Advanced Cancer In Palliative Care Research Articles

Prognostic risk stratification using C-reactive protein, albumin, and associated inflammatory biomarkers in patients with advanced cancer in palliative care

PurposeTo evaluate the prognostic value of C-reactive protein (CRP), albumin, CRP/albumin ratio (CAR), and modified Glasgow Prognostic Score (mGPS) at different thresholds in patients with advanced cancer in palliative care. MethodsProspective cohort study with patients evaluated at a palliative care unit in Brazil between July 2016 and March 2020. We included patients ≥ 20 years old, both sexes, able to provide the necessary information or accompanied by someone able to do so, and Karnofsky Performance Status ≥ 30 %. The exclusion criteria were the absence of laboratory data and previous diagnosis of autoimmune and infectious diseases. The thresholds analyzed were: CRP < 5 vs. 5-10 vs. > 10 mg/L, albumin < 2.4 vs. 2.4-2.9 vs. 3.0-3.5 vs. > 3.5 g/dL; CAR <1.2 vs. 1.2–2.0 vs. > 2.0, and mGPS equal to 0 vs. 1 vs. 2. Kaplan-Meier curves and Cox regression models (with hazard ratios [HR] and 95% confidence interval [CI]) were used to evaluate prognostic value, and the concordance statistic (C-statistic) was used to evaluate the predictive accuracy of these thresholds to predict death within 90 days. ResultsA total of 1,877 patients were included. Median overall survival was 51 (19;124) days and decreased in line with the deterioration of the inflammatory biomarkers. According to the Cox regression models, HR increased as the thresholds worsened (CRP: 1.74 [95% CI, 1.50-2.02] to 2.30 [95% CI, 2.00-2.64]; albumin: 1.77 [95% CI, 1.52-2.07] to 2.60 [95% CI, 2.15-3.14]; CAR: 1.47 [95% CI, 1.21-1.77] to 2.35 [95% CI, 2.05-2.69]; mGPS: 1.78 [95% CI, 1.40-2.23] to 1.89 [95% CI, 1.65-2.15]). All the inflammatory biomarkers evaluated showed discriminatory accuracy for predicting death (C-statistic >0.70), with CAR as the best parameter (C-statistic: 0.80). ConclusionOur results suggest that CRP, albumin, CAR, and mGPS can be used as clinically meaningful biomarkers to stratify patients with advanced cancer in palliative care according to the severity of these indicators.

Opioid use and subsequent delirium risk in patients with advanced cancer in palliative care: a multicenter registry study

The prevalent use of opioids for pain management in patients with advanced cancer underscores the need for research on their neuropsychiatric impacts, particularly delirium. Therefore, we aimed to investigate the potential association between opioid use and the risk of delirium in patients with advanced cancer admitted to the acute palliative care unit. We conducted a retrospective observational study utilizing a multicenter, patient-based registry cohort by collecting the data from January 1, 2019, to December 31, 2020, in South Korea. All data regarding exposures, outcomes, and covariates were obtained through retrospective chart reviews by a team of specialized medical professionals with expertise in oncology. Full unmatched and 1:1 propensity-score matched cohorts were formed, and stratification analysis was conducted. The primary outcome, delirium, was defined and diagnosed by the DSM-IV. Of the 2,066 patients with advanced cancer, we identified 42.8% (mean [SD] age, 64.4 [13.3] years; 60.8% male) non-opioid users and 57.2% (62.8 [12.5] years; 55.9% male) opioid users, respectively. Opioid use was significantly associated with an increased occurrence of delirium in patients with advanced cancer (OR, 2.02 [95% CI 1.22–3.35]). The risk of delirium in patients with advanced cancer showed increasing trends in a dose-dependent manner. High-dose opioid users showed an increased risk of delirium in patients with advanced cancer compared to non-opioid users (low-dose user: OR, 2.21 [95% CI 1.27–3.84]; high-dose user: OR, 5.75 [95% CI 2.81–11.77]; ratio of OR, 2.60 [95% CI 1.05–6.44]). Patients with old age, male sex, absence of chemotherapy during hospitalization, and non-obese status were more susceptible to increased risk of delirium in patients with cancer. In this multicenter patient-based registry cohort study, we found a significant, dose-dependent association between opioid use and increased risk of delirium in patients with advanced cancer. We also identified specific patient groups more susceptible to delirium. These findings highlight the importance of opioid prescription in these patients with advanced cancer, balancing effective doses for pain management and adverse dose-inducing delirium.

Introducing palliative care in advanced cancer: a systematic review.

Negative perceptions about palliative care (PC), held by patients with cancer and their families, are a barrier to early referral and the associated benefits. This review examines the approaches that support the task of introducing PC to patients and families and describes any evaluations of these approaches. A systematic review with a systematic search informed by the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines was performed on the online databases MEDLINE, PsychInfo and CINAHL from May 2022 to July 2022. Identified studies were screened by title and abstract, and included if they were empirical studies and described an approach that supported the introduction of PC services for adult patients. A narrative-synthesis approach was used to extract and present the findings. Searches yielded 1193 unique manuscripts, which, following title and abstract screening, were reduced to 31 papers subject to full-text review, with a final 12 studies meeting eligibility criteria. A diverse range of included studies described approaches used to introduce palliative care, which may be broadly summarised by four categories: education, clinical communication, building trust and rapport and integrative system approaches. While educational approaches were helpful, they were less likely to change behaviours, with focused communication tasks also necessary to facilitate PC introduction. An established relationship and trust between patient and clinician were foundational to effective PC discussions. A framework to assist clinicians in this task is likely to be multidimensional in nature, although more quantitative research is necessary to establish the most effective methods and how they may be incorporated into clinical practice.

Assessment of emotional distress in palliative care: Edmonton Symptom Assessment System-revised (ESAS-r) vs Distress Thermometer.

To evaluate the sensitivity and specificity of the Distress Thermometer (DT) as a screening tool for emotional distress in oncological palliative care patients and to compare the DT with the Edmonton Symptom Assessment System-revised (ESAS-r) and the gold standard to determine the most appropriate assessment method in palliative psychological care. Data were collected from psychological screening tests (ESAS-r and DT), and clinical interviews (gold standard) were conducted by a clinical psychologist specialist in palliative oncology from January 2021 to January 2022 in an oncology palliative care service. The sample consisted of 356 first-time patients with a diagnosis of advanced cancer in palliative care. The most frequently reported oncological diagnoses were gastrointestinal tract (49.3%) and breast (18.3%). Most patients were female (n=206; 57.9%), 60.4% were married/with a partner, 55.4% had between 6 and 9years of schooling, and a median age of 57 (range, 46-65) years. The cutoff of the DT was 5, with a sensitivity of 75.88% and specificity of 54.3%. Emotional problems (sadness and nervousness) had a greater area under the curve (AUC) when measured using the DT than the ESAS-r; however, only in the case of the comparative sadness and discouragement was the difference between the AUC marginally significant. The use of the DT as a screening tool in oncological palliative care is more effective in the evaluation of psychological needs than the ESAS-r. The DT, in addition to evaluation by an expert psychologist, allows for a more comprehensive identification of signs and symptoms to yield an accurate mental health diagnosis based on the International Classification of Diseases-11th Revision and/or Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition.

Effects of Music Therapy on Spiritual Well-Being among Patients with Advanced Cancer in Palliative Care: A Meta-Analysis of Randomized Controlled Trials

PurposePatients with advanced cancer in palliative care often experience physical and psychological symptoms that negatively impact their quality of life (QoL) and spiritual well-being. Music therapy can be used for symptom management in these patients. However, the effectiveness is uncertain. To determine the effectiveness of music therapy on spiritual well-being, QoL, pain, and psychological distress using randomized controlled trials (RCTs). Data SourceA systematic search was conducted in EMBASE, PubMed, Cochrane Library, CINAHL, Web of Science, and the ClinicalTrial.gov registry up to September 2022. ConclusionThe meta-analysis included seven RCTs with a total of 747 advanced cancer patients. Music therapy was found to significantly improve spiritual well-being with a mean difference of 0.43 (95% CI: 0.25 to 0.61, P < .001) in the intervention group compared to the control group. However, no significant group differences were found between the intervention and control groups for QoL (SMD: 0.53, 95% CI: –0.12 to 1.13, P = .11), pain (MD: –0.81, 95% CI: –2.06 to 0.44, P = .20), and psychological distress (SMD: –0.05, 95% CI: –0.41 to 0.32, P = .81). Music therapy can effectively improve the spiritual well-being of palliative care patients. However, its beneficial effects on QoL, pain, and psychological distress were minimal. Implications for Nursing PracticeMusic therapy interventions can be introduced to help patients deal with spiritual/existential needs. Future studies should identify optimal characteristics of music therapy interventions to aid in enhancing the quality of palliative care for patients with advanced cancer.

Risk factors for delirium among patients with advanced cancer in palliative care: a multicenter, patient-based registry cohort in South Korea.

Previous studies have comprehensively investigated the prevalence and various potential risk factors for delirium among patients with advanced cancer admitted to the acute palliative care unit (APCU). Our objective was to evaluate the comprehensive association between delirium and various risk factors among patients with advanced cancer in an acute palliative care setting using a patient-based multicenter registry cohort. We performed a multicenter, patient-based registry cohort study collected in South Korea between January 1, 2019, and December 31, 2020. Delirium was identified using a medical record review based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. In total, 2,124 eligible patients with advanced cancer in the APCU met the inclusion criteria. There were 127 out of 2,124 patients (prevalence, 6.0%; 95% CI, 5.0 to 7.1) with delirium during admission. Delirium in patients with advanced cancer was associated with age >70 years (OR, 1.793; 95% CI, 1.246 to 2.581), male sex (OR, 1.675; 95% CI, 1.131 to 2.479), no chemotherapy during hospitalization (OR, 2.019; 95% CI, 1.236 to 3.298), hearing impairment (OR, 3.566; 95% CI, 1.176 to 10.810), underweight (OR, 1.826; 95% CI, 1.067 to 3.124), current use of opioid medication (OR, 1.942; 95% CI, 1.264 to 2.982), previous history of delirium (OR, 12.497; 95% CI, 6.920 to 22.568), and mental illness (OR, 2.333; 95% CI, 1.251 to 4.352). In a large-scale multicenter patient-based registry cohort, delirium was associated with old age, male sex, no chemotherapy during hospitalization, hearing impairment, underweight, current use of opioid medication, and a history of delirium and mental illness. Our findings suggest physicians should pay attention to delirium in patients with advanced cancer admitted to the APCU with the above risk factors.

Ethical Considerations of Palliative Care for Advanced Cancer

Ethical Considerations of Palliative Care for Advanced Cancer

A novel nurse-coordinated home care model for palliative care in advanced cancer: A pilot interventional study from suburban Mumbai

Background: Demand for home-based health care services has increased considerably in India. Traditionally, home-based care services are physician-led which puts pressure on the understaffed healthcare sector. This study aims to pilot a new model, the Nurse coordinated Home Care (NCHC) service in suburban Mumbai (India). Methods: In this pilot interventional study, 101 patients with advanced cancer along with their caregivers were enrolled over 16 months. The nurse coordinator (NC) administered study questionnaires every month. Follow-up visits were based on case severity. Local general practitioners (LGPs) were identified and involved in patient care. Results: Severe Edmonton Symptom Assessment System (ESAS) symptoms were reduced by >2 points in 4 out of 7 instances (57.1%). The number of physician visits was lesser than NC visits (162 vs 341), home deaths were more than hospital deaths (57 vs 14), study retention rate was 99%, 87.5% LGPs participated, 98% of questionnaires were returned. Satisfaction on FAMCARE-2 showed a maximum score of ‘Satisfied’, caregiver burden in ZBI was little/no for 95%, mean scores for ESAS pain was 2, PPSv2 score was 70%−100% for the majority, mean scores on EORTC QLQ-C15-PAL were 77 - Functional scales, 21.5 - Symptom scales, and 64.3 - Global health status/quality of life. NCHC median intervention costs per patient were less than usual care (₹2049.50 vs ₹11490.09). Conclusion: A home care service model that includes nurse coordination and case management streamlines access to healthcare services and resources while reducing the cost of care along with reduced caregiver burden, with increased levels of satisfaction.

Chinese physicians\u2019 perceptions of palliative care integration for advanced cancer patients: a qualitative analysis at a tertiary hospital in Changsha, China

BackgroundLittle previous research has been conducted outside of major cities in China to examine how physicians currently perceive palliative care, and to identify specific goals for training as palliative care access expands. This study explored physicians’ perceptions of palliative care integration for advanced cancer patients in Changsha, China.MethodsWe conducted semi-structured qualitative interviews with physicians (n = 24) specializing in hematology or oncology at a tertiary hospital.ResultsMost physicians viewed palliative care as equivalent to end-of-life care, while a minority considered it possible to integrate palliative care with active treatment. Almost all physicians maintained separate conversations about palliative care with family members and patients, communicating more directly with family members than with patients about prognosis and goals of care. Physicians described experiencing ethical tension between the desire of family members to protect the patient from knowing they have advanced cancer, and the patient’s “right to decide” about palliative treatment. Physicians varied overall regarding perceptions of the role they should have in discussions about goals of care.ConclusionsAs palliative care access expands in China, medical training should encourage earlier integration of palliative care for advanced cancer, address ethical issues faced by physicians communicating about palliative care, and establish guidance on the role of the physician in discussions about goals of care.

Assessment of total pain in people in oncologic palliative care: integrative literature review.

The promotion of comfort and quality of life of people with cancer in palliative care requires flawless evaluation and management of pain, understood in its multidimensionality and integrality. The objective of this study was to present an overview of the scientific production referring to evaluation of the pain and total pain of patients with advanced cancer in palliative care. The study involved an integrative literature review, searching the databases PubMed, Embase, Cinahl, Lilacs and Web of Science using the descriptors ‘Total Pain’, ‘Cancer Pain’, ‘Pain’, ‘Symptom Assessment’, ‘Pain Measurement’, ‘Pain Evaluation’, ‘Neoplasms’, ‘Cancer’, ‘Tumor’, ‘Palliative Care’, ‘Hospice Care’, and ‘Terminal Care’. To select the studies, the authors used the reference manager Mendeley and the application Rayyan™, as well as blind and independent peer review. Twenty-two articles were selected, published between 2002 and 2020 in different countries, and classified into two thematic units: ‘Physical, social, emotional, and spiritual factors related to pain in cancer’ (N = 13) and ‘Importance of the overall evaluation and multidisciplinary team in the management of pain’ (N = 9). Advanced cancer is associated with high mortality, a decline in health status, the presence of pain, and complex psychosocial concerns. Pain and symptoms in patients in palliative care should be evaluated as a whole and controlled thorough the work of an interdisciplinary team. The qualitative synthesis of the results demonstrates that most of the evaluated studies have a mixed nature; there are significant methodological differences among them and a low level of evidence in studies relating to the subject of pain evaluation in palliative care.

Prognostic risk stratification of inflammatory markers related to c-reactive protein and albumin in patients with advanced cancer in palliative care

Rationale: The prognostic significance of systemic inflammation markers has been regarded as an outcome predictor in patients with advanced cancer. However, few studies have explored its prognostic role according to different thresholds. Thus, this study aimed to evaluate the prognostic value of C-reactive protein (CRP), albumin, CRP/albumin ratio (CAR), and modified Glasgow Prognostic Score (mGPS) according to different thresholds in patients with cancer in palliative care.

Hope and advance care planning in advanced cancer: Is there a relationship?

Clinicians often cite a fear of giving up hope as a reason they defer advance care planning (ACP) among patients with advanced cancer. The objective of this study was to determine whether engagement in ACP affects hope in these patients. This was a secondary analysis of a randomized controlled trial of primary palliative care in advanced cancer. Patients who had not completed ACP at baseline were included in the analysis. ACP was assessed in the forms of an end-of-life (EOL) conversation with one's oncologist and completion of a living will or advance directive (AD). Measurements were obtained at baseline and at 3 months. Hope was measured using the Herth Hope Index (HHI) (range, 12-48; higher scores indicate higher hope). Multivariate regression was performed to assess associations between ACP and hope, controlling for baseline HHI score, study randomization, patient age, religious importance, education, marital status, socioeconomic status, time since cancer diagnosis, pain/symptom burden (Edmonton Symptom Assessment System), and anxiety/depression score (Hospital Anxiety and Depression Scale)-all variables known to be associated with ACP and/or hope. In total, 672 patients with advanced cancer were enrolled in the overall study. The mean age was 69 ± 10 years, and the most common cancer types were lung cancer (36%), gastrointestinal cancer (20%) and breast/gynecologic cancers (16%). In this group, 378 patients (56%) had not had an EOL conversation at baseline, of whom 111 of 378 (29%) reported having an EOL conversation by 3 months. Hope was not different between patients who did or did not have an EOL conversation over the study period (mean ± standard deviation ∆HHI, 0.20 ± 5.32 vs -0.53 ± 3.80, respectively; P = .136). After multivariable adjustment, hope was significantly increased in patients who had engaged in an EOL conversation (adjusted mean difference in ∆HHI, 0.95; 95% CI, 0.08-1.82; P = .032). Similarly, of 216 patients (32%) without an AD at baseline, 67 (31%) had subsequently completed an AD. Unadjusted hope was not different between those who did and did not complete an AD (∆HHI, 0.20 ± 3.89 vs -0.91 ± 4.50, respectively; P = .085). After adjustment, hope was significantly higher in those who completed an AD (adjusted mean difference in ∆HHI, 1.31; 95% CI, 0.13-2.49; P = .030). The current results demonstrate that hope is not decreased after engagement in ACP and indeed may be increased. These findings may provide reassurance to clinicians who are apprehensive about having these important and difficult conversations. Many oncologists defer advance care planning (ACP) out of concern for giving up hope. This study demonstrates that hope is not decreased in patients who have engaged in ACP either as a conversation with their oncologists or by completing an advance directive. With this information, providers may feel more comfortable having these important conversations with their patients.

Factors affecting the oral health of inpatients with advanced cancer in palliative care

PurposePatients with terminal cancer undergoing multidisciplinary palliative care often have oral health problems, but these details are still unclear. This cross-sectional study aimed to elucidate the oral health of patients with terminal-stage cancer who are inpatient recipients of acute-phase palliative care, and to unveil the factors affecting their oral health.MethodsParticipants were 121 patients with terminal-stage cancer (68 males, 53 females, mean age: 73.6 ± 11.1 years) and oral health complaints. They received palliative care at Tokyo Medical and Dental University Medical Hospital between April 2017 and August 2019. Their demographic and medical details were extracted, retrospectively, from their medical records, and their oral health status, such as the number of natural teeth, removable denture usage, Oral Health Assessment Tool (OHAT), and Dysphagia Severity Scale, were evaluated. All outcomes were assessed by a dentist from the palliative care team.ResultsThe problems with soft tissue, saliva, and oral cleanliness were observed. The absence of posterior occlusal support was common, and the use of removable dentures was often inadequate. In contrast, swallowing function was relatively well-conserved and 46.3% of the participants were capable of nutrition intake solely by mouth. Multiple regression analysis revealed a significant association between total OHAT score and age, consciousness level, prognostic level, and method of nutritional intake.ConclusionThe results revealed that the oral health of terminal cancer patients under palliative care declined despite receiving routine oral care from nurses, and suggest the importance of including dental professionals in multidisciplinary palliative care.

August 11, 2021

Association Between Spirituality and Pain Linguistic Bias in Medical Records Dementia and Medicare Experiences at EOL Effect of Home Hospice on Survival Barriers to ACP for Pediatric Patients The Power of Clinician Empathy Opioid Use Behaviors Rave Reviews Association Between Spirituality, Religiosity, Spiritual Pain, Symptom Distress, and Quality of Life Among Latin American Patients with Advanced Cancer: A Multicenter Study Background: Spirituality and religiosity can be used as integrative therapy to promote general well-being and health.1–4 What is the association between spirituality, religiosity, spiritual pain, symptom distress, coping, and quality of life among Latin American patients with advanced cancer? Design and Participants: This study determined the frequency and intensity of spirituality and religiosity and their association with physical and psychological symptoms, spiritual pain, coping, and quality of life among Latin American patients receiving palliative care for advanced cancer at three US, Guatemalan, and Chilean institutions. Patients completed validated assessments: the Faith, Importance and Influence, Community, and Address tool; Edmonton Symptom Assessment Scale-Financial/Spiritual; Penn State Worry Questionnaire-Abbreviated; Center for Epidemiologic Studies Depression Scale; Brief-coping strategies (COPE); Brief religious coping (RCOPE); and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, Expanded version (FACIT-Sp-Ex). Descriptive statistics, frequency tabulation, the Kruskal-Wallis test, and Spearman correlation were used. Results: Patients (N = 325) were age median 58 years (range = 19–85), 60% female, and 62% Catholic (30% Christian not Catholic). Ninety-seven percent considered themselves spiritual (intensity median = 7 [IQR = 5–10], 0–10 scale) and 89% religious (7 [5–9]). Spirituality/religiosity importance was median 10 (IQR = 8–10). The frequency and associations between spirituality/religiosity and various items were: helps to cope with illness (98%, r = 0.66), is a source of strength/comfort (99%, r = 0.73), has positive effect on physical (81%, r = 0.42) and emotional symptoms (84%, r = 0.17), and helps caregivers cope (100%, r = 0.40) (all P<0.0001). Sixty percent reported their spiritual/religious needs had not been supported by the medical team; 52% reported spiritual pain (intensity median = 6 [IQR = 5–8]). Spiritual pain was associated with pain, fatigue, depression, anxiety, worry, behavioral disengagement, FACIT-Sp-Ex score, and negative RCOPE (all P<0.05). Commentary: Latin American patients often are underserved by the palliative care and hospice community. This multicenter study surveyed 325 Latin American patients with advanced cancer subjects regarding the association of spirituality with their quality of life and symptoms. Participants considered themselves both spiritual and religious and felt these beliefs had a positive impact on their lives. On the other hand, half had spiritual pain which was associated with physical pain and other symptoms. Surprisingly, 60% of patients enrolled in specialty palliative care clinics did not feel supported by the medical team. There were no data presented evaluating the association of spiritual pain and not feeling supported, nor information about the chaplain staffing in the clinics. Bottom Line: Spiritual support is often seen as nonessential to medical care and may be cut at the first sign of institutional belt tightening. To provide better, quality care, not just hospice and palliative medicine but the rest of the medical/business/industrial complex needs to understand and embrace the bio/psycho/social/spiritual model of care. Reviewer: Gregory L. Phelps, MD MPH FAAAHPM, Alleo Health System/Hospice of Chattanooga, Chattanooga, TN Source: Delgado-Guay MO, Palma A, et al. Association between spirituality, religiosity, spiritual pain, symptom distress, and quality of life among Latin American patients with advanced cancer: a multicenter study [published online ahead of print April 12, 2021]. J Palliat Med. doi: 10.1089/jpm.2020.0776

The impact of advance care planning on hope among patients with advanced cancer.

12029 Background: Providers often cite a fear of “giving up hope” as a reason they defer advance care planning (ACP) among patients with advanced cancer. We sought to determine whether engagement in ACP impacts patient’s hope. Methods: This is a secondary analysis of a randomized controlled trial of primary palliative care in advanced cancer. Patients who had not completed ACP at baseline were included in the analysis. ACP was assessed in the forms of an end of life conversation with one’s oncologist (EOL conversation) and completion of a living will/advance directive (AD). Measurements were obtained at baseline and 3 months. Hope was measured using the Herth Hope Index (HHI, range 12-48, higher scores indicate higher hope). ACP was measured with patient responses to a validated ACP questionnaire that queried (1) if they had had an EOL conversation with their provider and (2) if they had completed a living will or advance directive. Multivariate regression was performed to control for baseline HHI score, study randomization and age, religious importance, education, marital status, socioeconomic status, time since cancer diagnosis, pain/symptom burden (ESAS), and anxiety/depression score (HADS)—all variables known to be associated with ACP and/or hope. Results: A total of 672 patients with advanced cancer were enrolled in the overall study. The mean age was 69±10, and the most common cancer types were lung (36%), GI (20%) and breast/GYN (16%). In this group, 378 (56%) had not had an EOL conversation at baseline, of whom 29% (111/378) reported having an EOL conversation by 3 months. Hope was not different between patients who had or did not have an EOL conversation over the study period (ΔHHI 0.20 ± 5.32 vs -0.53 ± 3.80, p=0.136). After multivariable adjustment, hope was significantly increased in patients who had engaged in an EOL conversation (adjusted mean difference in ΔHHI 0.95 (95%CI 0.08-1.82), p=0.032). Similarly, of 216 (32%) patients without an AD at baseline, 31% (67/216) patients had subsequently completed one. Unadjusted hope was not different between those who had and had not completed an AD (ΔHHI 0.20 ± 3.89 vs -0.91 ± 4.50, p=0.085). After adjustment, hope was significantly higher in those who completed an AD (adjusted mean difference in ΔHHI 1.31 (95%CI 0.13-2.49), p=0.030), (Table). Conclusions: Our results demonstrate that hope is not decreased after engagement in ACP and may, in fact, be increased. These findings may provide reassurance to providers who are apprehensive about having these important and difficult conversations. Unadjusted and adjusted change in hope for those patients who had and had not had completed an EOL conversation or AD.[Table: see text]

Indicadores de qualidade da terapia nutricional enteral são ferramentas úteis para o monitoramento em pacientes com câncer avançado em cuidados paliativos?

Introduction: Enteral nutritional therapy (ENT) in patients with advanced cancer in palliative care should be directed towards a better quality of life, being important its monitoring so that the patient has access to the best that the therapy can offer. The objective of this study was to apply the quality indicators of ENT in patients with advanced cancer in palliative care. Methods: Descriptive, observational study with a quantitative approach. Seven ENT quality indicators proposed by the International Life Sciences Institute in Brazil were applied and the reasons for the suspension or interruption of the enteral diet during hospitalization were quantified. Results: 51 patients admitted from May to November 2019 participated in the study. The frequencies of inadvertent exit of enteral nutrition tube (0.02%), the days of adequate administration of the prescribed volume versus infused volume (92.6%) and diarrhea (2%) are within the goal used. The administration of protein (25.5%) and energy (57.4%), the frequency of episodes of abdominal distension (33.3%) and constipation (86.3%) were inadequate. The diet was interrupted or suspended mainly due to the occurrence of vomiting, end-of-life care or tube obstruction. Conclusion: The use of quality indicators of nutritional therapy proved to be viable in this group of patients. Some inadequacies found in this population may be associated with the change in the objective of nutritional therapy in patients with shorter life expectancy. Adaptations based on the prognosis may be necessary, in addition to the application of new indicators, or adjustments to the proposed goals.

Awareness and Attitudes of Primary Caregivers toward End-of-Life Care in Advanced Cancer Patients: A Cross-Sectional Study.

Introduction:Awareness of end-of-life care (EOLC) has been at grass root level in our country. The caregivers are clueless about the concept of comfort care and that terminally ill cancer patients need care at home rather than the paraphernalia of the hospital ward. The basic aim of the study was to assess the awareness of the EOLC in the caregivers of the advanced cancer patients.Methods:After Ethics Committee approval, this prospective cross-sectional observational study was conducted among primary caregivers of patients receiving palliative care for advanced cancer. The primary caregiver was identified and written informed consent was obtained. The questionnaire for assessing awareness and attitudes of primary caregivers toward EOLC in advanced cancer patients was prepared and validated. The standardized study questionnaire was completed by the primary caregiver assisted by the researcher. The categorical data were analyzed using Fisher's exact test and Chi-square tests. The intergroup correlation was done using the Chi-square and nonparametric tests.Results:The results showed that only mere 26% of caregivers were aware of the term palliative care. The female population was more knowledgeable about EOLC, with 68% of them willing to initiate the same. The rural population was more willing to adopt palliative care (47%) and was more receptive about discontinuing aggressive definitive therapy.Conclusion:We conclude that the awareness about EOLC remains poor in caregiver if patients with advanced cancer in spite of good awareness of the disease. The consequences of the outcome of disease, EOLC understanding, futility for definitive care, acceptability, and understanding of palliative care lacked in most of the caregivers.

Predictive Factors of Death on Hospitalization in Patients With Advanced Cancer in Palliative Care.

Prognostic assessment is essential to plan the care of patients with advanced cancer in palliative care. Thus, this study aims to assess the predictors of death in inpatients with advanced cancer in palliative care. This is a clinical, observational cohort study with patients aged >20 years, of both genders, evaluated within 48 hours of the first hospitalization. The independent variables were tumor location, nutritional risk [through the Patient-Generated Subjective Global Assessment (PG-SGA) short form], laboratory tests [C-reactive protein and albumin] and Karnofsky Performance Status (KPS). Logistic regression analyses were performed. Eighty-two patients were evaluated, whose mean age was 61.8 (± 13.2) years. Forty-nine (59.8%) patients died during hospitalization, among which the majority had KPS of 30-40% (p-value = 0.043), higher means of the total score of the PG-SGA (p-value = 0.050) and lower serum albumin concentrations (p-value = 0.011). According to the multivariate model, tumor location in the gastrointestinal (GI) tract (OR: 1.73; 95% CI: 1.57-1.94), 30-40% KPS (OR: 1.29; 95% CI: 1.07-1.63) and albumin concentrations <3.5 g/dL (OR: 4.65; 95% CI: 1.22-17.7) were independent factors associated with an increased chance of death from hospitalization. Presenting an advanced tumor with localization in the GI tract, KPS ≤40% and serum albumin concentration <3.5 g/dL at admission were predictors of death in inpatients under palliative care.

Associated factors of distress in patients with advanced cancer: A retrospective study.

The objective of this study was to assess the psychosocial distress and associated factors in advanced cancer patients consulting at the outpatient Palliative Care Unit at the National Cancer Institute in Mexico City. A retrospective study was conducted using electronic records (June 2015 to December 2016). A total of 646 patients with advanced cancer during their first visit to the outpatient palliative care unit at the National Cancer Institute in Mexico were evaluated using the Distress Thermometer (DT) and ECOG performance status scores. Overall, 62% were women, with a median age of 57 years, and married (54.8%). The most frequent diagnosis was gastrointestinal cancer (28.6%), and 38.9% had a functional performance status of ECOG 2. The median DT score was 4.0 (IQR = 2-6), with 56% reporting DT scores ≥4. The three most frequent problems ≥4 were sadness (82.6%), feeling weak (81.2%), worry (79.6%), and <4 were feeling weak (57.7%), fatigue (55.6%), and financial security (52.1%). The variables associated with distress according to the multiple logistic regression analysis were problems with housing (OR = 2.661, 95% CI = 1.538-4.602), sadness (OR = 2.533, 95% CI = 1.615-3.973), transportation (OR = 1.732, 95% CI = 1.157-2.591), eating (OR = 1.626, 95% CI = 1.093-2.417), nervousness (OR = 1.547, 95% CI = 1.014-2.360), and sleep (OR = 1.469, 95% CI = 1.980-2.203). The principal factors were related to distress levels, housing problems, transportation issues, and emotional problems such as sadness, nervousness, lower functionality, and younger age. Therefore, psychosocial support is of considerable relevance in palliative care. These findings will help clinicians understand the distress of patients with advanced cancer in palliative care in Latin American countries.

Analysis of the Clinical Efficacy of Dendritic Cell –cytokine Induced Killer Cell-based Adoptive Immunotherapy for Colorectal Cancer

ABSTRACT Background: To analyze the efficacy and safety of dendritic cell – cytokine – induced killer (DC-CIK) immunotherapy combined with chemotherapy for colorectal cancer. Method: A retrospective analysis was conducted in 116 patients from February 2012 to December 2017, who were divided into postoperative adjuvant chemotherapy group alone, combined DC-CIK immunotherapy group, advanced cancer palliative care group, and palliative care + DC-CIK immunotherapy group, to evaluate cellular immune function, disease-free survival(DFS) and overall survival(OS). Results: In the adjuvant therapy and palliative care group, the percentages of CD3+, CD8+ and NK cells after treatment were significantly lower than before, whereas in the other two groups given DC-CIK immunotherapy, the percentages of CD3+, CD8+, NK and NKT cells after treatment were all higher than before, with a significant increase compared with the chemotherapy group (P < .05). DFS (42.4 ± 5.26 m) in the group receiving postoperative adjuvant chemotherapy + DC-CIK immunotherapy was significantly longer than that (23.5 ± 2.79 m) in the group only given postoperative adjuvant chemotherapy (P < .05). OS in the group receiving palliative care + DC-CIK immunotherapy was slightly longer than that in the group only given palliative care for advanced cancer (29 m vs 26 m, P > .05).Conclusion: Combination with DC-CIK immunotherapy could effectively improve cellular immune function. Postoperative adjuvant chemotherapy in combination with DC-CIK immunotherapy could significantly prolong DFS, but palliative care in combination with DC-CIK immunotherapy did not significantly prolong OS in patients with advanced cancer.