established was less than 1 year until some years ago. At the present, the new targeted therapies and immunotherapy are changing the course of the disease. However, advanced NSCLC remains an incurable disease, with a poor prognosis for the majority of the affected patients, so that quality of life and relief from symptoms are primary objectives of treatment. Some evidences suggest that early palliative care (EPC) for these patients can improve quality of life and even survival.

Design

A systematic review of the studies evaluating the impact on objective and on patient-reported outcomes of the introduction of EPC in opposition to standard care (SC), for advanced lung cancer patients, was performed. Because of the small number of studies conducted in this area, retrospective studies were also considered for the review.

Results

Five studies were included because they matched the inclusion criteria previously defined as relevant for the study. The review found that both survival and quality of life were better for patients included in EPC groups.

Conclusions

While results of the studies included in this review are not always comparable because different methods and scales have been used, there is enough evidence for clinical oncologists to implement the use of EPC in clinical practice for advanced lung cancer patients.

Development of a Symptom Management Intervention: Qualitative Feedback From Advanced Lung Cancer Patients and Their Family Caregivers

BACKGROUND

Little is known about cancer patient and family caregiver preferences for the content and format of nonpharmacologic interventions. Revising interventions based on patient and caregiver feedback before implementation may improve intervention feasibility and acceptability, especially in the context of advanced-stage cancer.

OBJECTIVES

The aim of the study was to obtain feedback from patients with advanced-stage, symptomatic lung cancer and their family caregivers on the content and format of a nonpharmacologic symptom management intervention under development. The intervention blended evidence-based cognitive-behavioral and emotion-focused strategies to reduce physical and psychological symptoms.

METHODS

Semistructured qualitative interviews were conducted with 21 patients with advanced-stage, symptomatic lung cancer and caregivers. Participants reviewed handouts regarding intervention components and provided feedback.

RESULTS

Patients and caregivers desired intervention components that addressed the patient's high symptom burden such as education regarding treatment adverse effects and the provision of various coping tools. Offering interventions with a brief or flexible length and delivering them via telephone were other suggestions for enhancing intervention acceptability. Participants also preferred an equal focus on patient and caregiver concerns and a more positive intervention framework.

CONCLUSIONS

Intervention preferences of patients with advanced-stage lung cancer and caregivers underscore the severity of the disease and treatment process and the need to adapt interventions to patients with high symptom burden. These preferences may be incorporated into future intervention trials to improve participant recruitment and retention.

IMPLICATIONS FOR PRACTICE

Nurses can modify interventions to meet the needs of patients with advanced-stage, symptomatic lung cancer and caregivers. For example, flexibility regarding intervention content and length may accommodate those with significant symptoms.

Specialized palliative care in advanced cancer: What is the efficacy? A systematic review

Objective:

Due to the multiple physical, psychological, existential, and social symptoms involved, patients with advanced cancer often have a reduced quality of life (QoL), which requires specialized palliative care (SPC) interventions. The primary objective of the present systematic review was to review the existing literature about SPC and its effect on QoL, on physical and psychological symptoms, and on survival in adult patients with advanced cancer.

Method:

We utilized a search strategy based on the PICO (problem/population, intervention, comparison, and outcome) framework and employed terminology related to cancer, QoL, symptoms, mood, and palliative care. The search was performed in Embase, PubMed, and the Cochrane Central Register of Controlled Trials. Selected studies were analyzed and categorized according to methods, results, quality of evidence, and strength of recommendation.

Results:

Six randomized controlled trials (RCTs) were selected for analysis (out of a total of 1,115 studies). Two other studies were found by hand search, one of which was only published in conference abstract form. The RCTs differed in terms of aims, interventions, control groups, and outcomes; however, the primary aim of all of them was to investigate the effect of SPC on patient QoL. Five studies found improved QoL in the intervention group. Physical symptom intensity decreased in two studies, and three studies found improved mood in the intervention group. However, physical and psychological symptoms were secondary outcomes in these studies. Survival was improved in two studies. All the studies offered generalizability, but the level of evidence validity varied among them.

Significance of results:

Due to several methodological limitations, the evidence offered in these studies ranged from low to high. The evidence in this field of study in general is still nascent, but there is growing support for the utilization of SPC to improve the quality of life of adult patients with advanced cancer. The evidence that SPC reduces physical and psychological symptoms is moderate, while the evidence that it prolongs survival is low.

Coping in Patients With Incurable Lung and Gastrointestinal Cancers: A Validation Study of the Brief COPE

CONTEXT

Patients with incurable cancer engage in several coping styles to manage the impact of cancer and its treatment. The Brief COPE is a widely used measure intended to capture multiple and distinct types of coping. The Brief COPE has not been validated among patients with incurable cancer.

OBJECTIVES

We sought to validate seven subscales of the Brief COPE in a large sample of patients newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers (N = 350).

METHODS

Participants completed the Brief COPE and measures assessing quality of life (QOL) (Functional Assessment of Cancer Therapy-General) and psychological distress (Hospital Anxiety and Depression Scale) within eight weeks of diagnosis of incurable cancer. We evaluated the psychometric properties of the Brief COPE using a confirmatory factor analysis and tests of correlation with the QOL and distress scales.

RESULTS

The Brief COPE factors were consistent with the original subscales, although the Behavioral Disengagement Scale had low internal consistency. Factors showed anticipated relationships with QOL and distress measures, except emotional support coping, which was correlated with increased depression and anxiety. We also conducted an exploratory high-order factor analysis to determine if subscales' score variances grouped together. The high-order factor analysis resulted in two factors, with active, emotional support, positive reframing, and acceptance loading onto one factor and denial and self-blame loading onto the second.

CONCLUSION

The selected subscales of the Brief COPE are appropriate measures of coping among individuals newly diagnosed with incurable lung and gastrointestinal cancers.

Thoracic Re-irradiation for Locally Recurrent Lung Cancer

Background: Patients with recurrent or progressive lung cancer experience a significant symptom burden, negatively affecting quality of life and reducing life expectancy. Thoracic re-irradiation can be used for palliative treatment to relieve symptoms or as a curative treatment. Methods: Using patient charts, we identified and reviewed 28 cases that had received palliative thoracic re-irradiation for recurrent lung cancer. Results: Before re-irradiation, 32% of patients had stage III non-small cell lung cancer and six had small cell lung cancer. The median interval between treatments was 18.7 months. Median follow-up was 31.2 months from the initial radiotherapy and 5 months after re-irradiation. A better performance status before re-irradiation (<80 vs >80, p=0.09) and a lower overlap 90% isodose (<70 vs >70, p=0.09) showed trends toward improved survival. Grade 1-2 toxicity from re-irradiation was recorded in 12/28 patients, and no grade 3 or 4 acute toxicity was encountered. Conclusion: The role of palliative treatment in survival is not clear but it can provide symptomatic relief in patients, with no high grade toxicity. Further studies with greater patient numbers and longer follow-up times should facilitate determination of the role of this treatment in toxicity and effects on survival.

Impact of Symptom Clusters on Quality of Life Outcomes in Patients from Japan with Advanced Nonsmall Cell Lung Cancers

OBJECTIVE

Identify symptom clusters based on symptoms experienced by patients with advanced nonsmall cell lung cancers (NSCLCs), and examine the relationship between the symptom clusters and impairment in everyday life and quality of life (QOL).

METHODS

Using the M.D. Anderson Symptom Inventory, 9 symptom items and the QOL Questionnaire (QLQ-C-30) evaluation apparatus from the European Organization for Research and Treatment of Cancer, we evaluated symptom severity, interference in daily life, and QOL. Factor analysis and multiple regression analysis techniques were used.

RESULTS

Sixty patients with advanced NSCLCs seen in pulmonary medicine departments were included in the study. The average age of patients was 64.33 (standard deviation = 11.40). Thirty-six were male and 24 were female. Three symptom clusters were identified as fatigue/anorexia cluster (dry mouth, altered the sense of taste, drowsiness, fatigue/tiredness, and lack of appetite), pain cluster (anxiety, sadness, and pain), numbness cluster (numbness, leg weakness, and distress). The pain cluster had the strongest influence (adjusted R2 = 0.355) on daily life (emotions) while the numbness cluster most strongly affected walking. The fatigue/anorexia cluster explained 22.7% of role function variance. This symptom clustering may be unique among patients with advanced NSCLCs.

CONCLUSIONS

Each of these clusters affected QOL and everyday life with varying degrees of influence. In clinical screening assessments, focusing on symptom clusters could provide tailored management strategies for patients with advanced NSCLCs. These care strategies may improve outcomes specifically for advanced NSCLCs patients.

Randomized Pilot Trial of a Telephone Symptom Management Intervention for Symptomatic Lung Cancer Patients and Their Family Caregivers

CONTEXT

Lung cancer is one of the most common cancers affecting both men and women and is associated with high symptom burden and psychological distress. Lung cancer patients' family caregivers also show high rates of distress. However, few interventions have been tested to alleviate significant problems of this population.

OBJECTIVES

This study examined the preliminary efficacy of telephone-based symptom management (TSM) for symptomatic lung cancer patients and their family caregivers.

METHODS

Symptomatic lung cancer patients and caregivers (n = 106 dyads) were randomly assigned to four sessions of TSM consisting of cognitive-behavioral and emotion-focused therapy or an education/support condition. Patients completed measures of physical and psychological symptoms, self-efficacy for managing symptoms, and perceived social constraints from the caregiver; caregivers completed measures of psychological symptoms, self-efficacy for helping the patient manage symptoms and managing their own emotions, perceived social constraints from the patient, and caregiving burden.

RESULTS

No significant group differences were found for all patient outcomes and caregiver self-efficacy for helping the patient manage symptoms and caregiving burden at two- and six-weeks post-intervention. Small effects in favor of TSM were found regarding caregiver self-efficacy for managing their own emotions and perceived social constraints from the patient. Study outcomes did not significantly change over time in either group.

CONCLUSION

Findings suggest that our brief telephone-based psychosocial intervention is not efficacious for symptomatic lung cancer patients and their family caregivers. Next steps include examining specific intervention components in relation to study outcomes, mechanisms of change, and differing intervention doses and modalities.

Development of nurse-led follow-up in the management of patients with lung cancer

This paper describes the first two phases of an NHS R&D-funded study to develop and evaluate an alternative model of nurse-led follow-up care in the management of patients with lung cancer. Phase I of the study identified the needs of lung cancer patients during their follow-up period of care. This was achieved through observation of outpatient consultations and an audit of patients' medical records. Phase two of the study developed and piloted a nurse specialist-led model of follow-up care. This model moved away from the existing medical one focusing on disease surveillance towards a more patient-centred model responsive to the specific needs of lung cancer patients that were identified during Phase 1. The paper concludes that nurse-led follow-up care of lung cancer patients was demonstrated to be safe, acceptable and appropriately managed. Patients in the study reported positive benefits from a model of care responsive to the experience of, and needs arising from, living with lung cancer.

Psychological interventions to improve the quality of life in Indian lung cancer patients: A neglected area

The incidence of lung cancer is very high and evidence suggests that patients experience imbalanced emotional capabilities due to less survival rate compared to other cancers. Direct and indirect psychological interventions are mandatory to improve the outcome of lung cancer treatment. Although such interventions are being practiced in developed nations, the effects of psychological interventions on the treatment outcome in the Indian context are lacking. Since there is a definite correlation between treatment outcome and psychological issues, it is high time that clinicians in developing countries including India adopt practices to enhance the quality of life of lung cancer patients.

A randomised assessment of the use of a quality of life questionnaire with or without intervention in patients attending a thoracic cancer clinic

The study examined the impact of using a quality of life (QoL) questionnaire during a clinic to identify QoL issues and to improve QoL. 138 patients were randomised (1:1:1) to either (1) an Intervention group that completed the European Organisation for Research and Treatment of Cancer-Core Quality of Life Questionnaire and Lung Cancer Module (EORTC QLQ-C30 and LC13) at baseline and received feedback during a clinic, (2) an Attention group that completed the questionnaire at baseline without feedback and (3) a Control group that did not complete the questionnaire. All patients completed the same questionnaire 6 weeks later and a contact diary during the study period. There was a significant difference between the Intervention and Control groups for the mean number of QoL issues identified at baseline (4.69 vs. 2.81, P = 0.006) and the mean number of actions taken (4.41 vs. 2.46, P = 0.004). At 6 weeks, there was no difference between the groups in global QoL (Intervention vs. Control group, P = 0.596; Attention vs. Control, P = 0.973). The results suggest that the completion of the EORTC QLQ-C30 LC13 with feedback improves communication and increases the number of QoL issues identified and actions taken. However, the intervention does not impact on QoL per se. Clinicaltrials.gov: NCT01213745.

Coping with physical and psychological symptoms: a qualitative study of advanced lung cancer patients and their family caregivers

PURPOSE

Advanced lung cancer patients have high rates of multiple physical and psychological symptoms, and many of their family caregivers experience significant distress. However, little is known about strategies that these patients and their family caregivers employ to cope with physical and psychological symptoms. This study aimed to identify strategies for coping with various physical and psychological symptoms among advanced, symptomatic lung cancer patients and their primary family caregivers.

METHODS

Patients identified their primary family caregiver. Individual semi-structured qualitative interviews were conducted with 21 advanced, symptomatic lung cancer patients and primary family caregivers. Thematic analysis of interview data was framed by stress and coping theory.

RESULTS

Patients and caregivers reported maintaining a normal routine and turning to family and friends for support with symptom management, which often varied in its effectiveness. Whereas support from health-care professionals and complementary and alternative medicine were viewed favorably, reactions to Internet and in-person support groups were mixed due to the tragic nature of participants' stories. Several cognitive coping strategies were frequently reported (i.e., changing expectations, maintaining positivity, and avoiding illness-related thoughts) as well as religious coping strategies.

CONCLUSIONS

Results suggest that advanced lung cancer patients and caregivers may be more receptive to cognitive and religious approaches to symptom management and less receptive to peer support. Interventions should address the perceived effectiveness of support from family and friends.

The role of anti-angiogenesis in non-small-cell lung cancer: an update

Recognition of the vascular endothelial growth factor (VEGF) pathway as a key mediator of angiogenesis has led to the clinical study of several VEGF and VEGF receptor (VEGFR) targeted therapies in non-small-cell lung cancer (NSCLC). These targeted therapies include neutralizing antibodies to VEGF (bevacizumab and aflibercept) and VEGFR-2 (ramucirumab) and tyrosine kinase inhibitors (TKIs) with selectivity for the VEGFRs. Bevacizumab and ramucirumab are associated with survival advantages in the treatment of advanced NSCLC: bevacizumab in the first-line setting in combination with carboplatin/paclitaxel and ramucirumab in combination with docetaxel in the second-line setting. The VEGFR-2 TKIs have been associated with responses and improved progression-free survival in selected NSCLC settings; however, this level of activity has thus far been insufficient to confer significant survival advantages. This review will focus on the current state of VEGF targeted therapies in NSCLC.

Feasibility of using algorithm-based clinical decision support for symptom assessment and management in lung cancer

CONTEXT

Distressing symptoms interfere with the quality of life in patients with lung cancer. Algorithm-based clinical decision support (CDS) to improve evidence-based management of isolated symptoms seems promising, but no reports yet address multiple symptoms.

OBJECTIVES

This study examined the feasibility of CDS for a Symptom Assessment and Management Intervention targeting common symptoms in patients with lung cancer (SAMI-L) in ambulatory oncology. The study objectives were to evaluate completion and delivery rates of the SAMI-L report and clinician adherence to the algorithm-based recommendations.

METHODS

Patients completed a web-based symptom assessment and SAMI-L created tailored recommendations for symptom management. Completion of assessments and delivery of reports were recorded. Medical record review assessed clinician adherence to recommendations. Feasibility was defined as 75% or higher report completion and delivery rates and 80% or higher clinician adherence to recommendations. Descriptive statistics and generalized estimating equations were used for data analyses.

RESULTS

Symptom assessment completion was 84% (95% CI=81-87%). Delivery of completed reports was 90% (95% CI=86-93%). Depression (36%), pain (30%), and fatigue (18%) occurred most frequently, followed by anxiety (11%) and dyspnea (6%). On average, overall recommendation adherence was 57% (95% CI=52-62%) and was not dependent on the number of recommendations (P=0.45). Adherence was higher for anxiety (66%; 95% CI=55-77%), depression (64%; 95% CI=56-71%), pain (62%; 95% CI=52-72%), and dyspnea (51%; 95% CI=38-64%) than for fatigue (38%; 95% CI=28-47%).

CONCLUSION

The CDS systems, such as SAMI-L, have the potential to fill a gap in promoting evidence-based care.

Photodynamic therapy for lung cancer and malignant pleural mesothelioma

Photodynamic therapy (PDT) is a form of non-ionizing radiation therapy that uses a drug, called a photosensitizer, combined with light to produce singlet oxygen ((1)O2) that can exert anti-cancer activity through apoptotic, necrotic, or autophagic tumor cell death. PDT is increasingly being used to treat thoracic malignancies. For early-stage non-small cell lung cancer (NSCLC), PDT is primarily employed as an endobronchial therapy to definitively treat endobronchial or roentgenographically occult tumors. Similarly, patients with multiple primary lung cancers may be definitively treated with PDT. For advanced or metastatic NSCLC and small cell lung cancer (SCLC), PDT is primarily employed to palliate symptoms from obstructing endobronchial lesions causing airway compromise or hemoptysis. PDT can be used in advanced NSCLC to attempt to increase operability or to reduce the extent of operation intervention required, and selectively to treat pleural dissemination intraoperatively following macroscopically complete surgical resection. Intraoperative PDT can be safely combined with macroscopically complete surgical resection and other treatment modalities for malignant pleural mesothelioma (MPM) to improve local control and prolong survival. This report reviews the mechanism of and rationale for using PDT to treat thoracic malignancies, details prospective and major retrospectives studies of PDT to treat NSCLC, SCLC, and MPM, and describes improvements in and future roles and directions of PDT.

Sleep, mood, and quality of life in patients receiving treatment for lung cancer

PURPOSE/OBJECTIVES

To distinguish relationships among subjective and objective characteristics of sleep, mood, and quality of life (QOL) in patients receiving treatment for lung cancer.

DESIGN

Descriptive, correlational study.

SETTING

Two ambulatory oncology clinics.

SAMPLE

35 patients with lung cancer.

METHODS

The following instruments were used to measure the variables of interest: Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale, Functional Assessment of Cancer Treatment-Lung (FACT-L), a sleep diary, and a motionlogger actigraph.

MAIN RESEARCH VARIABLES

Sleep, mood, and QOL.

FINDINGS

Significant differences were found between sleep diary and actigraph measures of sleep efficiency (p = 0.002), sleep latency (p = 0.014), sleep duration (p < 0.001), and wake after sleep onset (p < 0.001). Poor sleepers (PSQI score greater than 5) were significantly different from good sleepers (PSQI score of 5 or lower) on sleep diary measures of sleep efficiency and sleep latency and the FACT-L lung cancer symptom subscale, but not on mood or actigraphy sleep measures.

CONCLUSIONS

Although patients with lung cancer may report an overall acceptable sleep quality when assessed by a single question, those same patients may still have markedly increased sleep latencies or reduced total sleep time. The findings indicate the complexity of sleep disturbances in patients with lung cancer. Lung cancer symptoms had a stronger association with sleep than mood. Research using prospective methods will help to elucidate their clinical significance.

IMPLICATIONS FOR NURSING

Patients receiving treatment for lung cancer are at an increased risk for sleep disturbances and would benefit from routine sleep assessment and management. In addition, assessment and management of common symptoms may improve sleep and, ultimately, QOL.

KNOWLEDGE TRANSLATION

A high frequency of sleep disturbances in patients receiving treatment for lung cancer was evident, and poor sleepers had lower QOL. Sleep disturbances may be more related to lung cancer symptoms than anxiety or depression. Improving lung cancer symptoms such as dyspnea may improve sleep.

Perceptions of health status and survival in patients with metastatic lung cancer

CONTEXT

Cognitive awareness of having a terminal illness is associated with critical treatment decisions and outcomes. However, little is known about the course and correlates of such perceptions in patients with metastatic lung cancer.

OBJECTIVES

We explored changes in perceptions of health status over time in patients with metastatic non-small cell lung cancer (NSCLC) and whether awareness of having a terminal illness was associated with survival.

METHODS

For this secondary analysis of clinical trial data, we assessed perceptions of health status at baseline, 12, 18, and 24 weeks. At each time point, patients with metastatic NSCLC completed a measure of quality of life (Functional Assessment of Cancer Therapy-Trial Outcome Index) and also reported whether they were "relatively healthy," "seriously but not terminally ill," or "seriously and terminally ill." We reviewed patients' medical records to gather data on clinical characteristics.

RESULTS

At baseline, 49.3% reported being relatively healthy, whereas the remainder self-identified as seriously but not terminally ill (38.2%) or seriously and terminally ill (12.5%). Over multiple assessments, 24.8% reported having a terminal illness. Adjusting for known prognostic factors, patients' time-varying perceptions of health status remained a significant predictor of survival (hazards ratio = 1.50, 95% CI = 1.07-2.09, P = 0.019).

CONCLUSION

A minority of patients with metastatic NSCLC acknowledged being terminally ill. Those reporting that they were seriously and terminally ill had shorter survival compared with those who did not consider themselves terminally ill, even after adjusting for decline in physical and functional well-being.

The experience of people with lung cancer with a volunteer-based lay navigation intervention at an outpatient cancer center

OBJECTIVE

To describe the experiences of patients with lung cancer with a volunteer-based lay navigation intervention.

METHODS

Forty patients with newly diagnosed lung cancer enrolled in a three-step navigation intervention delivered by trained volunteer lay navigators (VLNs), beginning prior to their first oncologist's appointment and ending before the start of treatment. Methodological triangulation of data was used in a mixed method study design. Cases were categorized based on the predominant needs met by the VLN: emotional, practical/informational, family, and complex. Data were analyzed using framework analysis.

RESULTS

The provision of emotional support, information, and referrals to other services by the VLN were of particular benefit to the patient and their families. Satisfaction with the program and its timing was high; it was considered an effective means for patients to share concerns and have their needs attended to before starting treatment.

CONCLUSION

This study demonstrates capacity for lay volunteers to address the multifaceted needs of lung cancer patients during their transition from primary care in the diagnosis to treatment phase.

PRACTICE IMPLICATIONS

Using volunteers as navigators offers an opportunity to meet patient needs with minimal resources, increase access to services for patients, and improve the sustainability of the program.

Collaborative Care in NSCLC; the Role of Early Palliative Care

The management of non-small cell lung cancer (NSCLC) has evolved into a multidisciplinary team approach that traditionally has involved medical oncology, radiation oncology, and thoracic surgery. However, in the era of personalized medicine the importance of molecular diagnostics requires adequate tissue for histologic subtyping and molecular testing and thus requires the engagement of other subspecialties such as pathology, respirology, and interventional radiology. Unfortunately in 2014, the majority of patients presenting with NSCLC will succumb to their disease and the early integration of palliative care into the treatment strategy will improve the quality of life and end-of-life care of our patients and may in fact improve their overall survival.

Reirradiation for locoregionally recurrent lung cancer: outcomes in small cell and non-small cell lung carcinoma

OBJECTIVES

To our knowledge this is the largest report analyzing outcomes for re-irradiation (reRT) for locoregionally recurrent lung cancer, and the first to assess thoracic reRT outcomes in patients with small cell lung cancer (SCLC).

METHODS

Forty-eight patients (11 SCLC, 37 non-small cell lung cancer [NSCLC]) receiving reRT to the thorax were identified; 44 (92%) received reRT by intensity-modulated radiotherapy. Palliative responses, survival outcomes, and prognostic factors were analyzed.

RESULTS

NSCLC patients received a median of 30 Gy in a median of 10 fractions, whereas SCLC patients received a median of 37.5 Gy in a median of 15 fractions. Median survival for the entire cohort from reRT was 4.2 months. Median survival for NSCLC patients was 5.1 months, versus 3.1 months for the SCLC patients (P=0.15). In NSCLC patients, multivariate analysis demonstrated that Karnofsky performance status≥80 and higher radiation dose were associated with improved survival following reRT, and 75% of patients with symptoms experienced palliative benefit. In SCLC, 4 patients treated with the intent of life prolongation for radiographic recurrence had a median survival of 11.7 months. However, acute toxicities and new disease symptoms limited the duration of palliative benefit in the 7 symptomatic SCLC patients to 0.5 months.

CONCLUSIONS

ReRT to the thorax for locoregionally recurrent NSCLC can provide palliative benefit, and a small subset of patients may experience long-term survival. Select SCLC patients may experience meaningful survival prolongation after reRT, but reRT for patients with symptomatic recurrence and/or extrathoracic disease did not offer meaningful survival or durable symptom benefit.

Creating computable algorithms for symptom management in an outpatient thoracic oncology setting

CONTEXT

Adequate symptom management is essential to ensure quality cancer care, but symptom management is not always evidence based. Adapting and automating national guidelines for use at the point of care may enhance use by clinicians.

OBJECTIVES

This article reports on a process of adapting research evidence for use in a clinical decision support system that provided individualized symptom management recommendations to clinicians at the point of care.

METHODS

Using a modified ADAPTE process, panels of local experts adapted national guidelines and integrated research evidence to create computable algorithms with explicit recommendations for management of the most common symptoms (pain, fatigue, dyspnea, depression, and anxiety) associated with lung cancer.

RESULTS

Small multidisciplinary groups and a consensus panel, using a nominal group technique, modified and subsequently approved computable algorithms for fatigue, dyspnea, moderate pain, severe pain, depression, and anxiety. The approved algorithms represented the consensus of multidisciplinary clinicians on pharmacological and behavioral interventions tailored to the patient's age, comorbidities, laboratory values, current medications, and patient-reported symptom severity. Algorithms also were reconciled with one another to enable simultaneous management of several symptoms.

CONCLUSION

A modified ADAPTE process and nominal group technique enabled the development and approval of locally adapted computable algorithms for individualized symptom management in patients with lung cancer. The process was more complex and required more time and resources than initially anticipated, but it resulted in computable algorithms that represented the consensus of many experts.

Personalizing therapy in advanced non-small cell lung cancer

The recognition that non-small cell lung cancer (NSCLC) is not a single disease entity, but rather a collection of distinct molecularly driven neoplasms, has permanently shifted the therapeutic landscape of NSCLC to a personalized approach. This personalization of NSCLC therapy is typified by the dramatic response rates seen in EGFR mutant NSCLC when treated with targeted tyrosine kinase inhibitor therapy and in ALK translocation-driven NSCLC when treated with ALK inhibitors. Targeted therapeutic approaches in NSCLC necessitate consideration of more invasive biopsy techniques aimed at providing sufficient tissue for both histological determination and molecular profiling in all patients with stage IV disease both at the time of diagnosis and at the time of disease progression. Comprehensive genotyping efforts have identified oncogenic drivers in 62% lung adenocarcinomas and an increasing proportion of squamous cell carcinomas of the lung. The identification of these oncogenic drivers and the triage of patients to clinical trials evaluating novel targeted therapeutic approaches will increasingly mold a landscape of personalized lung cancer therapy where each genotype has an associated targeted therapy. This review outlines the state of personalized lung cancer therapy as it pertains to individual NSCLC genotypes.

Impact of physiotherapy on patients with advanced lung cancer

Patients with lung cancer have high mortality and high morbidity. Lung cancer-related symptoms and problems such as dyspnea, fatigue, pain, and cachexia that begin in the early phase later result in poor physical functioning, psychosocial, and quality of life status. In addition, advancing age is associated with significant comorbidity. These patients may benefit from multidisciplinary therapy to reduce the perceived severity of dyspnea and fatigue and increase physical functioning and quality of life. Based on management of symptoms and problems such as dyspnea, physical inactivity, cancer-related fatigue, respiratory secretions, pain, and anxiety–depression of these patients, it is thought that physiotherapy techniques can be used on advanced lung cancer patients following a comprehensive evaluation. However, well-designed, prospective, and randomized-controlled trials are needed to prove the efficacy of physiotherapy and pulmonary rehabilitation in general for patients with advanced lung cancer.

Sexual activity and body image: examining gender variability and the influence of psychological distress in cancer patients

Psychosocial factors impacting on the overall quality of life for cancer patients may differ between men and women. This study examined the influence that psychological distress, clinical, and social variables have on sexual activity and body image in adult oncology patients. Symptom data was collected from the Memorial Symptom Assessment Scale (MSAS). Analysis indicated women and patients with reported functional limitations were more likely to be less satisfied with how they looked. The final model showed that younger adults, Caucasians, those who were married and patients with some functional limitations were more likely to have problems with sexual interest/activity. Gender was not a significant predictor of having problems with sexual interest/activity. These results can be used by clinicians to identify patients who may be at an increased risk for negative body image and problems in sexual functioning. Further research regarding gender differences in cancer-related psychological symptoms is needed to assist healthcare professionals in providing comprehensive care while alleviating unresolved and interrelated health and psychosocial symptoms.

Lung cancer stigma, anxiety, depression and symptom severity

OBJECTIVES

Compared to other cancers, lung cancer patients report the highest levels of psychological distress and stigma. Few studies have examined the relationship between lung cancer stigma (LCS) and symptom burden. This study was designed to investigate the relationship between LCS, anxiety, depression and physical symptom severity.

METHODS

This study employed a cross-sectional, correlational design to recruit patients online from lung cancer websites. LCS, anxiety, depression and physical symptoms were measured by patient self-report using validated scales via the Internet. Hierarchical multiple regression was performed to investigate the individual contributions of LCS, anxiety and depression to symptom severity.

RESULTS

Patients had a mean age of 57 years; 93% were Caucasian, 79% were current or former smokers, and 74% were female. There were strong positive relationships between LCS and anxiety (r = 0.413, p < 0.001), depression (r = 0.559, p < 0.001) and total lung cancer symptom severity (r = 0.483, p < 0.001). Although its contribution was small, LCS provided a unique and significant explanation of the variance in symptom severity beyond that of age, anxiety and depression, by 1.3% (p < 0.05).

CONCLUSIONS

Because LCS is associated with psychosocial and physical health outcomes, research is needed to develop interventions to assist patients to manage LCS and to enhance their ability to communicate effectively with clinicians.

Importance and relevance of pulmonary symptoms among patients receiving second- and third-line treatment for advanced non-small-cell lung cancer: support for the content validity of the 4-item Pulmonary Symptom Index

BACKGROUND

In advanced non-small-cell lung cancer (NSCLC), reducing symptoms can be a meaningful treatment outcome. This study characterizes the pulmonary symptoms of patients receiving second- and third-line systemic therapies for NSCLC and assesses the content validity of the 4-item Pulmonary Symptom Index (PSI) of the Functional Assessment of Cancer Therapy-Lung (FACT-L).

METHODS

Twenty patients with advanced NSCLC undergoing second- and third-line treatment ("qualitative sample") completed semistructured interviews regarding their NSCLC symptoms and the importance of pulmonary symptoms. Results were mapped to the PSI. In addition, existing PSI data from 912 patients with cancer ("validation sample") was analyzed to evaluate the scalability of the 4 PSI items.

RESULTS

In the qualitative sample, mean age was 62 years (range 30-79 years); 80% had nonsquamous histologic type, and 25% had comorbid chronic obstructive pulmonary disease (COPD). A core set of pulmonary symptoms emerged in the data-shortness of breath, cough, and chest tightness. These mapped to 3 PSI items. A quarter of the patients reported an absence of pulmonary symptoms, which supports the inclusion of the final PSI item, "breathing is easy." In the validation sample, for the shortness of breath/breathing ease item pair, weighted kappa representing chance-adjusted agreement ranged from 0.39 to 0.54 and percent agreement from 44% to 49% (both considered moderate), supporting a distinct contribution of each item.

CONCLUSION

The PSI captures the most important and relevant symptoms reported by patients with NSCLC receiving second- and third-line treatment. Our results suggest that the PSI may provide a clinically useful method to measure patient benefit from lung cancer therapies.

Support service use and interest in support services among distressed family caregivers of lung cancer patients

OBJECTIVE

This study examined support service use and interest in support services among distressed family caregivers of patients recently entering comprehensive cancer care facilities.

METHODS

Primary family caregivers of lung cancer patients (N=83) were recruited from three medical centers within 12 weeks of the patient's new visit to the oncology clinic. All family caregivers were screened for psychological distress, and those reporting significant anxiety or depressive symptoms were eligible for this study. Caregivers completed a baseline assessment of support service use (i.e., use of mental health services and complementary and alternative medicine [CAM]) and interest in support services. Support service use was also assessed 3 months later.

RESULTS

Although all caregivers reported clinically meaningful distress, only 26% used mental health and 39% used CAM services during the 3-month study period. Patients' receipt of chemotherapy was positively associated with caregivers' mental health service use, whereas greater education and receiving assistance with caregiving tasks were associated with CAM use. Forty percent of caregivers who did not use CAM at baseline were interested in CAM. In addition, 29% of caregivers who did not receive mental health services at baseline were interested in professional psychosocial support, and 29% of caregivers who did not receive staff assistance with practical needs at baseline were interested in this service.

CONCLUSIONS

Findings suggest that distressed family caregivers of lung cancer patients underuse mental health services and that a sizable minority are interested in professional help with psychosocial and practical needs.

Photodynamic therapy for the treatment of non-small cell lung cancer

Photodynamic therapy is increasingly being utilized to treat thoracic malignancies. For patients with early-stage non-small cell lung cancer, photodynamic therapy is primarily employed as an endobronchial therapy to definitely treat endobronchial, roentgenographically occult, or synchronous primary carcinomas. As definitive monotherapy, photodynamic therapy is most effective in treating bronchoscopically visible lung cancers ≤1 cm with no extracartilaginous invasion. For patients with advanced-stage non-small cell lung cancer, photodynamic therapy can be used to palliate obstructing endobronchial lesions, as a component of definitive multi-modality therapy, or to increase operability or reduce the extent of operation required. A review of the available medical literature detailing all published studies utilizing photodynamic therapy to treat at least 10 patients with non-small cell lung cancer is performed, and treatment recommendations and summaries for photodynamic therapy applications are described.

Management of non-small cell lung cancer with oligometastasis

Patients with oligometastatic Non-Small Cell Lung Cancer (NSCLC) present a potential opportunity for curative therapy; however, the challenge remains the definitive treatment of their localized disease and ablation of their limited overt metastatic sites of disease. In selecting patients with oligometastatic NSCLC for definitive therapy, proper staging through radiographic studies, including PET and brain MRI, and the pathologic staging of the mediastinal lymph nodes and potential sites of metastatic disease, are critical. With that in mind, the available literature suggests that in highly selected patients with solitary metastases to the brain, adrenals and other organs, long term survival may be achieved with combined definitive therapy of both the primary lung tumor and the solitary metastatic site.

Personalized therapy for non-small cell lung cancer: which drug for which patient?

The elucidation of the molecular alterations in non-small cell lung cancer (NSCLC) and the development of molecularly targeted agents have permanently shifted NSCLC therapy to a personalized approach. In the metastatic setting, the addition of the anti-vascular endothelial growth factor monoclonal antibody, bevacizumab, to chemotherapy improves overall survival. The oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, gefitinib and erlotinib, prolong progression-free survival in patients selected for the presence of an EGFR activating mutation. The monoclonal antibody to EGFR, cetuximab, improves survival in patients with metastatic NSCLC, and the inhibitor of the echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion protein, crizotinib, has resulted in an unprecedented overall survival advantage in patients harboring the EML4-ALK translocation. In the adjuvant setting, gefitinib has not been shown to improve patient survival outcomes; however, there are several ongoing clinical trials in the adjuvant setting evaluating the role of erlotinib, bevacizumab, and the MAGE-A3 and MUC1 vaccines. The realm of personalized lung cancer therapy also includes the study of chemotherapy selected on the basis of the pharmacogenetic profile of a patient's tumor. Several ongoing clinical trials in both the metastatic and adjuvant settings are studying the excision repair cross-complementing group 1 (ERCC1) protein, the ribonucleotide reductase subunit 1 (RRM1) protein, thymidylate synthase, and BRCA1 as predictors of chemotherapy response. This review will outline the current state of the art of personalized NSCLC therapy.

Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access

Abstract Background: Cancer causes significant symptom burden and diminished quality of life. Despite the expansion of supportive and palliative care services (SPCS), little is known about rates of utilization and barriers to access to these services among oncology outpatients.

METHODS

We performed a cross-sectional survey in three outpatient medical oncology clinics. Patients with a diagnosis of breast, lung, or gastrointestinal (GI) cancer and a Karnofsky score of ≥60 were included. Patients reported their use of SPCS and any perceived barriers. Multivariable logistic regression was used to identify factors associated with SPCS use.

RESULTS

Among 313 participants, (50.5%) had not used SPCS since cancer diagnosis. The most common services used were nutrition (26.5%), psychiatric/psychological counseling (29.7%), and physical therapy (15.1%). Pain/palliative care and cancer rehabilitation consultations were used by 8.5% and 4.1% of participants, respectively. In multivariate analysis, graduate education was associated with greater SPCS use (adjusted odds ratio [AOR] 2.14, 95% confidence interval [CI] 1.08-4.26) compared with those with high school or less, whereas having lung cancer was associated with less SPCS use (AOR 0.48, 95% CI 0.24-0.96) when compared with those having breast cancer. The biggest reported barriers to using SPCS were a lack of awareness (22.4%) and lack of physician referral (23%).

CONCLUSIONS

Approximately half of these patients had not accessed SPCS since cancer diagnosis and cite lack of awareness and physician nonreferral as barriers. Further research is needed to understand patients' needs and beliefs regarding SPCS, and how to integrate SPCS into conventional treatments to improve cancer care.