1
|
Fox JA, Rosenberg J, Ekberg S, Langbecker D. Palliative care in the context of immune and targeted therapies: A qualitative study of bereaved carers' experiences in metastatic melanoma. Palliat Med 2020; 34:1351-1360. [PMID: 32338133 DOI: 10.1177/0269216320916154] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Immune and targeted therapies continue to transform treatment outcomes for those with metastatic melanoma. However, the role of palliative care within this treatment paradigm is not well understood. AIM To explore bereaved carers' experiences of immune and targeted therapy treatment options towards end of life for patients with metastatic melanoma. DESIGN An interpretive, qualitative study using a social constructivist framework was utilised. Interviews were recorded, transcribed and analysed using grounded theory methods. SETTING/PARTICIPANTS Participants (n = 20) were bereaved carers of patients who had received some form of immune and/or targeted therapy at one of three Australian metropolitan melanoma treatment centres. RESULTS Carers struggled to reconcile the positive discourse around the success of immune and targeted therapies in achieving long-term disease control, and the underlying uncertainty in predicting individual responses to therapy. Expectations that immune and targeted therapies necessarily provide longer-term survival were evident. Difficulty in prognostication due to clinical uncertainty and a desire to maintain hope resulted in lack of preparedness for treatment failure and end of life. CONCLUSION Immune and targeted therapies have resulted in increased prognostic challenges. There is a need to engage, educate and support patients and carers to prepare and plan amid these challenges. Educational initiatives must focus on improving communication between patients, carers and clinicians; the differences between palliative and end-of-life care; and increased competency of clinicians in having goals-of-care discussions. Clinicians must recognise and communicate the benefit of collaborative palliative care to meet patient and family needs holistically and comprehensively.
Collapse
Affiliation(s)
- Jennifer A Fox
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - John Rosenberg
- University of the Sunshine Coast, Caboolture, QLD, Australia
| | - Stuart Ekberg
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | | |
Collapse
|
2
|
Marinelli D, Giusti R, Mazzotta M, Filetti M, Krasniqi E, Pizzuti L, Landi L, Tomao S, Cappuzzo F, Ciliberto G, Barba M, Vici P, Marchetti P. Palliative- and non-palliative indications for glucocorticoids use in course of immune-checkpoint inhibition. Current evidence and future perspectives. Crit Rev Oncol Hematol 2020; 157:103176. [PMID: 33276183 DOI: 10.1016/j.critrevonc.2020.103176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 12/17/2022] Open
Abstract
Immune-checkpoint inhibitors significantly reshaped treatment landscapes in several solid tumors. Concurrently with disease-oriented therapies, cancer patients often require proper management of drug-related adverse events and/or cancer-related symptoms. Glucocorticoids (GC) are a cornerstone of symptom management in advanced cancer care and in the management of immune-related adverse events (irAEs) due to immune-modulating therapies. Moreover, GC are often administered in patients with autoimmune diseases (AID), either alone or in combination with other treatments. While handling of irAEs with GC is supported by multiple guidelines, it is unclear whether GC administration because of pre-existing AID or because of palliative needs is associated with inferior outcomes in cancer patients treated with immune-checkpoint inhibitors (ICIs). When globally considered, the available evidence seems to orient towards less favorable survival outcomes when GC administration is driven by a palliative intent. Conversely, steroid administration for non-palliative intent seems to be associated with stable or negligibly reduced survival outcomes.
Collapse
Affiliation(s)
- Daniele Marinelli
- Department of Clinical and Molecular Medicine, Sapienza - University of Rome, Sant'Andrea Hospital, Rome, Italy; Division of Medical Oncology 2, IRCCS Regina Elena, National Cancer Institute, Rome, Italy
| | | | - Marco Mazzotta
- Division of Medical Oncology 2, IRCCS Regina Elena, National Cancer Institute, Rome, Italy
| | - Marco Filetti
- Department of Clinical and Molecular Medicine, Sapienza - University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Eriseld Krasniqi
- Division of Medical Oncology 2, IRCCS Regina Elena, National Cancer Institute, Rome, Italy
| | - Laura Pizzuti
- Division of Medical Oncology 2, IRCCS Regina Elena, National Cancer Institute, Rome, Italy
| | - Lorenza Landi
- Division of Medical Oncology 2, IRCCS Regina Elena, National Cancer Institute, Rome, Italy
| | - Silverio Tomao
- Department of Radiological, Oncological and Anatomo-Pathological Sciences, Policlinico Umberto I, 'Sapienza' University of Rome, Rome, Italy
| | - Federico Cappuzzo
- Division of Medical Oncology 2, IRCCS Regina Elena, National Cancer Institute, Rome, Italy
| | - Gennaro Ciliberto
- Scientific Direction, IRCCS Regina Elena, National Cancer Institute, Rome, Italy
| | - Maddalena Barba
- Division of Medical Oncology 2, IRCCS Regina Elena, National Cancer Institute, Rome, Italy.
| | - Patrizia Vici
- Division of Medical Oncology 2, IRCCS Regina Elena, National Cancer Institute, Rome, Italy
| | - Paolo Marchetti
- Department of Clinical and Molecular Medicine, Sapienza - University of Rome, Sant'Andrea Hospital, Rome, Italy
| |
Collapse
|
3
|
Fox J, Janda M, Bennett F, Langbecker D. An outreach telephone program for advanced melanoma supportive care: Acceptability and feasibility. Eur J Oncol Nurs 2019; 42:110-115. [PMID: 31493669 DOI: 10.1016/j.ejon.2019.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE People with advanced melanoma face an uncertain trajectory as new treatments now have the potential to provide longer-term survival for some. However, the disease course is variable and unpredictable, with many expressing a need for better supportive care. This study aimed to investigate the acceptability and feasibility of extending an existing melanoma-specific self-referral or 'passive' telephone consultation support service to an 'active' outreach call to offer a supportive care program tailored to the needs of the patient. METHOD Participants were enrolled by their oncology nurse into a single group pre-post intervention study. Participants received an outreach telephone call focused on knowledge and skill development. Participants completed questionnaires at baseline and four weeks post-intervention. Post-intervention interviews with patients and involved staff were used to explore acceptability and feasibility of the outreach service call. RESULTS Of 18 participants approached, 15 enrolled and 14 received the intervention. Staff time required for intervention delivery provided evidence for feasibility. Participants perceived the intervention as acceptable, and beneficial. In interviews, having someone with melanoma-specific knowledge to talk with was a key benefit of the outreach call program. Many participants expressed that they would have wished to receive the outreach call at an earlier stage, for example at the time of recurrence of/progression to advanced melanoma. CONCLUSIONS Extending an existing self-referral support service model to use a more 'active' outreach approach is acceptable and feasible. The next step in the evaluation process for this intervention is a randomised controlled trial to determine effectiveness and cost-effectiveness.
Collapse
Affiliation(s)
- Jennifer Fox
- School of Nursing, Faculty of Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Qld, 4075, Australia.
| | - Monika Janda
- Centre for Health Service Research, Faculty of Medicine, Institute of Health and Biomedical Innovation, The University of Queensland, Woolloongabba, Qld, 4102, Australia; School of Public Health and Social Work, Faculty of Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Australia.
| | - Fiona Bennett
- Melanoma Patients Australia, Mater Foundation, 620 Stanley Street, Woolloongabba, Brisbane, 4102, Australia.
| | - Danette Langbecker
- Centre for Online Health - Centre for Health Services Research, The University of Queensland, Ground floor, Building 33, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, Qld, 4102, Australia.
| |
Collapse
|
4
|
Wong A, Billett A, Milne D. Balancing the Hype with Reality: What Do Patients with Advanced Melanoma Consider When Making the Decision to Have Immunotherapy? Oncologist 2019; 24:e1190-e1196. [PMID: 31015314 DOI: 10.1634/theoncologist.2018-0820] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/19/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Immunotherapy has resulted in unprecedented improvements in survival and maintained quality of life for many patients with advanced melanoma. However, durable responses are observed in only a minority of patients, and severe treatment side effects are experienced by 5%-30%. There are no reliable tests that can differentiate between patients who are likely to respond to immunotherapy and those who will not. Hence, new challenges have arisen as clinicians try to facilitate patients in their decision-making regarding immunotherapy. Furthermore, little is known about the real-world patients' experience and understanding of immunotherapy outside the clinical trial setting. Here, we explore the perspectives of patients undergoing immunotherapy for melanoma and focus on factors that influenced their treatment decision-making. MATERIALS AND METHODS Twenty-three in-depth semistructured interviews were conducted with patients receiving pembrolizumab for stage IV melanoma at an Australian public cancer hospital. Patients were recruited at a range of time points after commencing therapy, and their experience of treatment was explored. Interviews were audio recorded, transcribed verbatim, coded, and analyzed thematically. RESULTS Immunotherapy is viewed as a symbol of hope, with high-profile anecdotes reinforcing this perception. Only a minority of patients expressed a good understanding of the likely efficacy and potential treatment side effects. Patients are reliant on their clinicians' recommendation regarding immunotherapy treatment decisions. CONCLUSION Novel treatments such as immunotherapy provide significant hope for patients. This may influence their preference for immunotherapy over and above the usual considerations of the trade-off between efficacy and toxicity. Careful counsel and individualized patient resources may further facilitate treatment decision-making. IMPLICATIONS FOR PRACTICE This study highlighted some of the misconceptions held by patients that need to be addressed when discussing the possibility of receiving treatment with immunotherapy for advanced melanoma. Patients placed a lot of importance on high-profile anecdotes rather than truly understanding likely outcomes of treatment based on personal circumstances. The majority of patients had a poor understanding of the potential side effects and long-term implications of treatment with immunotherapy. Careful counsel is required in order to facilitate informed decision-making about treatment and to ensure possible side effects are known and appreciated. Further research is needed to develop tools to aid decision-making in everyday clinical practice.
Collapse
Affiliation(s)
- Annie Wong
- Department of Cancer Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - Alex Billett
- Department of Cancer Experiences Research, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - Donna Milne
- Department of Cancer Experiences Research, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- Melanoma and Skin Unit, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| |
Collapse
|
5
|
Fox JA, Langbecker D, Rosenberg J, Ekberg S. Uncertain diagnosis and prognosis in advanced melanoma: a qualitative study of the experiences of bereaved carers in a time of immune and targeted therapies. Br J Dermatol 2019; 180:1368-1376. [PMID: 30515757 DOI: 10.1111/bjd.17511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recent advances in advanced melanoma therapies are associated with improved survival for some patients. However, how patients with diagnoses of advanced disease and their carers experience this expanding treatment paradigm is not well understood. OBJECTIVES To explore bereaved carers' accounts of the trajectory of advanced melanoma involving treatment by immune or targeted therapies, to build an understanding of their experiences of care relating to diagnosis and prognosis. METHODS A qualitative exploratory design, using methods drawn from grounded theory, was adopted. Analyses drew on in-depth interviews with 20 bereaved carers from three metropolitan melanoma treatment centres in Australia. A flexible interview guide and structured approach to concurrent data collection and analysis were applied. RESULTS Carers described qualities of the experience, including the shock of diagnosis after a sometimes-innocuous presentation with vague symptoms. They reported an unclear prognosis with complexity arising from interplay between an uncertain disease trajectory and often ambiguous expectations of outcomes of emerging immune and targeted therapies. Uncertainty dominated carers' experiences, increasing the complexity of care planning. CONCLUSIONS Effective communication of an advanced melanoma diagnosis and prognosis is critical. Recognition of the uncertainty inherent in the benefit of immune and targeted therapies in a constructive manner may facilitate more timely and effective care-planning conversations between patients, carers and medical specialists.
Collapse
Affiliation(s)
- J A Fox
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Kelvin Grove, QLD, Australia
| | - D Langbecker
- The University of Queensland, Centre for Health Services Research, St Lucia, QLD, Australia
| | - J Rosenberg
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Kelvin Grove, QLD, Australia
| | - S Ekberg
- Queensland University of Technology, Institute of Health and Biomedical Innovation, Kelvin Grove, QLD, Australia
| |
Collapse
|
6
|
Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018; 19:e588-e653. [DOI: 10.1016/s1470-2045(18)30415-7] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/16/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
|
7
|
Wong A, Williams M, Milne D, Morris K, Lau P, Spruyt O, Fullerton S, McArthur G. Clinical and palliative care outcomes for patients of poor performance status treated with antiprogrammed death-1 monoclonal antibodies for advanced melanoma. Asia Pac J Clin Oncol 2017; 13:385-390. [DOI: 10.1111/ajco.12702] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 04/08/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Annie Wong
- Department of Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
| | - Molly Williams
- Department of Palliative Care; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Donna Milne
- Department of Cancer Experiences Research; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Kortnye Morris
- Department of Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Peter Lau
- Department of Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
| | - Odette Spruyt
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
- Department of Palliative Care; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Sonia Fullerton
- Department of Palliative Care; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
| | - Grant McArthur
- Department of Cancer Medicine; Peter MacCallum Cancer Centre; Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology; University of Melbourne; Melbourne Victoria Australia
| |
Collapse
|
8
|
Affiliation(s)
- Victoria L Chiou
- Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Mauricio Burotto
- Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| |
Collapse
|