Multisite, Randomized Trial of Early Integrated Palliative and Oncology Care in Patients with Advanced Lung and Gastrointestinal Cancer: Alliance A221303

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.

Meta-Analysis of Effects of Early Palliative Care on Health-Related Outcomes Among Advanced Cancer Patients

BACKGROUND

Early palliative care (PC) has received more attention for improving health-related outcomes for advanced cancer patients in recent years, but the results of previous studies are inconsistent.

OBJECTIVES

This study aimed to use meta-analysis and trial sequence analysis to evaluate the effect of early PC on health-related outcomes of advanced cancer patients.

METHODS

All English publications were searched in PubMed, Web of Science, Embase, and the Cochrane Library from inception to March 2023, with a restriction that the study type was a randomized controlled trial.

RESULTS

The results showed that early PC positively affected quality of life, satisfaction with care, and symptom burden reduction. However, early PC had no significant effect on anxiety or survival. Trial sequence analysis results showed that the effect of early PC on the quality of life was stable.

DISCUSSION

This systematic review suggested that early PC could positively affect health-related outcomes for advanced cancer patients. Early PC can be used widely in clinical settings to improve health-related outcomes of advanced cancer. However, because of the trial sequence analysis results, further well-designed, clinical, randomized controlled trials with larger sample sizes are necessary to draw definitive conclusions.

Patient-Reported Outcomes in Clinical Trials: From an Endpoint to an Intervention in Cancer Care

Underreporting of patient symptoms by clinicians is a common and well-documented phenomenon that has led to integrating patient-reported outcomes (PROs) as endpoints into clinical trials. While PROs are often used to measure disease symptoms, cancer therapy toxicities, and quality of life, they can also assess patients' general experiences and preferences. With the increasing use of electronic medical records and the digital health revolution in oncology, conversion from paper to electronic PROs (ePROs) has also facilitated the integration of PROs into routine care. Evidence from clinical trials is rapidly emerging to support ePROs as a care delivery innovation, given the potential for ePROs to improve patient outcomes through timely evaluation and response to patient needs. Meanwhile, work is ongoing to understand and address ePRO use and challenges to equitable integration, including technical and language barriers for patients, clinicians, and health systems. Nonetheless, the health system and regulatory bodies continue to develop stipulations to promote the use of ePROs. Herein, we review the evolution of PROs from an endpoint to an intervention in prospective clinical trials in oncology.

Palliative Care Interventions Effects on Psychological Distress: A Systematic Review & Meta-Analysis

BACKGROUND

Managing psychological distress is an objective of palliative care. No meta-analysis has evaluated whether palliative care reduces psychological distress.

OBJECTIVES

Examine the effects of palliative care on depression, anxiety, and general psychological distress for adults with life-limiting illnesses and their caregivers.

DESIGN

We searched PubMed, PsycInfo, Embase, and CINAHL for randomized clinical trials (RCTs) of palliative care interventions. RCTs were included if they enrolled adults with life-limiting illnesses or their caregivers, reported data on psychological distress at 3 months after study intake, and if authors had described the intervention as "palliative care."

RESULTS

We identified 38 RCTs meeting our inclusion criteria. Many (14/38) included studies excluded participants with common mental health conditions. There were no statistically significant improvements in patient or caregiver anxiety (patient SMD: -0.008, P = 0.96; caregiver SMD: -0.21, P = 0.79), depression (patient SMD: -0.13, P = 0.25; caregiver SMD -0.27, P = 0.08), or psychological distress (patient SMD: 0.26, P = 0.59; caregiver SMD: 0.04, P = 0.78).

CONCLUSIONS

Psychological distress is not likely to be reduced in the context of a typical palliative care intervention. The systemic exclusion of patients with common mental health conditions in more than 1/3 of the studies raises ethical questions about the goals of palliative care RCTS and could perpetuate inequalities.

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

Investigating the Relationship between Fear of Failure and the Delivery of End-of-Life Care: A Questionnaire Study

OBJECTIVE

To investigate whether fear of failure (FOF) influences a clinician's perception of how confident and comfortable they are in their delivery of end-of-life (EOL) care.

METHODS

Cross-sectional questionnaire study with recruitment of physicians and nurses across two large NHS hospital trusts in the UK and national UK professional networks. A total of 104 physicians and 101 specialist nurses across 20 hospital specialities provided data that were analysed using a two-step hierarchical regression.

RESULTS

The study validated the PFAI measure for use in medical contexts. Number of EOL conversations, gender, and role were shown to impact confidence and comfortableness with EOL care. Four FOF subscales did show a significant relationship with perceived delivery of EOL care.

CONCLUSION

Aspects of FOF can be shown to negatively impact the clinician experience of delivering EOL care.

CLINICAL IMPLICATIONS

Further study should explore how FOF develops, populations that are more susceptible, sustaining factors, and its impact on clinical care. Techniques developed to manage FOF in other populations can now be investigated in a medical population.

Video and In-Person Palliative Care Delivery Challenges before and during the COVID-19 Pandemic

CONTEXT

Palliative care (PC) clinicians faced many challenges delivering outpatient care during the coronavirus-19 (COVID-19) pandemic.

OBJECTIVES

We described trends for in-person and video visit PC delivery challenges before and during the COVID-19 pandemic in the U.S.

METHODS

We performed a secondary data analysis of patient characteristics and PC clinician surveys from a multisite randomized controlled trial at 20 academic cancer centers. Patients newly diagnosed with advanced lung cancer (N = 653) were randomly assigned to receive either early in-person or telehealth PC and had at least monthly PC clinician visits. PC clinicians completed surveys documenting PC delivery challenges after each encounter. We categorized patients into 3 subgroups according to their PC visit dates relative to the onset of the COVID-19 pandemic in the U.S.-pre-COVID-19 (all visits before March 1, 2020), pre/post-COVID-19 (≥1 visit before and after March 1, 2020), and post-COVID-19 (all visits after March 1, 2020). We performed Pearson's chi-squared, Fisher's exact, and Kruskal-Wallis tests to examine associations.

RESULTS

We analyzed 2329 surveys for video visits and 2176 surveys for in-person visits. For video visits, the pre-COVID-19 subgroup (25.8% [46/178]) had the most technical difficulties followed by the pre/post-COVID-19 subgroup (17.2% [307/1784]) and then the post-COVID-19 subgroup (11.4% [42/367]) (P = 0.0001). For in-person visits, challenges related to absent patients' family members occurred most often in the post-COVID-19 subgroup (6.2% [16/259]) followed by the pre/post-COVID-19 subgroup (3.6% [50/1374]) and then the pre-COVID-19 subgroup (2.2% [12/543]) (P = 0.02).

CONCLUSION

Technical difficulties related to PC video visits improved, whereas in-person visit challenges related to absent patients' family members worsened during the pandemic.

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.

Pitfalls and Prospects - Lessons Learned from Early Palliative Care Research

Lessons Learned from Early Palliative Care ResearchBuilding on a single-site trial of introducing palliative care soon after cancer diagnosis, researchers set out to conduct a multisite trial. Here, investigators describe how their experience with methodologic challenges that ultimately yielded indeterminate findings transformed their approach for two subsequent, ongoing multisite palliative care trials.

Effects of early palliative care on patients with incurable cancer: A meta-analysis and systematic review

OBJECTIVE

This meta-analysis aims to compare the effects of early palliative care on patients with incurable cancer with those of standard oncologic care or on-demand palliative care.

METHODS

Pubmed, Embase, Web of Science, Cochrane Library, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (ICTRP) were searched for relevant randomised controlled trials. We also screened reference lists of included studies for additional qualified studies. We used Cochrane Collaboration Risk of Bias Tool to evaluate quality of included studies. DerSimonian and Laird's random effects meta-analysis was used to synthesise the effects.

RESULTS

Sixteen in 1376 studies were included. The pooled data suggested that patients receiving early palliative care had better quality of life (SMD = 0.737, 95% CI: 0.240-1.234), fewer symptoms (SMD = 0.304, 95% CI: 0.097-0.510), better mood (SMD = -0.443, 95% CI: -0.605 to -0.282), better survival (hazard ratio [HR] of death: HR = 1.521, 95% CI: 1.521-1.923; 1-year overall survival probability: HR = 1.238, 95% CI: 1.031-1.486) and higher probability of dying at home (HR = 1.153, 95% CI: 1.027-1.295) than patients in the control group. And there is no difference between resource use.

CONCLUSION

Early palliative care improves lives of patients with incurable cancer, but the evidence level is low because of high heterogeneity of quality of life and small numbers of included studies for other results.

Initiating early palliative care for older people with advanced cancer and its barriers

PURPOSE OF REVIEW

Early palliative care (EPC) is known to generally improve both health-related quality of life (QoL) and symptom intensity at small effect sizes. However, it is unclear whether EPC is effective in older people, a population that is notoriously unaccounted for. This review summarizes the recent evidence concerning the efficacy of EPC in older patients with advanced cancer and delineates existing barriers to accessing respective services.

RECENT FINDINGS

The search for studies published in MEDLINE from January 2020 to September 2021 yielded six relevant records. Data from a recent feasibility trial and subgroups from larger randomised trials point to a somewhat lesser decline in QoL for patients undergoing EPC compared to those receiving treatment as usual. However, enrolling older patients in such trials remains a major challenge mostly due to them feeling too ill to participate.

SUMMARY

For older patients, the efficacy of EPC, like many other medical interventions, has hardly been studied so far. Existing work yielded several specific barriers for older patients to access this type of care. Future research should prioritize efficacy trials of EPC tailored to the needs of older patients enabling clinicians to enter truly evidence-based shared decision-making with their patients.

Effects of Early Palliative Care in Advanced Cancer Patients: A Meta-Analysis

Objective: Advanced cancer patients often suffer from a reduced quality of life (QoL) and cancer-related symptoms. Early palliative care may improve their QoL and symptom severity. Methods: We conducted a meta-analysis of the effects of early palliative care on QoL, symptom severity, and other outcomes in advanced cancer patients, and searched PubMed, Embase, CINAHL, MEDLINE, and the Cochrane Library databases for potential randomized controlled trials (RCTs). The primary outcome was QoL. The secondary outcomes were symptom intensity and functional well-being (Trial Outcome Index, TOI). The study protocol has been registered and approved by PROSPERO (CRD42020164047). Results: We obtained 12 RCTs enrolling 2980 participants. Compared with the usual care, early palliative care significantly improved QoL at ≤ 3 months (SMD = .16, 95% CI = .05-.27) and when treated more 3 months (SMD = .26, 95% CI = .11-.40). Compared with usual treatment, patients who received early palliative care exhibited a significant reduction in symptom intensity when treated more than 3 months (SMD = .18, 95% CI = .06-.31) and in TOI ≤ 3 months (SMD = .28, 95% CI = .11-.45). Conclusions: Early palliative care improves QoL, symptom intensity, and TOI in advanced cancer patients. We recommend introducing early palliative care for advanced cancer patients as the approach provides additional clinical benefits compared with usual care.

Patient-Centered Palliative Care for Patients With Advanced Lung Cancer

The evidence base demonstrating the benefits of an early focus on palliative care for patients with serious cancers, including advanced lung cancer, is substantial. Early involvement of specialty-trained palliative care clinicians in the care of patients with advanced lung cancer improves patient-reported outcomes, such as quality of life, and health care delivery, including hospice utilization. Since the time that many of these palliative care trials were conducted, the paradigm of cancer care for many cancers, including lung cancer, has changed dramatically. The majority of patients with advanced lung cancer are now treated with immune checkpoint inhibitors or targeted therapies, both of which have had a significant impact on patient's experience and outcomes. With this changing landscape of lung cancer therapeutics, patients are facing new and different challenges, including dealing with novel side effect profiles and coping with greater uncertainty regarding their prognosis. Patients who are living longer with their advanced cancer also struggle with how to address survivorship issues, such as sexual health and exercise, and decision making about end-of-life care. Although palliative care clinicians remain well-suited to address these care needs, they may need to learn new skills to support patients treated with novel therapies. Additionally, as the experience of patients with advanced lung cancer is becoming more varied and individualized, palliative care research interventions and clinical programs should also be delivered in a patient-centered manner to best meet patient's needs and improve their outcomes. Tailored and technology-based palliative care interventions are promising strategies for delivering patient-centered palliative care.

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.

Quality of Life and Role of Palliative and Supportive Care for Patients With Brain Metastases and Caregivers: A Review

Brain metastases (BM) are the most commonly diagnosed secondary brain lesions in adults, influencing these patients' symptoms and treatment courses. With improvements in oncologic treatments, patients with BM are now living longer with their advanced cancers, and issues pertaining to quality of life become more pressing. The American Society of Clinical Oncology has recommended early implementation of palliative care for cancer patients, though incorporation and implementation of palliative and other supportive services in the setting of true multidisciplinary care requires additional attention and research for patients with intracranial metastases. We review the physical, cognitive, and psychosocial challenges patients with BM and their caregivers face during their cancer course as well as the current published research on quality of life metrics relating to this patient population and the diverse roles specialty palliative care, rehabilitation services, and other healthcare providers play in a comprehensive multidisciplinary care model.

Increasing Readiness for Early Integrated Palliative Oncology Care: Development and Initial Evaluation of the EMPOWER 2 Intervention

CONTEXT

Early integrated palliative care improves quality of life, but palliative care programs are underutilized. Psychoeducational interventions explaining palliative care may increase patients' readiness for palliative care.

OBJECTIVES

To 1) collaborate with stakeholders to develop the EMPOWER 2 intervention explaining palliative care, 2) examine acceptability, 3) evaluate feasibility and preliminary efficacy.

METHODS

The research was conducted at a North American cancer center and involved 21 stakeholders and 10 patient-participants. Investigators and stakeholders iteratively developed the intervention. Stakeholders rated acceptability of the final intervention. Investigators implemented a pre-post trial to examine the feasibility of recruiting 10 patients with metastatic cancer within one month and with a ≥50% consent rate. Preliminary efficacy outcomes were changes in palliative care knowledge and attitudes.

RESULTS

Using feedback from four stakeholder meetings, we developed a multimedia intervention tailored to three levels of health-literacy. The intervention provides knowledge and reassurance about the purpose and nature of palliative care, addressing cognitive and emotional barriers to utilization. Stakeholders rated the intervention and design process highly acceptable (3.78/4.00). The pilot met a priori feasibility criteria (10 patients enrolled in 14 days; 83.3% consent rate). The intervention increased palliative care knowledge by 83.1% and improved attitudes by 18.9 points on a 0 to 51 scale (Ps < 0.00001).

CONCLUSIONS

This formative research outlines the development of a psychoeducational intervention about palliative care. The intervention is acceptable, feasible, and demonstrated promising pilot test results. This study will guide clinical teams in improving patients' readiness for palliative care and inform the forthcoming EMPOWER 3 randomized clinical trial.

Psychological Response to the Diagnosis of Advanced Cancer: A Systematic Review

BACKGROUND

Despite major efforts to address psychological distress and quality of life (QOL) in people with cancer, only none to small intervention effect has been observed. There is reason to question whether psychosocial needs of patients have already been met under the usual oncology care.

PURPOSE

The purpose of this systematic review was to examine changes in depression, anxiety and QOL during the existential plight in advanced cancer.

METHODS

A literature search was performed in the PubMed and APA PsycINFO databases from year 1976 up to May 31, 2021. Longitudinal observational or experimental research targeting depression, anxiety or QOL in advanced cancer (stage III or IV), with baseline time since cancer diagnosis within 100 days, follow-up within 16 weeks post-baseline were eligible. Quality rating was based on the GRADE guidelines.

RESULTS

Overall QOL did not reveal clinically relevant changes for the majority of studies as evaluated by effect size and raw score changes (median effect size 0.01, interquartile range -0.10-0.15). Nonetheless, modest to moderate improvement was found for depression (median effect size 0.28, interquartile range 0.03-0.38) and anxiety (median effect size 0.57, interquartile range 0.32-0.79).

CONCLUSION

Transient distress symptoms and temporarily reduced functioning in the oncology setting may be considered normal, whereas impaired overall QOL needs to be addressed. Developing innovative interventions that enhance QOL for patients newly diagnosed with advanced cancer without interfering with patients' natural adaptation process is imperative.

Appropriate referral timing to specialized palliative care service: survey of bereaved families of cancer patients who died in palliative care units

Few studies have investigated appropriate referral timing of specialized palliative care (SPC) from the perspective of cancer patients' and families' experiences. We aimed to clarify appropriate SPC referral timing for patients with advanced cancer and their families. We used data from a nationwide bereaved family survey in Japan. We sent a questionnaire to 999 bereaved families of cancer patients who died in 164 palliative care units (PCUs) and analyzed the first SPC referral timing and how patients evaluated it. We defined SPC as outpatient or inpatient palliative care service comprising certified palliative care physicians, advanced-practice nurses, and multidisciplinary practitioners. Finally, 51.6% (n = 515) of all responses were analyzed. The SPC referral timing was evaluated as appropriate (26.1%), late or too late (20.2%), early or too early (1.2%), or none of these (52.5%). Of these, 32.3% reported that they were referred to an SPC when diagnosed with advanced or incurable cancer or during anti-cancer treatment, and 62.6% reported they were referred after anti-cancer treatment. Patient-perceived appropriateness of SPC referral timing was associated with their good death process. After excluding "none of these" responses, a significantly higher proportion of respondents who reported being referred to SPC at diagnosis and during anti-cancer treatment evaluated the response timing as appropriate, compared to those who reported being referred after anti-cancer treatment. Appropriate timing for SPC referrals relates to quality of death; findings suggest that appropriate timing is at the time of diagnosis or during anti-cancer treatment.

Discussing Prognosis with Empathy to Cancer Patients

PURPOSE OF REVIEW

Our goal was to provide healthcare professionals (HCPs) with evidence-based data about what can be done to handle prognostic discussions with empathy.

RECENT FINDINGS

First, disclosing prognosis involves a good reason to do so and making sure that the patient will be able to process the discussion. Second, communication tips are given for the three dimensions of empathy: "establishing rapport with the patient," which should not be overlooked; the emotional dimension, which involves an accurate understanding of the patient and communication skills; and the "active/positive" dimension which is about giving hope, explaining things clearly and helping patients take control with shared decision-making and a planned future. Although communication tips are helpful, empathy training should be based more on the development of HCPs' emotional skills, in order to help them regulate their emotions and thus be more comfortable with those of patients and families. Furthermore, research into empathy toward minorities and relatives is needed.

Should Loss of Appetite Be Palliated in Patients with Advanced Cancer?

Loss of appetite is common among patients with advanced cancer. However, it remains controversial how, when, and if to palliate this symptom. Here, we provide an update on recent as well as past literature to address the question of whether loss of appetite should be palliated in patients with advanced cancer. In our opinion—and as discussed here—we believe that this symptom should be palliated, although perhaps not always with pharmacologic interventions.

A Palliative Care Intervention for Patients on Phase 1 Studies

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

Independent Research on Cancer Pain Management in the Setting of Early Palliative Care: A Flywheel to Counteract General Opioid Misuse and Abuse

The increased recognition of the high prevalence and important burden of cancer pain and the documentation of a large proportion of patients receiving inadequate analgesic treatment should have reinforced the need for evidence-based recommendations. The World health Organization (WHO) guidelines on cancer pain management—or palliative care—are traditionally based on a sequential, three-step, analgesic ladder according to pain intensity: nonopioids (paracetamol or nonsteroidal anti-inflammatory drugs) to mild pain in step I; weak opioids (eg, codeine or tramadol) to mild-moderate pain in step II; and strong opioids to moderate-severe pain in step. III. Despite the widespread use of this ladder, unrelieved pain continues to be a substantial concern in one third of patients with either solid or hematologic malignancies. The sequential WHO analgesic ladder, and in particular, the usefulness of step II opioids have been questioned but there are no universally used guidelines for the treatment of pain in patients with advanced cancer and not all guideline recommendations are evidence-based. The American Society of Clinical Oncology and the European Society of Medical Oncology have recommended the implementation of early palliative care (EPC), which is a novel model of care, consisting of delivering dedicated palliative service concurrent with active treatment as early as possible in the cancer disease trajectory. Improvement in cancer pain management is one of the several important positive effects following EPC interventions. Independent well-designed research studies on pharmacological interventions on cancer pain, especially in the EPC setting are warranted and may contribute to spur research initiatives to investigate the poorly addressed issues of pain management in non cancer patients.

Association of a pediatric palliative oncology clinic on palliative care access, timing and location of care for children with cancer

Background

Most pediatric palliative care (PPC) services are inpatient consultation services and do not reach patients and families in the outpatient and home settings, where a vast majority of oncology care occurs. We explored whether an embedded pediatric palliative oncology (PPO) clinic is associated with receipt and timing of PPC and hospital days in the last 90 days of life.

Methods

Oncology patients (ages 0–25) with a high-risk event (death, relapse/progression, and/or phase I/II clinical trial enrollment) between 07/01/2015 and 06/30/2018 were included. PPO clinic started July 2017. Two cohorts were defined: pre-PPO (high-risk event(s) occurring 07/01/2015–06/30/2017) and post-PPO (high-risk event(s) occurring 07/01/2017–06/30/2018). Descriptive statistics were performed; demographic, disease course, and outcomes variables across cohorts were compared.

Results

A total of 426 patients were included (pre-PPO n = 235; post-PPO n = 191). Forty-seven patients with events in both pre- and post-PPO cohorts were included in the post-PPO cohort. Mean age at diagnosis was 8 years. Diagnoses were evenly distributed among solid tumors, brain tumors, and leukemia/lymphoma. Post-PPO cohort patients received PPC more often (45.6% vs. 21.3%, p < 0.0001), for a longer time before death than the pre-PPO cohort (median 88 vs. 32 days, p = 0.027), and spent fewer days hospitalized in the last 90 days of life (median 3 vs. 8 days, p = 0.0084).

Conclusion

A limited-day, embedded PPO clinic was associated with receipt of PPC and spending more time at home in patients with cancer who had high-risk events. Continued improvements to these outcomes would be expected with additional oncology provider education and PPO personnel.