A Qualitative Study Exploring Patient, Family Carer and Healthcare Professionals' Direct Experiences and Barriers to Providing and Integrating Palliative Care for Advanced Head and Neck Cancer

Predisposing, Enabling, and Need Factors Driving Palliative Care Use in Head and Neck Cancer

OBJECTIVE

Characterizing factors associated with palliative care (PC) use in patients with stage III and VI head and neck cancer using Anderson's behavioral model of health service use.

STUDY DESIGN

A retrospective study of the 2004 to 2020 National Cancer Database.gg METHODS: We used multivariate logistic regression to assess the association of predisposing, enabling, and need factors with PC use. We also investigated the association of these factors with interventional PC type (chemotherapy, radiotherapy, surgery) and refusal of curative treatment in the last 6 months of life.

RESULTS

Five percent of patients received PC. "Predisposing factors" associated with less PC use include Hispanic ethnicity (adjusted odds ratio [aOR], 086; 95% confidence interval [CI], 0.76-0.97) and white and black race (vs white: aOR, 1.14; 95% CI, 1.07-1.22). "Enabling factors" associated with lower PC include private insurance (vs uninsured: aOR, 064; 95% CI, 0.53-0.77) and high-income (aOR, 078; 95% CI, 0.71-0.85). "Need factors" associated with higher PC use include stage IV (vs stage III cancer: aOR, 2.25; 95% CI, 2.11-2.40) and higher comorbidity index (vs Index 1: aOR, 1.58; 95% CI, 1.42-1.75). High-income (aOR, 0.78; 95% CI, 0.71-0.85) and private insurance (aOR, 0.6; 95% CI, 0.53, 0.77) were associated with higher interventional PC use and lower curative treatment refusal (insurance: aOR, 0.82; 95% CI, 0.55, 0.67; income aOR, 0.48; 95% CI, 0.44, 0.52).

CONCLUSION

Low PC uptake is attributed to patients' race/culture, financial capabilities, and disease severity. Culturally informed counseling, clear guidelines on PC indication, and increasing financial accessibility of PC may increase timely and appropriate use of this service.

Education About Specialty Palliative Care Among Nonhealthcare Workers: A Systematic Review

CONTEXT

Despite the expansion of palliative care (PC) services, the public has little knowledge and holds misperceptions about PC, creating barriers to accessing timely specialty PC.

OBJECTIVES

To systematically review the evidence regarding the efficacy of educational interventions to improve knowledge and attitudes about PC among nonhealthcare workers.

METHODS

We searched five databases (PubMed/MEDLINE, Embase, CIANHL, Web of Science, and Scopus) for studies investigating educational interventions about specialty PC in adults who identified as patients, caregivers, or members of the public. We included studies that were available in English and had a comparator group. We excluded studies that only sampled health professionals or children. We used the Mixed Methods Appraisal Tool to assess quality and risk of bias.

RESULTS

Of 12,420 records identified, we screened 5948 abstracts and assessed 526 full texts for eligibility. Twenty-one articles were extracted for analysis, representing 20 unique educational interventions. Common methodologies included quasi-experimental (9, 45%), randomized controlled trial (4, 20%), and nonrandomized trial (2, 10%). Common components of the educational interventions included video presentations (9, 45%), written materials (8, 40%), and lectures (4, 20%). Content included definition (14, 70%) and philosophy (14, 70%) of PC, distinctions between PC and hospice (11, 55%), and eligibility for PC (11, 55%). Fourteen (70%) interventions showed statistically significant positive differences in either knowledge or attitudes about PC.

CONCLUSIONS

While educational interventions can positively impact knowledge and attitudes about PC among nonhealthcare workers, more research is needed to inform the design, delivery, and evaluation of interventions to increase knowledge and attitudes about PC.

Palliative care interventions for patients with head and neck cancer: protocol for a scoping review

INTRODUCTION

A head and neck cancer (HNC) diagnosis significantly impacts a patient's quality of life (QOL). Palliative care potentially improves their QOL. We will conduct a scoping review to identify existing knowledge about palliative care interventions for patients with HNC.

METHODS AND ANALYSIS

This scoping review was designed in accordance with the JBI Manual for Evidence Synthesis: Scoping Reviews and will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Our eligibility criteria follow the Population, Intervention, Comparison or Control, Outcomes and Study characteristics framework. The population is adult patients with locally advanced, metastatic, unresectable and/or recurrent HNC. We include peer-reviewed journal articles and articles in the press, in English, reporting on palliative care interventions with at least two of the eight National Consensus Project on Clinical Practice Guidelines for Quality Palliative Care domains; studies with and without comparators will be included. The outcomes are patient QOL (primary) and symptom severity, patients' satisfaction with care, patients' mood, advance care planning and place of death (secondary). We developed a search strategy across ten databases, to be searched from the inception to 11 September 2023: Medline ALL (Medline and EPub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase Classic+Embase, Emcare and PsycINFO all from the OvidSP platform; CINAHL from EBSCOhost, Scopus from Elsevier, Web of Science from Clarivate and Global Index Medicus from WHO. We will extract data using a piloted data form and analyse the data through descriptive statistics and thematic analysis.

ETHICS AND DISSEMINATION

Ethics approval is not needed for a scoping review. We will disseminate the findings to healthcare providers and policy-makers by publishing the results in a scientific journal.

The role of palliative care in relapsed and metastatic head and neck cancer patients in a single ESMO integrated oncology and palliative care centre

BACKGROUND

Palliative care (PC) for patients with advanced cancer improves symptom management and quality of life and may promote home deaths. Limited data are available regarding PC in advanced head and neck cancer (HNC) patients. The aim of this study was to describe the type of care and modalities of integration of specialized PC in a population of relapsed and/or metastatic head and neck cancer patients, followed in a single institution over 4 years.

METHODS

Between January 2016 and December 2019, data on patients with relapsed and/or metastatic head and neck cancer not suitable for curative treatment diagnosed at the Oncology Institute of Southern Switzerland were reviewed retrospectively. Site, type and lines of treatment, treatment response, referral to specialist palliative care (yes or no), type of symptoms, tracheostomy and/or feeding-tube presence, and site of death were documented. Comparisons were made between patients benefitting from PC integration vs standard care.

RESULTS

Eighty-six patients with relapsed/metastatic HNC were identified, 63 (73.3%) of whom were referred to specialized PC. Patients were mainly men (66, 76.7%), with a median age of 69 years (range 44-95). The most common site of tumour was the oropharynx (31, 36%), followed by the larynx (21, 24.4%), oral cavity (19, 22.1%), hypopharynx (14, 16.3%), and unknown primary (1, 1.2%). Forty-four patients (51.2%) were treated with systemic treatment. The median time interval between the diagnosis and palliative care referral was 1.7 months. At the time of our analysis, 69 patients had died (58 in the PC group and 11 in the non-PC group). Fifteen patients (25.9%) in the PC group and 4 (36.4%) in the non-PC group had received aggressive treatment (chemotherapy, tracheostomy and/or feeding tube) in the last month of life, with no significant difference between groups (p = 0.44). There was no difference in the incidence of home death (19.1% PC group vs 9.1% non-PC group, p = 0.67) or presence of caregiver (69.8% PC group vs 78.2% non-PC group, p = 0.58) between groups, while palliative care was associated with more opioid use (90.5% vs 17.4%, p < 0.0001). Patients in the PC group had a shorter survival compared to the non-PC group (5.7 vs 19.9 months, p = 0.0063).

CONCLUSIONS

This study shows that patients appear to be at risk of receiving inappropriate invasive treatments close to death and of dying in hospital settings. Further research is needed to investigate how early PC may affect decision-making around treatments and improve HNC patients' holistic wellbeing.

An integrated care systems model approach for speech and language therapy head and neck cancer services in England: service development and re-design in Cheshire and Merseyside

PURPOSE OF REVIEW

The incidence of head and neck cancer (HNC) is increasing globally and changes in treatment mean that patients are living longer with the condition. It is recognised that while there have been improvements at the diagnostic phase of the pathway, follow-up and on-going care can be fragmented and inequitable. Integrated care models (ICMs) are acknowledged as beneficial. The National Health Service in England is moving to a model whereby services are being re-organised to integrated care systems. This paper reviews the literature and discusses potential models of care to enhance speech and language therapy (SLT) provision for patients with HNC in line with the emerging ICS.

RECENT FINDINGS

The COVID-19 pandemic has provided an opportunity to review service provision and SLT teams quickly adapted to offering remote support. Discussions are currently on-going to explore the potential for patient initiated follow-up via the PETNECK 2 trial and the Buurtzorg 'neighbourhood model' holds promise.

SUMMARY

ICMs put the patient at the centre of care and have reported benefits for experience of care and clinical outcomes. Navigating organisational structures is complex. The Buurtzorg model provides a practical and theoretical framework to support organisational change.

"Who can I ring? Where can I go?" Living with advanced cancer whilst navigating the health system: a qualitative study

BACKGROUND

People with advanced cancer often experience greater physical and psychosocial morbidity compared to those with early disease. Limited research has focused on their experiences within the Australian health system. The aim of this study was to explore the lived experiences of adults receiving care for advanced cancer.

METHODS

A qualitative design with a descriptive phenomenological approach was used to explore the lived experiences of people with advanced cancer following their diagnosis. Twenty-three people living with an advanced solid malignancy receiving care were referred by their oncologists to take part in an interview conducted at their home, the hospital, or over the phone.

RESULTS

Three key themes emerged relating to participants' experiences of living with advanced cancer: (1) living with a life-limiting diagnosis and uncertainty, (2) living with symptom burden and side effects, and (3) living within the health system, with two subthemes, the patient-clinician relationship, and care coordination. Participant relationships with their health professionals were particularly important and had a defining impact on whether patient experiences living with cancer were positive or negative.

CONCLUSION

People with advanced cancer experienced broad variation in their experiences navigating the health system, and their relationships with clinicians and other health professionals were important factors affecting their perceptions of their experiences. Attention to the coordination of care for people with advanced cancer is necessary to improve their experiences and improve symptom control and the management of their psychosocial burden.

Head and neck cancer end of life care: complex challenges

Head and neck cancers frequently carry a poor prognosis and are commonly associated with complex medical needs and symptoms. Timing of referral to specialist palliative care teams (SPCTs) is challenging. We present the case of a 57-year-old woman with locally highly advanced head and neck cancer. The patient had highly complex medical needs including a tracheostomy to maintain airway patency, artificial feeds via jejunostomy and impaired communication due to hearing loss, tracheostomy and fatigue. She required support with advance care planning and complex symptom management of pain related to abdominal skin excoriation due to leakage of gastric contents; bleeding of necrotic tumour; anxiety and discomfort due to displacement of tracheostomy. Care by an integrated SPCT allowed smooth transition from hospital to community settings with smooth ongoing management despite highly complex needs. This complex symptom management included tracheostomy removal in the home towards the end of life.

"My life's not my own": A qualitative study into the expectations of head and neck cancer carers

INTRODUCTION

Cancers that originate from the upper aerodigestive tract are collectively known as head and neck cancer. The most common are squamous cell carcinomas of the oropharynx, larynx, and oral cavity. Head and neck cancer patients experience significant physical and psychological changes because of the disease and treatment. There is a substantial strain on family carers who have extensive responsibilities over most aspects of the patient's life. The aim of the study was to understand the perspectives of being an HNC carer and their perceived expectations of the role.

METHODS

The study adopted a qualitative research design with a social constructionist epistemology. Interviews were conducted with 20 carers who were currently caring for someone diagnosed with head and neck cancer.

RESULTS

Three overarching themes were identified: taking responsibility for the patient's nutrition, navigating a new and different relationship, and "my life's not my own." Participants felt responsible for ensuring the patient was eating and became increasingly frustrated when the patient was unable to intake food. Carers prioritised the patients' needs at the expense of their own, and several came to resent the role.

CONCLUSION

Carers' expectations of their role informed how they approached giving care. Carers need to be supported from diagnosis and encouraged to prioritise their own wellbeing.

The unmet needs of patients with advanced incurable head and neck cancer and their carers: A systematic review and meta-ethnography of qualitative data

INTRODUCTION

Patients with advanced-stage head and neck cancers (HNC) endure a significant symptom burden and suffer greatly towards the end of their lives. Qualitative evidence can provide insight into how existing services meet their needs. We aimed to synthesise qualitative data from patients with advanced HNC and their carers to inform improvements to services and care.

METHODS

A systematic search was conducted in MEDLINE and EMBASE for studies containing qualitative data from patients with advanced HNC and their carers. An interpretive account was generated using the meta-ethnography methodology.

RESULTS

We identified 8 studies including 38 patients and 25 carers. Twenty-six themes were synthesised into five concepts: psychological impact and adjustment, physical limitations and deliverance of symptomatic care, communication and information needs from healthcare professionals, social support and dependence, and needs of the primary caregiver. We identified that patients had complex psychological needs, centred on uncertainty and fear of suffering. Patients desired full information and found poor communication highly distressing. There was a dearth of literature on the subjective impact of physical limitations. Patients became reliant on social networks, and those with lower quality relationships coped poorly. However, caregivers struggled to meet patients' complex needs, resulting in distress and isolation.

CONCLUSIONS

Patients with advanced HNCs have complex needs that are not met in current systems. Further qualitative work focusing on the physical and psychological impact of advanced HNC would be of value.

Introduction to Special Issue on Advanced Cancer Care and Palliative Care Integration

Palliative care is uniquely positioned to optimize the care of the oncology patient through exploring unmet needs and utilizing interdisciplinary care. The studies presented here highlight some of the ways this can be done which includes: identifying patients at risk or in need; providing solutions to those requiring community supports; addressing psychological and existential concerns; managing symptoms over the course of a disease; communicating prognosis effectively and with compassion; exploring goals of care and advance directives; and facilitating conversations regarding goals, preferences, and values.