Can Oncologists Prompt Patient Prognostic Awareness to Enhance Decision-Making? Data From the NEOetic Study

Prognostic Disclosure in Metastatic Breast Cancer: Protocol for a Scoping Review

BACKGROUND

Prognostic disclosure enables shared decision-making by keeping patients informed about their health and involved in treatment-related choices. In metastatic cancer, patients who understand their prognosis are better placed to evaluate their health situation, have more realistic expectations about treatment, and better end-of-life (EoL) care. However, many oncologists feel uncomfortable discussing prognoses with their patients, as they worry about causing psychological distress and diminishing hope. Other barriers to prognostic disclosure are associated with the inherent uncertainty of prognostication, which is especially prominent in metastatic breast cancer (mBC), as are a lack of timely discussions about EoL care and poor quality of care at EoL. Despite this background, a preliminary literature search has shown that, to date, knowledge about prognostic disclosure in mBC has not been systematically mapped.

OBJECTIVE

The overall aim of this scoping review will be to comprehensively explore the existing literature pertaining to prognostic disclosure in mBC.

METHODS

This scoping review will follow Arksey and O'Malley's expanded framework. We will systematically search electronic databases for peer-reviewed, published journal articles to identify appropriate studies. First, 2 members of the research team will independently review titles and abstracts. Then, they will review full texts to establish whether articles meet inclusion criteria. A data chart for collecting and sorting information will be developed. Results will be reported following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines and summarized quantitatively and qualitatively.

RESULTS

We expect to present the results in a scoping review in 2025.

CONCLUSIONS

To our knowledge, this scoping review will be the first systematic effort aimed at mapping existing literature on prognostic disclosure in mBC, in which rapidly developing therapeutic approaches and changing disease trajectories generate new uncertainties and place new communicative demands on oncologists. The insights gained from this scoping review will inform the development of an interview schedule with oncologists, oncology residents, oncology nurses, and patients with mBC to explore their experiences, views, and perceptions about prognostic disclosure.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/57256.

To be aware or not to be aware of the prognosis in the terminal stage of cancer? A systematic review of the associations between prognostic awareness with anxiety, depression, and quality of life according to cancer stage

Prognostic awareness (PA) has an important role in promoting informed care planning in cancer patients. However, studies in the literature showed discordant results regarding the impact of PA on psychological and quality of life outcomes. The present systematic review aimed to investigate the associations between PA with anxiety, depression, and quality of life in oncological patients according to early, advanced, and terminal cancer stages. The review adhered to PRISMA guidelines and was registered on PROSPERO. The research identified 42.357 studies, of which 54 were included. The main result showed that the associations of PA with anxiety, depression, and quality of life varied according to the cancer stage. In studies with early and advanced cancer patients, 0 % and 9 %, respectively, showed favourable associations, while in those with terminal cancer patients, 53 % showed favourable associations. In terminal stage cancer, the associations were favourable when patients were enrolled in hospice, had a mean survival time shorter than 60 days, and a mean age older than 65 years. These findings suggest that it could be important within psychological interventions for patients to consider the impact of PA at different stages of cancer. While in the early and advanced stages of cancer, patients might benefit most from interventions focused on implementing psychological resources to face the illness and maintaining a hopeful outlook, in the terminal stage of cancer, it could be important to promote the process of becoming aware of their prognosis.

Changes in perception of prognosis in the last year of life of patients with advanced cancer and its associated factors: Longitudinal results of the eQuiPe study

BACKGROUND

Many patients with advanced cancer are unaware of their limited prognosis, however little is known about the change in awareness during the last year of their lives.

AIM

To investigate changes in the perception of prognosis in the last year of life of patients with advanced cancer and its associated factors.

DESIGN

Prospective, longitudinal, multicentre, observational study in patients with advanced cancer (eQuiPe). Patients completed 3-monthly follow-up questionnaires until death.

SETTING/PARTICIPANTS

Adult patients diagnosed with advanced cancer were recruited by their treating physician or self-enrolled in one of the forty Dutch hospitals. Only deceased patients with available prognostic data were included for analysis (n = 801).

RESULTS

Perception of prognosis changes in the last year of life with an increase in the percentage of patients who are aware of their limited prognosis (from 15% to 40%). Especially in the last 6 months of life, most of the changes were towards a more realistic perception of prognosis. Patients who did not want to know their prognosis remained relatively stable in their wish not to know (range: 14%-18%). Time to death was associated with having a perception of prognosis of < 1 year, >1 year or not knowing the prognosis, but was not associated with not wanting to know the prognosis.

CONCLUSION

Becoming aware of their limited prognosis may make patients with advanced cancer more receptive to start end-of-life discussions. Although some patients prefer not to know their prognosis, it remains important to respectfully explore their preferences and wishes for end-of-life care.

Clinical research framework proposal for ketogenic metabolic therapy in glioblastoma

Glioblastoma (GBM) is the most aggressive primary brain tumor in adults, with a universally lethal prognosis despite maximal standard therapies. Here, we present a consensus treatment protocol based on the metabolic requirements of GBM cells for the two major fermentable fuels: glucose and glutamine. Glucose is a source of carbon and ATP synthesis for tumor growth through glycolysis, while glutamine provides nitrogen, carbon, and ATP synthesis through glutaminolysis. As no tumor can grow without anabolic substrates or energy, the simultaneous targeting of glycolysis and glutaminolysis is expected to reduce the proliferation of most if not all GBM cells. Ketogenic metabolic therapy (KMT) leverages diet-drug combinations that inhibit glycolysis, glutaminolysis, and growth signaling while shifting energy metabolism to therapeutic ketosis. The glucose-ketone index (GKI) is a standardized biomarker for assessing biological compliance, ideally via real-time monitoring. KMT aims to increase substrate competition and normalize the tumor microenvironment through GKI-adjusted ketogenic diets, calorie restriction, and fasting, while also targeting glycolytic and glutaminolytic flux using specific metabolic inhibitors. Non-fermentable fuels, such as ketone bodies, fatty acids, or lactate, are comparatively less efficient in supporting the long-term bioenergetic and biosynthetic demands of cancer cell proliferation. The proposed strategy may be implemented as a synergistic metabolic priming baseline in GBM as well as other tumors driven by glycolysis and glutaminolysis, regardless of their residual mitochondrial function. Suggested best practices are provided to guide future KMT research in metabolic oncology, offering a shared, evidence-driven framework for observational and interventional studies.

Expectations concerning cancer treatment: perspectives of medical oncologists and patients on advanced, unresectable lung carcinoma

Introduction

This study seeks to compare expectations regarding systemic cancer treatment for advanced lung cancer from the perspectives of both patient and medical oncologist.

Methods

A cross-sectional study involving 17 medical oncologists from 13 Spanish hospitals between 2021 and 2022. Patients with advanced, unresectable lung cancer were recruited prior to initiating systemic cancer treatment. Both patients and oncologists completed the NEOetic-EIT and the STAR.

Results

Seventeen medical oncologists specializing in lung cancer participated, with a mean age of 36.2 years (range 28-56); 65% were female. The study included 298 patients with advanced, unresectable lung cancer, predominantly non-small cell type (72%), and most at stage IV (77%). Most patients were retired or unemployed (71%), and married or partnered (77%). Treatment approaches varied, with 44% based on biomarkers. Oncologists had greater expectations of positive outcomes for participants with better baseline prognosis, such as ECOG 0, newly diagnosed, locally advanced, unresectable non-small cell lung cancer, and those receiving biomarker-based treatments. In contrast, patients' treatment expectations did not vary based on sociodemographic or clinical factors. Generally, patients had high expectations of cure, in contrast to oncologists' lower expectations, though both anticipated similar quality-of-life improvements. Patients anticipated more side effects than oncologists. Among oncologists, expectations varied by gender and decreased with age and experience, with no differences detected among patients based on gender, age, or doctor-patient relationship.

Conclusion

This study reveals the complex expectations of patients and oncologists in advanced lung cancer treatment. It underscores the need for effective communication in oncology to align patient expectations with clinical realities.

Promoting patient-centered care in CAR-T therapy for hematologic malignancy: a qualitative meta-synthesis

BACKGROUND

CAR-T therapy has emerged as a potentially effective treatment for individuals diagnosed with hematologic malignancies. Understanding patients' unique experiences with this therapeutic approach is essential. This knowledge will enable the development of tailored nursing interventions that align with the increasing importance of patient-centered care.

OBJECTIVE

To examine and synthesize qualitative data on patients and their family caregivers' experiences during the treatment journey.

DESIGN

We conducted a systematic review and qualitative meta-synthesis. Eligible studies contained adult patient or family caregiver quotes about experiences of CAR-T therapy, published in English or Chinese in a peer-reviewed journal since 2015. Data sources included MEDLINE, CINAHL, Embase, PsycINFO, Web of Science, Scopus, Cochrane Library, CNKI, and WanFang.

METHODS

Systematic search yielded 6373 identified articles. Of these, 12 reports were included in the analysis, which covered 11 separate studies. Two reviewers independently extracted data into NVIVO 12.0. Qualitative meta-synthesis was performed through line-by-line coding of full text, organization of codes into descriptive themes, and development themes.

RESULTS

The qualitative meta-synthesis yielded eight primary themes. Noteworthy revelations from patients and their family caregivers regarding the CAR-T therapy journey encompassed various aspects. Prior to CAR-T therapy, patients experienced a lack of actual choice, struggled with expectations for treatment outcomes, and encountered intricate emotional experiences. During or immediately after CAR-T therapy, patients reported both comfortable and uncomfortable experiences. Additionally, patients emphasized that concerns regarding treatment efficacy and adverse reactions intensified treatment-related distress. After CAR-T therapy, significant changes were observed, and the burden of home-based rehabilitation. Additionally, we found factors contributed to the high CAR-T therapy cost.

CONCLUSIONS

To ensure the safety and sustainability of CAR-T therapy, it is crucial to address the physical and psychological aspects of the patient's experience. Effective communication and comprehensive management are highly valued by patients and their caregivers. Further research should investigate ways to reduce burdens and develop self-management education programs for patients and their families.

The trajectory of prognostic cognition in patients with advanced cancer: is the traditional advance care planning approach desirable for patients?

Most patients with advanced cancer initially express a desire to be informed of their prognosis, and prognostic discussions between patients and their oncologists can trigger the subsequent trajectory of prognostic cognitions. On the continuum of prognostic cognition, including inaccurate/accurate prognostic awareness (awareness of incurability of cancer, terminal nature of illness or life expectancy) and prognostic acceptance (accepting one's prognosis), patients' perceptions of being informed of their prognosis by oncologists and patients' coping strategy for serious medical conditions regulate prognostic cognitions. However, nearly half of the patients with advanced cancer have poor prognostic awareness, and few patients achieve prognostic acceptance. These phenomena partly act as barriers to participation in advance care planning. When oncologists engage in advance care planning conversations, they must assess the patient's prognostic cognition and readiness for advance care planning. Considering the inaccurate prognostic awareness in a non-negligible proportion of patients and that astatic patients' preferences for future treatment and care are influenced by prognostic cognition, more research on decision-making support processes for high-quality and goal-concordant end-of-life care is needed along with research of advance care planning. In addition to making decisions regarding future medical treatment and care, oncologists must engage in continuous and dynamic goal-of-care conversations with empathic communication skills and compassion from diagnosis to end-of-life care.

Challenging Rationality: Examining the Belief in Cure Among Patients With Advanced Incurable Cancers

Citing a recently published study, this letter to the editor highlights again the critical role of prognostic awareness in the decision-making process for cancer therapeutics.

Clinicians' and Advanced Cancer Patients' Estimates of Treatment Efficacy and Toxicity in Oncologic Treatment

The purpose of the study was to compare curability expectations between clinicians and patients and examine the influence of sociodemographic and clinical variables on these expectations and satisfaction within the clinician-patient relationship. This prospective study, conducted from February 2020 to May 2023, involved 986 advanced cancer patients. The patients completed questionnaires assessing treatment efficacy and toxicity predictions and the Scale to Assess the Therapeutic Relationship (STAR). Seventy-four percent of advanced cancer patients had an inaccurate perception of treatment curability. Clinicians perceived male patients with lung or digestive cancer without adenocarcinoma at locally advanced stages, with fewer comorbidities and better functional status (ECOG), as having higher curability expectations. Clinicians tended to have more realistic expectations than patients, since they had to consider the presence of treatment's side effects, while patients underestimated the possibility of experiencing these adverse effects. Patients who had more favorable expectations regarding survival and quality of life were found to be more satisfied with the care provided by their oncologists. It is crucial for patients to understand the treatment goals and establish realistic expectations in order to actively participate in decision-making and achieve a better quality of life at the end of life.