Early palliative care for solid and blood cancer patients and caregivers: Quantitative and qualitative results of a long-term experience as a case of value-based medicine

End-of-life care in hematological malignancies - a nationwide comparative study on the Swedish Register of Palliative Care

BACKGROUND

Patients with hematological malignancies are less likely to be referred to specialized palliative care, and more likely to receive aggressive end-of-life care than patient with solid tumors. The Swedish Register of Palliative Care (SRPC) collects end-of-life care quality data from a majority of health facilities in Sweden. We here use the national data from the SRPC to evaluate the quality of end-of-life care in patients with hematological malignancies in Sweden.

METHODS

In a retrospective, observational registry study all adult registered cancer deaths in the years 2011-2019 were included. For the main analysis, patients with unexpected deaths or co-morbidities were excluded. Descriptive statistics and multiple logistic regression, adjusting for age and sex, were used.

RESULTS

A total of 119 927 patients were included, 8 550 with hematological malignancy (HM) and 111 377 with solid tumor (ST), corresponding to 43% of all deaths due to HM and 61% of ST deaths during the observed period. Significantly more ST patients than HM received end-of-life care in a specialized palliative unit (hospice, palliative ward or specialized home care), 54% vs 42% (p<0.001), and this difference could be seen also in the very old (80+). End-of-life care quality measures were significantly worse for HM patients than ST patients, which could partly be explained by the lower receipt of specialized palliative care. The most common symptom in both groups were pain, followed by anxiety. HM patients were less likely to achieve complete symptom relief (p<0.001) which appears to be related to the receipt of specialized palliative care.

CONCLUSION

Patients with hematological malignancies are more likely to die in emergency hospital and less likely to receive specialized palliative competence in end-of-life. This also translates into less qualitative end-of-life care and less efficient symptom relief.

The benefits of early palliative care on psychological well-being, functional status, and health-related quality of life among cancer patients and their caregivers: a systematic review and meta-analysis

BACKGROUND

Patients with cancer and their caregivers experience significant psychological, physical, and emotional burdens throughout the disease trajectory which reduces their quality of life (QoL). Early palliative care (EPC) has been proposed as a strategy to alleviate physical, psychological and emotional burdens and improve health outcomes. While evidence generally supports the benefits of EPC, variations in reported outcomes highlight the need for a deeper understanding of its impact across different patient populations and healthcare settings.

OBJECTIVE

The primary aim of this study was to evaluate the pooled effects of EPC on psychological, functional status, and QoL outcomes in both cancer patients and their caregivers. The secondary aim was to evaluate the satisfaction of the patients and their family caregivers.

METHODS

A systematic review and meta-analysis were conducted following the preferred reporting item for systematic review and meta-analysis (PRISMA) guidelines. Four databases, PubMed, Scopus, EBSCOhost, and Cochrane, were searched up to January 2024. This study included randomized controlled trial (RCT) and pilot-RCT studies reporting psychological outcomes (anxiety, depression), functional status, QoL, and satisfaction in cancer patients and their caregivers. Subgroup analysis was performed to explore the short-term (< 24 weeks) versus long-term (≥ 24 weeks) effects of EPC. Mean differences (MD) and standard mean differences (SMD) were calculated using a fixed-effects model according to the Mantel-Haenszel model and a random-effects model according to the DerSimonian and Laird method.

RESULTS

A total of 24 studies met our inclusion criteria. For cancer patients, EPC significantly reduced anxiety (MD = -0.62, 95% CI: -1.02; -0.23, p = 0.002) and improved QoL (SMD 0.13, 95%CI: 0.06; 0.19, p = 0.0004). However, there was no significant reduction in depression (SMD -0.15, 95% CI: -0.36; 0.05, p = 0.14) and improvement in functional status (MD = 2.14, 95% CI: -0.78; 5.06, p = 0.15). Subgroup analysis revealed that long-term EPC significantly reduced anxiety and depression while improving QoL, but had no significant effects on functional status. For caregivers, EPC did not significantly impact either physical or mental QoL (Short form/SF-36 physical: MD = 0.81, 95% CI: -0.46; 2.09, p = 0.21; SF-36 Mental: MD = 0.53, 95% CI: -1.03; 2.08, p = 0.51). Moreover, satisfaction was more likely to be higher in patients and their caregivers who received EPC than in those who received usual care (MD 2.45, 95% CI: 0.90; 4.01, p = 0.002, MD 4.09, 95% CI: 0.60; 7.58, p = 0.02, respectively).

CONCLUSION

EPC reduces long term psychological burden and improve QoL and care satisfaction experience among patients with cancer. Therefore, EPC should be more broadly introduced into cancer care earlier to address patient's psychological burdens.

Receipt of specialized palliative care and health care utilization at the end of life in hematological cancer patients - the Stockholm experience

BACKGROUND

The treatments of hematological malignancies tend to be intense, and compared with solid tumors, less is known about the health care consumption during end of life (EOL). Therefore, the aim was to study the receipt of specialized palliative care (SPC) and how it affects health care utilization, in relation to sex, age, socioeconomics, and frailty risk (Hospital Frailty Risk Score [HFRS]).

METHODS

In a retrospective, observational registry study, all patients who died of a hematological malignancy during the years 2015-2021 in the Stockholm County were included and analyzed with descriptive statistics and logistic regression models.

RESULTS

Of the 2,858 included patients (mean age 76 years, 41% women), 38% had myeloid malignancies, 41% lymphocytic malignancies, and 21% had myeloma. During the last 3 months of life, 56% received SPC, with an overrepresentation of women, aOR 1.35 (1.16-1.58, p < 0.0001), whereas persons with risk of frailty (HFRS) were underrepresented, aOR 0.74 (0.63-0.86, p < 0.0001). Unplanned ER visits were more likely in persons aged over 80 years (p = 0.004) and in persons with frailty risk (p < 0.0001). Patients receiving SPC had a substantially reduced likelihood of ER visits, aOR 0.34 (0.29-0.40, p < 0.0001). Emergency hospitals as place of death was positively associated with frailty risk, aOR 1.50 (1.23-1.83, p < 0.0001) but negatively associated with age over 80 years (p < 0.0001) and especially with receipt of SPC, aOR 0.05 (0.04-0.06, p < 0.0001).

INTERPRETATION

Receipt of SPC could possibly reduce the need for emergency care in the end of life and the Stockholm model might facilitate referral to SPC for hematological patients.

Psychological assessment and the role of the psychologist in early palliative care

Background

Early palliative care (EPC) is a recommended model for improving the quality of life for patients with advanced cancer and their caregivers. However, limited research has focused on the role of psychological evaluation within EPC. The Veneto Institute of Oncology (IOV), a Comprehensive Cancer Centre, employs an interdisciplinary team to assess patients with advanced-stage disease. This study aims to assess the psychological needs of these patients, investigate any correlations between psychological symptoms (PSs) and factors such as awareness of diagnosis and prognosis, symptoms detected using the Edmonton Symptom Assessment System (ESAS), as well as the patient's gender, age, social issues, and survival and to clarify the psychologist's role within the interdisciplinary team.

Methods

Data were retrieved from a prospectively maintained database. From 1st January 2018 to 31st December 2021, 819 consecutive patients were evaluated during EPC consultations, with 753 participants enrolled in the study. The ESAS was administered to each patient before the consultation.

Results

More than half of the patients (385, 57.1%) reported at least one PS, with an ESAS score of ≥4. Specifically, 34.9% reported depression, 28.7% reported anxiety, and 43.2% indicated feeling "not well." Referring oncologists tended to overestimate the presence of PSs compared to patient self-reports (51.8% versus 41.3%). According to the psychologists' assessment, 29.2% of participants were found to have depression, and 10.8% of participants had anxiety. Additionally, 31 patients (10.8%) with psychological disorders were diagnosed with an adaptation disorder related to a physical condition. The psychology service engaged 47% of patients, while 18.5% declined psychological support. Patients exhibiting other ESAS symptoms with scores of ≥4 had an increased odds ratio for reporting PSs of ≥4. However, multivariable analysis revealed no significant relationship between PSs and awareness of diagnosis and prognosis.

Conclusion

The systematic use of self-assessment in EPC is essential for understanding patient's experience, determining whether PSs stem from physical disorders, and prioritizing interventions. Awareness of prognosis does not correlate with increased anxiety and depression in patients. Therefore, EPC is an ideal opportunity to discuss prognosis and facilitate patients' end-of-life choices early in their care journey.

Evaluating the caregiver experience during neoadjuvant therapy for pancreatic ductal adenocarcinoma

INTRODUCTION

Neoadjuvant therapy (NT) is increasingly recommended for patients with localized pancreatic ductal adenocarcinoma (PDAC). Recent research has highlighted the significant treatment burden that patients experience during NT, but caregiver well-being during NT is poorly understood.

METHODS

A cross-sectional mixed-methods analysis of primary caregivers of patients with localized PDAC receiving NT was undertaken. All patients completed the Caregiver Quality of Life Index-Cancer (CQOLC) survey, while semi-structured interviews were conducted among a convenience sample of participants.

RESULTS

Among 28 caregivers, the mean age was 60.1 years, and most were patient spouses/significant others (71.4%). Patients had resectable (18%), borderline resectable (46%), or locally advanced (36%) PDAC with a mean treatment duration of 2.9 months at the time of their caregiver's enrollment. Most caregivers felt that they received adequate emotional/psychosocial support (80%) and understood the rationale for NT (93%). A majority (60%) reported that caregiving responsibilities impacted their daily lives and required a decrease in their work hours, leading to financial challenges (47%). While overall QOL was moderate (mean 83 ± 21.1, range 0-140), "emotional burden" (47.3 ± 20.9), and "positive adaption" (57.3 ± 13.9) were the lowest ranked CQOLC subsection scores.

DISCUSSION

Caregivers of patients with PDAC undergoing NT experience significant emotional symptoms and impact on their daily lives. Assessing caregiver needs and providing resources during NT should be a priority.

Caregiver's quality of life in advanced cancer: validation of the construct in a real-life setting of early palliative care

Introduction

Early palliative care (EPC) improves the quality of life (QoL) of advanced cancer patients and their caregivers. The increasingly widespread use of this care model requires the development of measures supporting its interventions. Although the construct of patient's QoL has been extensively investigated and several QoL measures have been further validated, there is a paucity of data concerning the QoL of the caregiver. In 2018, McDonald and colleagues addressed this issue by interviewing 23 primary caregivers of advanced cancer patients who participated in an EPC randomized clinical trial to understand their perspective on the QoL construct. The Authors identified six major dimensions associated with the construct of caregiver's QoL. The present retrospective study aimed to validate these dimensions on a larger sample and in a real-life EPC setting.

Methods

Previously collected reports from 137 primary caregivers of advanced cancer patients on EPC answering questions about their experience with this care model were qualitatively analyzed through a deductive, thematic approach to identify and confirm the six dimensions constituting the construct of interest based on McDonald's and colleagues' results.

Results

The six dimensions ("living in the patient's world", "burden of illness and caregiving", "assuming the caregiver role", "renegotiating relationships", "confronting mortality", and "maintaining resilience") were consistently found in the reports from primary caregivers in a real-life EPC setting, confirming to be significant themes associated to their QoL.

Conclusion

A definite and recurrent construct of primary caregiver's QoL as described by McDonald and colleagues was also found in a larger sample and in a real-life EPC setting. Thus it may lay the groundwork for the development of a dedicated questionnaire.

Palliative care needs of patients with hematologic malignancies and family caregivers and challenges of palliative care provision in Asia: A review of evidence

Patients with hematologic malignancies often experience fatigue, lack of vitality, and energy, and high psychological distress. High levels of unmet care needs of patients with hematologic malignancies in Asia were identified. This review provides an overview of current evidence on the experiences and palliative care needs of patients with hematologic malignancies and their families and the barriers and challenges of integrating palliative care into hematology care in Asia. Patients with hematologic malignancies who received palliative care could benefit from less aggressive end-of-life treatments. However, the uncertain and variable nature of the prognosis and illness trajectories of hematologic malignancies increase the difficulties of integrating palliative care into hematologic care. Patients and their families are often referred to palliative care services late, which leaves a short window for palliative care teams to provide holistic needs assessment and person-centered care for those who need it. In addition, cultural differences in medical decision-making patterns and complex social norms and interactions among patients, families, and healthcare staff make it even more challenging to initiate palliative care conversations in Asia. Future research should focus on the development and evaluation of culturally appropriate palliative care for patients with hematologic malignancies and their family caregivers in Asia, given that the low rate of service intake and poor public awareness of the important role of palliative care in disease trajectories were reported. The socio-cultural context surrounding individuals should be taken into consideration to ensure the provision of person-centered care for this group of patients. Digital health could be one of the possible solutions forward to address local needs and challenges.

Stigma of Palliative Care among Patients with Advanced Cancer and Their Caregivers on Early Palliative Care

The early referral to palliative care (PC) represents a successful value-based model with proven benefits regarding the quality of life and clinical outcomes for advanced cancer patients and their caregivers. Yet, its provision remains typically confined to the last weeks of life as per the historical, late PC model. The stigma according to which PC represents end-of-life care has been identified as the root of the problem. To explore the presence and effects of the stigma in a clinical context, we surveyed 78 patients and 110 caregivers (mean age: 71.7 and 60.7, respectively) on early PC to study what their perception of PC was before their direct experience. The responses were analyzed through a qualitative descriptive approach. The participants explicitly mentioned a lack of knowledge about PC (53% of the sample), which they identified also among physicians and the population (13%); an identification of PC with the late PC model (53%); and a detrimental reaction to the proposal of an early PC referral (83%). However, the participants explicitly mentioned that a direct experience of early PC allowed for an acquired awareness of early PC meaning and benefits (52%), as well as a comprehension of its differences with late PC (34%); the regret for the delayed referral (8%); the perception of the word "palliative" as a barrier (21%); and the belief that early PC should be part of the cancer routine practice (25%). A comprehensive multi-level intervention is necessary for a widespread understanding of the essence of anticipated PC.

Electronic Patient-Reported Outcome Measures (ePROMs) Improve the Assessment of Underrated Physical and Psychological Symptom Burden among Oncological Inpatients

For advanced cancer inpatients, the established standard for gathering information about symptom burden involves a daily assessment by nursing staff using validated assessments. In contrast, a systematic assessment of patient-reported outcome measures (PROMs) is required, but it is not yet systematically implemented. We hypothesized that current practice results in underrating the severity of patients' symptom burden. To explore this hypothesis, we have established systematic electronic PROMs (ePROMs) using validated instruments at a major German Comprehensive Cancer Center. In this retrospective, non-interventional study, lasting from September 2021 to February 2022, we analyzed collected data from 230 inpatients. Symptom burden obtained by nursing staff was compared to the data acquired by ePROMs. Differences were detected by performing descriptive analyses, Chi-Square tests, Fisher's exact, Phi-correlation, Wilcoxon tests, and Cohen's r. Our analyses pointed out that pain and anxiety especially were significantly underrated by nursing staff. Nursing staff ranked these symptoms as non-existent, whereas patients stated at least mild symptom burden (pain: mean_NRS/epaAC = 0 (no); mean_ePROM = 1 (mild); p < 0.05; r = 0.46; anxiety: mean_epaAC = 0 (no); mean_ePROM = 1 (mild); p < 0.05; r = 0.48). In conclusion, supplementing routine symptom assessment used daily by nursing staff with the systematic, e-health-enabled acquisition of PROMs may improve the quality of supportive and palliative care.