Palliative Symptom Control Research Articles

Hemostatic radiotherapy: a narrative review of the literature.

In locally advanced cancer, bleeding is a common clinical presentation and radiotherapy (RT) provides a noninvasive, well-tolerated, cost-effective treatment. However, the choice for fractionation dose and schedule seem to merely depend on physician's preference rather than specific guidelines. We reviewed the available literature on palliative hemostatic RT for response rate (RR) and bleeding duration in relation with the given dose. The PubMed database was used to search for articles, which were assessed by predetermined inclusion and exclusion criteria. A total of 54 articles, published over the last 20 years until December 2023 were analyzed for dose and/or fractionation regimen and their relation to the RR. A variety of fractionation schedules are used for palliative symptom control, including hemostasis. Research focusing on hemostatic irradiation specifically and prospective studies are rare. Moreover, to our knowledge, there are no specific (prospective) studies ongoing. Both external beam radiotherapy (EBRT) and brachytherapy lead to bleeding control and daily or weekly hypofractionated irradiation is safe and effective for both high and low biological equivalent dose (BED) regimens. If feasible, based on patient condition, some studies favor higher BED regimens to obtain more durable tumor/higher bleeding response. Higher radiation dose for thoracic irradiation may be indicative for simultaneous presentation of obstruction and/or dysphagia. Brachytherapy may be used solely or in combination with EBRT or in the setting of re-irradiation. Short-course regimens are preferred in patients in with low performance index scores. For future studies, multivariate analysis, including BED, can be important to assess efficacy of different fractionation schedules for a variety of tumor etiologies. Hemostatic RT, both by EBRT and brachytherapy, appears to be a safe and effective palliative treatment that clinically and statistically significantly reduces bleeding in cancer patients. The available literature is limited regarding prospective and uniform evaluation of hemostatic RT, including fractionation schedules. BED seems to be indicative for a better RR for specific indications. Current evidence suggests that treatment decisions should be tailored according to the patients' condition, tumor etiology and other clinical symptoms. More (prospective) research focusing on hemostasis is necessary to develop clear guidelines.

Approach to relapsed CLL including Richter Transformation

Approach to relapsed CLL including Richter Transformation

Osteosarcoma/Ewing Sarcoma

Osteosarcoma/Ewing Sarcoma

Hypofractionated Radiotherapy for Breast Cancer: Findings From an International ESTRO-GIRO Survey

Hypofractionated radiotherapy (HF) for early breast cancer has been found to be equivalent to conventional fractionation (CF) in several large studies. More recently, accelerated HF regimens and HF in more advanced disease has been evaluated and adopted. Using data from the European Society of Radiation Oncology' (ESTRO) Global Impact of Radiotherapy in Oncology (GIRO) initiative survey on HF, this study aims to identify patterns, facilitators and barriers to uptake of breast cancer HF across World Bank income groups.The ESTRO-GIRO initiative administered an anonymous, electronic survey to radiation oncologists from January 2018 to January 2019. Details on physician demographics, clinical practice, preferred HF regimen for specific breast cancer clinical scenarios (curative and palliative), and justifications for HF practices were collected. Curative scenarios included: node-negative (N0) following breast-conserving surgery (BCS) and mastectomy, and node-positive (N+) following BCS and mastectomy. Palliative scenarios evaluated HF for symptom control. Factors associated with HF were assessed using multivariate logistic regression models.A total of 1,434 physicians responded to the breast survey scenarios, with 1251 (87%) from high-income (HICs) and upper middle-income countries (UMICs) and 183 (13%) from lower middle-income countries (LMICs). The most common HF fraction size was between 2.5 and 2.9 Gy delivered in a total of 15 fractions for curative indications (30%); only 1% of respondents reported using a 5-fraction regimen. For palliative indications, the most common HF fraction size was between 3 Gy and 3.5 Gy in 10 fractions (23%). In N0 disease following BCS, there was no significant difference in use of hypofractionation in LMICs compared to HICs and UMICs. Respondents in Africa were less likely to hypo fractionate compared to Europe (OR = 0.29 (0.12,0.69), P = 0.006) and those using Cobalt-60 were less likely to hypo fractionate (OR = 0.55 (0.37,0.84), P = 0.005). In the other curative scenarios, those in LMICs were more than twice as likely to hypo fractionate compared to those in HICs and UMICs. There were no differences in use of HF across income groups for palliative symptom control. Published evidence was the most cited justification for HF (89%) across income groups. Lack of advanced technology was cited as a barrier by 14% in LMICs, compared to 5% in HICs and UMICs.Patterns of HF for breast cancer varied across income groups for curative indications, with minimal uptake of accelerated regimens. Targeted interventions are needed to address barriers to HF and support evidence-based utilization.

For people with COVID-19 and terminal disease, what are the effects of pharmacological interventions for palliative symptom control?

For people with COVID-19 and terminal disease, what are the effects of pharmacological interventions for palliative symptom control?

Interventions for palliative symptom control in COVID-19 patients.

Interventions for palliative symptom control in COVID-19 patients.

Evidence-Based Practice in the Global Setting: An International Survey of Hypofractionation

Multiple large clinical trials have established the equivalence or non-inferiority of hypofractionated radiotherapy compared to conventionally fractionated treatment. The objective of this study is to determine real-world variations in the adoption of hypofractionation across different geographic regions and practice settings for cancers of the breast, prostate, and cervix, and for bone metastases, and barriers and facilitators to such adoption. An anonymous, electronic survey was distributed from January to December 2018 in English, Spanish, and Mandarin to radiation oncologists through the ESTRO Global Impact of Radiotherapy in Oncology initiative. There were 2,259 respondents from Europe (56%), Asia Pacific (19%), Middle East (5%), 12% Latin America, (12%), North America (6%), and Africa (2%). This survey assessed preference for hypofractionation and specific fractionation regimens across 4 disease sites (breast, prostate, cervix, and bone metastases) in curative and palliative scenarios. Perceived barriers and facilitators to adoption were evaluated. In regression analyses, hypofractionation preference was defined as use of hypofractionation for >75% of patients within each disease site and in >50% of clinical scenarios overall. Hypofractionation preference was more common in node-negative than in node-positive breast cancer (83% vs 46%, respectively; p<0.001), in low- and intermediate- vs. high-risk prostate cancer or cases requiring pelvic irradiation (56% vs. 32%, respectively; p=0.00001); hypofractionation was more common in North America and Europe than other regions. In cervix cancer, hypofractionation was preferred in 30% of locally advanced cervical cancer cases in Africa, but in <10% of cases in other regions. For palliative symptom control, hypofractionation was preferred by 93%, 91%, and 84% of respondents for breast cancer, prostate cancer, and cervix cancer respectively, and in 95% for bone metastases (p<0.001) across geographic regions. Lack of long-term data, inferior local control, toxicity, and inadequate technology were the most commonly cited barriers. In adjusted analyses, hypofractionation preference was associated with age <55 (odds ratio [OR] = 1.46, 95% CI 1.23 to 1.88), practice in a high-income country (OR=2.72, 95% CI 2.12 to 3.49), in a university setting (OR=1.30, 95% CI 1.04 to 1.67), in a center with a catchment area with >1,000,000 population (OR=1.57, 95% CI 1. to 2.0), and with intensity modulated radiotherapy (OR=1.70, 95% CI 1.22 to 2.34). Significant variation was observed in preference for hypofractionation across indications and between geographic regions, with greater concordance in preference for palliative indications. Improving the cost-effectiveness of radiotherapy and the quality of care delivered requires greater international attention to continuing medical education and policy reform that aligns evidence-based practice with physician incentives.

Evidence for the use of Levomepromazine for symptom control in the palliative care setting: a systematic review.

BackgroundLevomepromazine is an antipsychotic drug that is used clinically for a variety of distressing symptoms in palliative and end-of-life care. We undertook a systematic review based on the question “What is the published evidence for the use of levomepromazine in palliative symptom control?”.MethodsTo determine the level of evidence for the use of levomepromazine in palliative symptom control, and to discover gaps in evidence, relevant studies were identified using a detailed, multi-step search strategy. Emerging data was then scrutinized using appropriate assessment tools, and the strength of evidence systematically graded in accordance with the Oxford Centre for Evidence-Based Medicine’s ‘levels of evidence’ tool. The electronic databases Medline, Embase, Cochrane, PsychInfo and Ovid Nursing, together with hand-searching and cross-referencing provided the full research platform on which the review is based.Results33 articles including 9 systematic reviews met the inclusion criteria: 15 on palliative sedation, 8 regarding nausea and three on delirium and restlessness, one on pain and six with other foci. The studies varied greatly in both design and sample size. Levels of evidence ranged from level 2b to level 5, with the majority being level 3 (non-randomized, non-consecutive or cohort studies n = 22), with the quality of reporting for the included studies being only low to medium.ConclusionLevomepromazine is widely used in palliative care as antipsychotic, anxiolytic, antiemetic and sedative drug. However, the supporting evidence is limited to open series and case reports. Thus prospective randomized trials are needed to support evidence-based guidelines.

Ambulante Palliativversorgung von Tumorpatienten im Raum Leipzig

In many model regions of Germany, palliative home care can be improved for cancer patients over longer periods so that most of these patients could die at home. However, there is a shortage of ambulatory care for dying patients in regions without special agreements for this type of care. The aim of the study was to identify beneficial as well as impedimentary factors of outpatient palliative care. Therefore we interviewed 91 tumour patients and collected medical, psychosocial and sociodemographic data with standardized questionnaires. Nearly half of the patients (43%) had moderate to strong pain during domestic care and felt depressed (44%) and anxious (26%). Home hospice services, social workers, and psychologists were rarely involved in home care. Ambulatory home care was often interrupted because of hospital stays. Palliative symptom control in outpatients should be performed by qualified and interdisciplinary palliative-care teams, so that patients can receive more psychosocial support and hospital stays can be prevented.

Introduction: Advances in treatment of metastatic colorectal cancer

Despite advances in screening and treatment, colorectal cancer remains one of the most common malignant diseases in Europe and Northern America, with high mortality and difficult though varied and changing management challenges. Many patients have metastatic disease at the time of diagnosis or develop metastases, often involving the liver, after resection. In the past, in patients who were deemed unresectable, long-term survival was rare. With the limited efficacy of bolus or infusional fluorouracil modulated by leucovorin the major options for treatment of advanced colorectal cancer until relatively recently median overall survival was only 11.5 months. 1 Unavoidably, palliative symptom control became the focus of management early in the course of disease. The introduction of cytotoxic medications such as oxaliplatin and irinotecan, monoclonal antibodies such as bevacizumab and cetuximab, and their incorporation into fluorouracil-based first-line and salvage regimens has led to improved response rates and a prolonged duration of survival that currently exceeds two years, while surgical intervention in selected patients responding to preor peri-operative chemotherapy yields durations of survival that are considerably longer. 2 12 Data consistently support strategies making all effective agents available to patients during the course of their treatment. 13,14 With this increased number and range of treatment possibilities, however, important questions are now emerging regarding the best method of treatment selection as well as the employment of agents as monotherapy, in combination, and in what sequence. The requirement for multidisciplinary cooperation becomes evident.

Bacterial Infections in Terminally Ill Hospice Patients

Terminally ill patients are very susceptible to infections, which are the result of disease-related processes and/or therapy-induced mechanisms. These patients are already subject to multiple severe symptoms and associated comorbid conditions, with much resultant distress. Infection increases this symptom burden and further reduces quality of life. We have retrospectively investigated the prevalence of infection and clinical course in 102 consecutive patients who died after admission to a tertiary palliative care unit and assessed the site-specific frequency of infection, pathogenic organisms involved, and the pattern of antibiotic agents used. The prevalence of symptoms and comorbid conditions on admission and during the progress phase of care were noted. Median overall survival of the total cohort was 12 days. The median survival of patients with infections was 22 days. Thirty-seven patients (36.3%) were diagnosed with 42 separate infections. The sites of infections were the urinary tract (42.5%), the respiratory tract (22.9%), blood (12.5%), skin and subcutaneous tissues (12.5%), and the eyes (10.0%). There were 20 separate positive cultures isolated from specimens obtained from 13 individual patients. Three isolates were obtained from 1 patient, 2 isolates obtained from 5 patients, and 1 isolate was obtained from each of the 7 remaining patients. Escherichia coli was the most common pathogen isolated. Eleven patients with infections (31.4%) were diagnosed on admission, and antibiotic treatment was commenced within 48 hours of admission in 21 patients (60%). Overall antibiotic response and symptom control of infections was observed to be a minimum of 40%. Psychological distress was common in this group of patients (P = 0.001) as were disabling symptoms on admission, such as pain, immobility, and weakness. Symptoms indicating poor survival, such as severe pain and dyspnea, were not significantly associated with infection. Decreased patient survival in this cohort was not significantly associated with the presence of bacterial infection (P = 0.07), irrespective of whether or not a positive culture isolate was obtained. We conclude that appropriate management of infection resulted in enhanced palliative symptom control.

Need for staging laparoscopy in patients with gastric cancer

AIMS: The aim of preoperative staging in gastric cancer is to correctly identify patients with advanced disease who should not be subjected to surgery and to allow the treatment of those who are admitted for operation to be planned accurately. This study assessed the impact of a policy of selective staging laparoscopy in patients deemed suitable for curative or palliative surgery, to ascertain whether the selective approach increased the frequency of abandoned or unplanned surgical procedures. METHODS: Fifty consecutive patients with gastric or type III gastro-oesophageal junction cancer staged by computed tomography (CT) alone, in whom surgery was felt to be appropriate for 'cure' or palliative symptom control, were studied. Specific CT, endoscopic and biochemical criteria were applied prospectively to select out a subgroup of 18 patients who also underwent preoperative staging laparoscopy. The overall accuracy of staging and operative outcomes were assessed. RESULTS: Using this selective approach the resection rate was 98 per cent, although three patients in each group had their planned procedure altered to a less radical (two in each group) or more radical (one in each group) resection (P = 0.23). Overall, 41 of 50 patients were staged correctly (accuracy 82 (95 per cent confidence interval 69-90) per cent) and 86 per cent of patients underwent the planned surgical procedure. The only abandoned operation occurred in the staging laparoscopy group. CONCLUSIONS: It is possible to plan a patient's operation accurately without the need for a staging laparoscopy in all cases.

Palliative Care and Hospice Programs

Palliative Care and Hospice Programs

The Edmonton Symptom Assessment Scale (ESAS) as an Audit Tool

To ensure quality of care, palliative care programs need to document the effectiveness of their relief of physical and psychological distress. The Edmonton Symptom Assessment Scale (ESAS) is a validated, reliable instrument developed to measure 9 different symptoms in palliative care patients. To see if symptom management could be compared across institutions, we first reviewed the charts of 188 successive admissions to the palliative care unit at St. Boniface General Hospital, Winnipeg, Manitoba. Our study showed that the ESAS is a useful audit tool for assessing patterns of palliative symptom control that allows for institutional comparisons. Procedures that ensure completeness of data collection remain to be developed.