Bridging the Divide: Integrating Cancer-Directed Therapy and Palliative Care

Quality End-of-Life Cancer Care: An Unfulfilled but Achievable Imperative

BACKGROUND

Disease-focus management of late-stage cancer without addressing patients' preferences or quality of life (QoL) can lead to unsatisfactory patient and disease outcomes.

METHODS

A PRISMA-adherent systematic review of the literature was conducted via PubMed, Embase, Scopus, and Google Scholar to assess the current late-stage cancer treatment modality, setting, timing, and cost, their impact on patient and disease outcomes, and possible interventions for improvement.

RESULTS

Out of many studies, twelve from North America, Western Europe, and Asia met our inclusion criteria. A detailed analysis of the 929,408 late-stage cancer patients included revealed common management practices. Typically, patients were subjected to sustained intensive disease-focused treatment through the end-of-life (EoL) while deferring palliative care and other host-sustaining measures. Such practices compromised patients' QoL and increased costs without meeting their needs and expectations or significantly altering the course of the disease. To forestall such practices, five pragmatic host-focused management principles are proposed. In contrast to clinical practice guidelines (CPG), they can be promoted directly to current and future cancer care professionals as an easy-to-memorize and apply template: to the former via continuing medical education, podcasts, webinars, and other tutorials; to the latter by its incorporation into Oncology, Hematology, Hospice, and other cancer-training programs.

CONCLUSIONS

Despite major advances in early-stage cancer treatment and survival, late-stage cancer care is hindered by continuous disease-focused practices pursued through the EoL that lead to unsatisfactory patient and disease outcomes. Such practices can be reversed by adopting host-focused management principles that promote QoL and meet patients' needs and expectations as a basis for delivering holistic cancer care through the EoL.

Palliative Care Use Among People Living With HIV and Cancer: An Analysis of the National Cancer Database (2004-2018)

PURPOSE

People living with HIV (PLWH) diagnosed with cancer are less likely to receive quality cancer treatment compared with HIV-negative patients. Timely provision of palliative care (PC) during cancer treatment can increase patient's survival and improve quality of life. Our objective was to compare the use of PC by HIV status among adults diagnosed with cancer in the United States.

METHODS

More than 19 million individuals age 18-90 years diagnosed with the 11 most common cancers among PLWH were selected from the National Cancer Database (2004-2018). The National Cancer Database defined PC as any surgery, radiation, systemic therapy, or pain management treatment with noncurative intent. Multivariable logistic regression was used to examine associations between HIV status and PC receipt by cancer site and stage after adjustment for covariates.

RESULTS

The study population included 52,306 HIV-positive (average age: 56.5 years) and 19,115,520 HIV-negative (average age: 63.7 years) cancer cases. PLWH diagnosed with stage I-III cancer were more likely to receive PC compared with their HIV-negative counterparts (adjusted odds ratio [aO]: 1.96; 95% CI, 1.80 to 2.14); however, they were also less likely to receive curative cancer treatment (aOR, 0.48; 95% CI, 0.40 to 0.59). PLWH diagnosed with stage IV cancer were less likely to receive PC (aOR, 0.70; 95% CI, 0.66 to 0.74) compared with HIV-negative patients. When evaluated by cancer site, PLWH diagnosed with stage IV lung (aOR, 0.80; 95% CI, 0.73 to 0.87) and colorectal (aOR, 0.72, 95% CI, 0.54 to 0.95) cancers were less likely to receive PC than HIV-negative patients.

CONCLUSION

PLWH diagnosed with stage IV cancer, particularly lung and colorectal cancers, were less likely to receive PC compared with cancer patients without HIV. PLWH with nonmetastatic disease were more likely to receive PC but less likely to receive curative treatment, reinforcing that clinical strategies are needed to improve the quality of care among PLWH.

NCCN Guidelines® Insights: Palliative Care, Version 2.2021

Palliative care has evolved to be an integral part of comprehensive cancer care with the goal of early intervention to improve quality of life and patient outcomes. The NCCN Guidelines for Palliative Care provide recommendations to help the primary oncology team promote the best quality of life possible throughout the illness trajectory for each patient with cancer. The NCCN Palliative Care Panel meets annually to evaluate and update recommendations based on panel members' clinical expertise and emerging scientific data. These NCCN Guidelines Insights summarize the panel's recent discussions and highlights updates on the importance of fostering adaptive coping strategies for patients and families, and on the role of pharmacologic and nonpharmacologic interventions to optimize symptom management.

Association of Early Palliative Care Use With Survival and Place of Death Among Patients With Advanced Lung Cancer Receiving Care in the Veterans Health Administration

Importance

Palliative care is a patient-centered approach associated with improvements in quality of life; however, results regarding its association with a survival benefit have been mixed, which may be a factor in its underuse.

Objective

To assess whether early palliative care is associated with a survival benefit among patients with advanced lung cancer.

Design, Setting, and Participants

This retrospective population-based cohort study was conducted among patients with lung cancer who were diagnosed with cancer between January 1, 2007, and December 31, 2013, with follow-up until January 23, 2017. Participants comprised 23 154 patients with advanced lung cancer (stage IIIB and stage IV) who received care in the Veterans Affairs health care system. Data were analyzed from February 15, 2019, to April 28, 2019.

Exposure

Palliative care defined as a specialist-delivered palliative care encounter received after lung cancer diagnosis.

Main Outcomes and Measures

The primary outcome was survival. The association between palliative care and place of death was also examined. Propensity score and time-varying covariate methods were used to calculate Cox proportional hazards and to perform regression modeling.

Results

Of the 23 154 patients enrolled in the study, 57% received palliative care. The mean (SD) age of participants was 68 (9.5) years, and 98% of participants were men. An examination of the timing of palliative care receipt relative to cancer diagnosis found that palliative care received 0 to 30 days after diagnosis was associated with decreases in survival (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.97-2.30), palliative care received 31 to 365 days after diagnosis was associated with increases in survival (aHR, 0.47; 95% CI, 0.45-0.49), and palliative care received more than 365 days after diagnosis was associated with no difference in survival (aHR, 1.00; 95% CI, 0.94-1.07) compared with nonreceipt of palliative care. Receipt of palliative care was also associated with a reduced risk of death in an acute care setting (adjusted odds ratio, 0.57; 95% CI, 0.52-0.64) compared with nonreceipt of palliative care.

Conclusions and Relevance

The results suggest that palliative care was associated with a survival benefit among patients with advanced lung cancer. Palliative care should be considered a complementary approach to disease-modifying therapy in patients with advanced lung cancer.

Temporal trends and social barriers for inpatient palliative care delivery in metastatic prostate cancer patients receiving critical care therapies

BACKGROUND

Use of inpatient palliative care (IPC) in advanced cancer patients represents a well-established guideline recommendation. A recent analysis demonstrated that genitourinary (GU) cancer patients benefited of IPC at the second lowest rate within the four examined primaries, namely lung, breast, colorectal, and GU. Based on this observation, we examined temporal trends and predictors of IPC use in metastatic prostate cancer patients receiving critical care therapies (CCT).

MATERIALS AND METHODS

We identified mPCa patients receiving CCT within the Nationwide Inpatient Sample database (2004-2015). IPC use rates were evaluated using univariable estimated annual percentage changes analyses. Multivariable logistic regression (MLR) models were used after adjustment for clustering at hospital level.

RESULTS

Of 4168 mPCa patients receiving CCT, 449 (11.3%) received IPC. IPC use increased from 1.2 to 22.3% (EAPC: +19.6%, p < 0.001). After stratification according to regions, race, and teaching status, the highest increase of IPC use was recorded in the South (from 0 to 25.4 %, EAPC: +27.6%), in Caucasians (from 1.5 to 24.4 %, EAPC: +19.8%; p < 0.001) and in teaching hospitals (from 0.9 to 26.2 %, EAPC: +19.6%; p < 0.001). In MLR models, teaching status (Odds ratio [OR]: 1.74, p < 0.001) and contemporary year interval (OR: 4.63, p < 0.001) were associated with higher IPC rates. Conversely, African American race (OR: 0.66, p < 0.001) and primary diagnosis of GU disorders (OR: 0.49, p < 0.001) and gastrointestinal (GI) disorders at admission (OR: 0.61, p = 0.02) were associated with lower IPC rates.

CONCLUSIONS

IPC use rate in mPCa patients receiving CCT sharply increased between 2004 and 2015. The highest increase of IPC use across time was recorded in the South, in Caucasian race, and in teaching hospitals. African-American race and nonteaching status were identified as independent predictors of lower IPC use and represent targets for efforts aimed at improving IPC delivery in mPCa patients receiving CCT.

Understanding the Barriers to Introducing Early Palliative Care for Patients with Advanced Cancer: A Qualitative Study

Background: Palliative care is often underutilized or initiated late in the course of life-threatening illness. Randomized clinical Early Palliative Care (EPC) trials provide an opportunity for changing oncologists' perceptions of palliative care and their attitudes to referring patients to palliative care services. Aim: To describe French oncologists' perceptions of EPC and their effects on referral practices before a clinical EPC trial was launched. Design: A qualitative study involving semistructured face-to-face interviews. The data were analyzed using the Grounded Theory coding method. Setting/Participants: Thirteen oncologists and 19 palliative care specialists (PCSs) working at 10 hospitals all over France were interviewed. Most of them were involved in clinical EPC trials. Results: The findings suggest that referral to PCSs shortly after the diagnosis of advanced cancer increases the terminological barriers, induces avoidance patterns, and makes early disclosure of poor prognosis harder for oncologists. This situation is attributable to the widespread idea that palliative care means terminal care. In addition, the fact that the EPC concept is poorly understood increases the confusion between EPC and supportive care. Conclusion: Defining the EPC concept more clearly and explaining to health professionals and patients what EPC consists of and what role it is intended to play, and the potential benefits of palliative care services could help to overcome the wording barriers rooted in the traditional picture of palliative care. In addition, training French oncologists how to disclose "bad news" could help them cope with the emotional issues involved in referring patients to specialized palliative care.

Cancer Chemotherapy near the End of Life: The Time has come to set Guidelines for its Appropriate Use

Aims and Background

This study retrospectively analyzes the use of chemotherapy in patients who died of advanced cancer either after having been in care at the Medical Oncology Unit (MOU) of the University Hospital of Bologna, Italy, or after having been assisted in their terminal disease phase by the Bologna Oncological Hospice at Home (OHH) of the Associazione Nazionale Tumori (ANT) Italia Foundation. In the latter group, the prescription and delivery of chemotherapy had been performed by doctors of medical oncology departments other than the MOU.

Results

Between January 2003 and September 2005, 793 deaths of patients were recorded (MOU: 312; OHH: 481). At least one cycle of chemotherapy had been received by 445 patients (56.1%). The most common cancer types were lung cancer (26.7%), colorectal cancer (14.8%), and breast cancer (11.2%). At the time of the last chemotherapy (l-CT), the median age of the patients was 68 years (range, 22–98 years) and the median KPS was 70 (range, 40–100). The median interval between l-CT and death was 71 days (range, 1-1913 days). One hundred and one patients (22.7%) had received their l-CT in the last 30 days of their life, 86% of them having intermediately chemosensitive (71%) or chemoresistant (14%) tumors. The l-CT in the last month of life was first line in 56% of cases and consisted of costly new-generation drugs in 36.6% of cases.

Conclusions

The study suggests the urgent need to lay down guidelines for the appropriate use of chemotherapy in advanced cancer patients with a short life expectancy.

The influence of familial factors on the choice of the place of death for terminally ill breast cancer patients: a retrospective single-center study

BACKGROUND

The social or familial factors influencing the location chosen for end-of-life (EOL) care for terminally ill breast cancer patients are unknown.

METHODS

We retrospectively analyzed 195 patients with recurrent or progressive breast cancer who received anticancer treatment at the National Cancer Center Hospital between January 2008 and May 2012. Detailed data concerning the patients' demographic, familial, and clinical characteristics were collected, and multivariate and Cox logistic regression analyses were performed to evaluate the impact of these characteristics on the place of EOL care and on survival, respectively.

RESULTS

Sixty-eight patients (34.9 %) died in a hospital, 26 patients (13.3 %) at home, and 101 patients (51.8 %) in hospice. Most of the patients having caregivers received EOL care at palliative care facilities (hospice or home) [odds ratio (OR) 2.57; 95 % confidence interval (CI) 1-6.6; p = 0.05]. In contrast, patients with factors suggesting a clinically severe status (performance status ≥2, use of opioids, delirium, and ascites) more often received EOL care in a hospital. Among patients who received EOL care at hospice or home, patients with minor children received EOL care at home (OR 0.08; 95 % CI 0.02-0.38; p = 0.001). Patients with brain metastases chose hospice (OR 12.37; 95 % CI 2.25-68.13; p = 0.004). Furthermore, having a caregiver was associated with prolonged survival (hazard ratio 0.62; 95 % CI 0.39-0.97; p = 0.035).

CONCLUSION

Familial factors such as having children and caregivers significantly influenced the place of EOL care for terminally ill breast cancer patients.

Improving neuro-oncological patients care: basic and practical concepts for nurse specialist in neuro-rehabilitation

Background

Neuro-oncological population well expresses the complexity of neurological disability due to the multiple neurological deficits that affect these patients. Moreover, due to the therapeutical opportunities survival times for patients with brain tumor have increased and more of these patients require rehabilitation care. The figure of nurse in the interdisciplinary specialty of neurorehabilitation is not clearly defined, even if their role in this setting is recognized as being critical and is expanding.

The purpose of the study is to identify the standard competencies for neurorehabilitation nurses that could be taught by means of a specialization course.

Methods

A literature review was conducted with preference given to works published between January 2000 and December 2008 in English. The search strategy identified 523 non-duplicated references of which 271 titles were considered relevant. After reviewing the abstracts, 147 papers were selected and made available to a group of healthcare professionals who were requested to classify them in few conceptual main areas defining the relative topics.

Results

The following five main areas were identified: clinical aspects of nursing; nursing techniques; nursing methodology; relational and organisational models; legal aspects of nursing. The relative topics were included within each area. As educational method a structured course based on lectures and practical sessions was designed. Also multi-choices questions were developed in order to evaluate the participants’ level of knowledge, while a semi-structured interview was prepared to investigate students’ satisfaction.

Conclusions

Literature shows that the development of rehabilitation depends on the improvement of scientific and practical knowledge of health care professionals. This structured training course could be incorporated into undergraduate nursing education programmes and also be inserted into continuing education programmes for graduate nurses. Developing expertise in neuro-rehabilitation for nurses, will be critical to improve overall care and care management of patients with highly complex disabilities as patients affected by brain tumors. The next step will be to start discussing, at the level of scientific societies linked to the field of neurorehabilitation and oncology, the development of a specialisation course in neurorehabilitation nursing.

Chemotherapy at the end of life: up until when?

AIM

The aim of this study is to analyze the use of CT in terminal stage cancer and the percentage of patients who received UCPD in 2009 and 2010 on the Medical Oncology and Palliative Home Care integrated service (UCPD) ward of the Marqués de Valdecilla University Hospital.

METHOD

Retrospective analysis of death rate registered on the Medical Oncology ward for 2009 and 2010 and the recorded date of the last CT given. The data are analyzed using the SPSS version 15.0 statistic package. Data were obtained from the Database Minimum Set for oncology admissions.

RESULTS

The death rate on the Medical Oncology ward is 22-24%. Total number of cases studied is 303. 47% of patients are aged 60 or younger. 81.8% (248) received active cancer treatment; of these, 138 (55.6%) in the last month, and 84 (33.8%) in the last 2 weeks. Only 66 patients out of those who died on the ward (21%) were previously sent to the UCPD.

CONCLUSIONS

Even when it is known that the majority of cancer patients become resistant to CT at the end of their lives, it is often given to patients of all ages. The request for palliative care is rare and often late.

Treating cancer patients who are near the end of life in the emergency department

Cancer-related visits to the emergency department (ED) can be expected to increase in the next decade as the population ages. Some of the these patients and their caregivers will come to the ED without prior end-of-life care planning, and others will require modification of prior plans based on disease progression. In this article, we discuss some of these end-of-life issues related to and including those of legal documents, transmission of patient wishes, limiting factors in implementing those wishes, and the new horizon of palliative care in the ED.

The palliative prognostic score and survival in patients with advanced solid tumors receiving chemotherapy

PURPOSE

To evaluate the accuracy of the Palliative Prognostic Score (PaP score) in selecting metastatic gastrointestinal or nonsmall-cell lung cancer patients candidate to palliative chemotherapy.

MATERIALS AND METHODS

The PaP score was calculated in 173 patients with advanced, pretreated gastrointestinal or nonsmall-cell lung cancer before starting a further line of chemotherapy with palliative aim. Symptom distress score was calculated using the Edmonton Symptom Assessment System (ESAS) before every course of chemotherapy. Univariate analysis of survival was performed using the logrank test; multivariate analysis was performed using the Cox regression model. Symptom distress scores were compared using multivariate analysis of variance test for repeated measures, and overall symptom distress score was compared using analysis of variance test for repeated measures.

RESULTS

Overall median survival was 26 weeks; in PaP score class A it was 32 weeks, and in class B 8 weeks (p < 0.0001). No patient was classified in class C. The two-class PaP score resulted in an independent prognostic factor (p = 0.022), as well as Karnofsky performance status (p = 0.002) and colorectal cancer (p = 0.017). A trend towards worsening of symptom distress was observed in the entire population and in class A. The high number of missed data did not permit an adequate analysis in class B.

CONCLUSIONS

The PaP score seems to discriminate patients who could benefit by palliative chemotherapy from those who could better benefit by supportive and palliative approach. However, the data are insufficient to validate the use of the PaP score in patients to be treated with palliative chemotherapy, and further trials should be planned to assess its ability to improve the quality of care in oncology and the appropriateness in the choice of palliative chemotherapy.