Palliative Treatment Plan Research Articles

Biliary drainage in palliative and curative intent European patients with hilar cholangiocarcinoma and malignant hilar obstruction: a retrospective single center analysis

Background and aimsRelief of cholestasis in hilar cholangiocarcinoma is commonly undertaken in both curative and palliative treatment plans. There are numerous open questions with regard to the ideal biliary drainage strategy – including what constitutes clinical success (CS). In the existing data, curative patients and patients from the Western world are underrepresented.Patients and methodsWe performed a retrospective analysis of patients with complex malignant hilar obstruction (Bismuth-Corlette II and higher) due to cholangiocarcinoma who underwent biliary drainage at a German referral center between 2010 and 2020. We aimed to define CS and complication rates and directly compare outcomes in curative and palliative patients.Results56 curative and 72 palliative patients underwent biliary drainage. In patients with curative intent, CS was achieved significantly more often regardless of what definition of CS was applied (e.g., total serum bilirubin (TSB) < 2 mg/dl: 66.1% vs. 27.8%, p = < 0.001, > 75% reduction of TSB: 57.1% vs. 29.2%, p = 0.003). This observation held true only when subgroups with the same Bismuth-Corlette stage were compared. Moreover, palliative patients experienced a significantly greater percentage of adverse events (33.3% vs. 12.5%, p = 0.01). Curative intent treatment and TSB at presentation were predictive factors of CS regardless of what definition of CS was applied. The observed CS rates are comparable to published studies involving curative patients, but inferior to reported CS rates in palliative series mostly from Asia.ConclusionsBiliary drainage in complex malignant hilar obstruction due to cholangiocarcinoma is more likely to be successful and less likely to cause adverse events in curative patients compared to palliative patients.

412: Comparing palliative treatment plans for vertebral metastases on the RT-SIM CT versus diagnostic CT

412: Comparing palliative treatment plans for vertebral metastases on the RT-SIM CT versus diagnostic CT

O114: Enhancing palliative oesophageal cancer treatment pathway prediction and prognostication through machine learning models

Abstract Introduction Non-curative treatment plans comprise the majority of Oesophageal Cancer (OC) decision-making by Multidisciplinary Teams (MDTs), operating under significant caseload pressures. Machine Learning (ML) can semi-automate, streamline, and standardise these decisions to predict treatments and prognosticate for new patients. We present ML models which predict treatment decisions and prognostication in palliative OC patients. Methods Using clinicopathological data from 437 palliative OC cases treated at a single tertiary centre over 12 years, we trained several ML algorithms (Multinomial Logistic Regression [MLR], Random Forests [RF], Extreme Gradient Boost [XGB], Decision Tree [DT], and Random Survival Forests [RSF]) to predict treatment pathways (best supportive care, chemotherapy, radiotherapy, palliative stent, or stent plus oncological adjunct) and survival prognoses. Model performance was evaluated using Area Under the Curve (AUC) for classifier models and C-index (1-concordance) along with calibration plots for the survival model. Additionally, the models were integrated into a web application for clinician-friendly usability. Results Mean AUCs for the classifier models were: MLR 0.801±0.090, RF 0.806±0.078, XGB 0.817±0.079 and DT 0.762±0.108. Mean C-Index for the RSF survival model was 0.330±0.018 while calibration curves showed good calibration within the first 6-12months (median survival for the cohort was 6.31 months (range 0.1-105.8 months)). Conclusion This study is the first use of ML to predict palliative treatment plans and offer prognostication for OC patients, seamlessly integrated into a user-friendly interface for real-time treatment pathway prediction. This offers significant potential to streamline MDT caseload and provide data-driven decision-support for clinicians counselling these patients.

Effectivity of Palliative Care Bundle on Advanced Gallbladder Cancer: A Randomised Controlled Trial.

The main aim of this study was to develop, test, and compare palliative care bundles to improve functional recovery, resilience, and quality of life among advanced gallbladder cancer patient with their routine palliative care. This study was to test a palliative care bundle, a single-center, and two-arm randomised controlled trial done on a total of 116 participants (58 in each arm) from July 2019 to December 2021 at All India Institute of Medical Sciences, Rishikesh. By the end of 4th month, the recruitment rate was 96.7%, retention rate acceptance rate was 95%, and adherence rate was 85%. The palliative care bundle showed that a significant difference in trial outcome index score (P = 0.014*) indicates the effectiveness of the palliative care bundle related to improvement in physical mobility, resilience, and quality of life of patients and reduced caregiver burden. Reported barriers faced by participants were physical exhaustion (65%), psychological factors (25%), social factors (15%) and unfamiliar surroundings (5%). Caregivers reported barriers that their job (40%), physical fatigue related to the care of their patient (40%), their education (10%), and lack of support for their other family members (10%) were some reasons forcing them not to practice palliative care bundle. The palliative care bundle did not interfere with the palliative treatment plan of any patients and significantly improved physical mobility, resilience, quality of life of patients, and reduced caregiver burden. Hence, a palliative care bundle can be considered in the palliative care of advanced cancer patients during their palliative treatment to provide holistic care.

Improvement of pain management in a comprehensive cancer center: a comparison of two cross-sectional studies 8years apart.

In 2011, a multidisciplinary palliative team (MPT) was established at Rigshospitalet (DK) and a cross-sectional study in inpatients was carried out at the Departments of Oncology and Hematology. High symptom burden, high prevalence of pain (64%), and insufficient analgesic treatment were demonstrated. In 2019, a similar study was carried out. This study compares prevalence of symptoms including pain and analyzes analgesic treatment of adult in-patients in a comprehensive cancer center. Two cross-sectional studies (May-Jun 2011; Feb-Sep 2019). malignant diseases, age ≥ 18 y, able to understand Danish. EORTC QLQ-C30 and Brief Pain Inventory (BPI) were applied. A total of 134 and 183 inpatients were included in 2011 and 2019, respectively. Differences in the two populations were seen; in 2019 more patients had advanced disease (P = 0.0096), lower performance status (P = 0.0028), and a palliative treatment plan (P = 0.0034). The prevalence of impairments and symptoms was high and similar in the 2years with exception of severe pain (P = 0.0143) and neuropathic pain (P < 0.0001) which increased in 2019. Moreover, pain relief significantly improved, and significantly fewer patients with pain were left untreated. Significant increase in opioid and adjuvant analgesic prescription in 2019. An overall unchanged high symptom burden was observed. However, improvement of pain management was observed in 2019. The establishment of a MPT may possibly have contributed to improved pain management.

Chemovirotherapy for pancreatic cancer: Gemcitabine plus oncolytic measles vaccine virus.

Oncolytic virotherapy with vaccine viruses employs replicative vectors, which quite selectively infect tumor cells leading to massive virus replication followed by subsequent profound tumor cell death (oncolysis). Measles vaccine virus (MeV) has already shown great oncolytic activity against different types of cancers, including pancreatic cancer. Gemcitabine is a first line chemotherapeutic drug used for pancreatic cancer in palliative treatment plans. Furthermore, this drug can be used to induce senescence, a permanent cell cycle arrest, in tumor cells. In our preclinical work, three well-characterized immortalized human pancreatic cancer cell lines were used to investigate the combinatorial effect of MeV-based virotherapy together with the chemotherapeutic compound gemcitabine. Viability assays revealed that the combination of only small amounts of MeV together with subtherapeutic concentrations of gemcitabine resulted in a tumor cell mass reduction of >50%. To further investigate the replication of the oncolytic MeV vectors under these distinct combinatorial conditions, viral growth curves were generated. As a result, viral replication was found to be only slightly diminished in the presence of gemcitabine. As gemcitabine induces senescence, the effect of MeV on that phenomenon was explored using a senescence-associated β-galactosidase assay. Notably, gemcitabine-induced tumor cell senescence was not impaired by MeV. Accordingly, the chemovirotherapeutic combination of gemcitabine plus oncolytic MeV constitutes a novel therapeutic option for advanced pancreatic carcinoma that is characterized by the mutual improvement of the effectiveness of each therapeutic component.

Outcomes of Peer Review for Radiotherapy Treatment Plans With Palliative Intent.

Peer review of a proposed treatment plan is increasingly recognized as an important quality activity in radiation medicine. Although peer review has been emphasized in the curative setting, applying peer review for treatment plans that have palliative intent is receiving increased attention. This study reports peer review outcomes for a regional cancer center that applied routine interprofessional peer review as a standard practice for palliative radiotherapy. Peer review outcomes for palliative radiotherapy plans were recorded prospectively for patients who began radiotherapy between October 1, 2015, and September 30, 2017. Recommended and implemented changes were recorded. The content of detailed discussions was recorded to gain insight into the complexities of palliative treatment plans considered during peer review. Peer review outcomes were reviewed for 1,413 treatment plans with palliative intent. The proportions of detailed discussions and changes recommended were found to be 139 (9.8%) and 29 (2.1%), respectively. The content of detailed discussions and changes recommended was categorized. Major changes represented 75.9% of recommended changes, of which 84.2% were implemented clinically. Many complexities exist that are specific to palliative radiotherapy. Interprofessional peer review provides a forum for these complexities to be openly discussed and is an important activity to optimize the quality of care for patients with treatment plans that have palliative intent.

On-Board Cone Beam Computed Tomography as Radiation Therapy Simulation for Emergent Cases

To investigate dosimetric clinical appropriateness of on-board kV cone beam computed tomography patient simulation (CBCT-Sim) for palliative treatment plans at a remote satellite clinic having no conventional computed tomographic simulation (CT-Sim) when travel isn't a viable option. Our current approach is a separation calculation using two opposing fields on a water phantom. A CBCT of the patient would improve the plan by utilizing the patient's actual geometry and we expect to see dose points in the CBCT-Sim plan image set less than 3% different than a conventional CT, and the separation calculation to be within 5% of the conventional CT-Sim plan. Patients treated for the four most likely emergent or immobile disease sites (brain, thoracic spine, lumbar spine, and pelvis) with an original CT-Sim and at least one CBCT during course of treatment were investigated retrospectively. Three brain patients, three T-spine, three L-spine, and two pelvis patients were used. The patients’ images were copied into a new, anonymous patient. A new CT-density curve was created in the treatment planning software for the CBCT based on CT-density phantom data. A standard plan for each given site was planned on the original CT image set, then copied on both a heterogenous and homogenous CBCT image set. The homogenous CBCT image was density overridden to water. A rectangular water phantom was also created for a separation calculation plan, which is our standard practice for these cases. For the brain cases, the CT and heterogenous CBCT plans were both contoured with critical structures. For all cases, seven to eleven points of interest in all directions (isocenter, and fractional separation distances in 3-dimentional space) were used to compare both CBCT-Sim plans and the separation calculation to the standard CT plan. For all cases, the average dose difference per case compared to the standard CT-Sim plan was less than 3% for either CBCT-Sim plan and less than 4% for the separation calculation plan; however, the separation calculations showed large deviations, up to 7.2%, while the CBCTs showed a maximum of 4.8%. Between all cases, the average dose difference was lowest compared to CT-Sim plans for the heterogenous CBCT plan with 1.2±0.7%, while the homogenous CBCT plan difference was 1.4±0.7% and the separation calculation was 1.7±1.1%. The most dosimetric benefit for the heterogenous CBCT-Sim plans was seen for the brain plans, followed by the T-spine plans, with negligible benefit for pelvis and L-spine plans. Dosimetric accuracy is improved with a CBCT-Sim compared to our standard separation-based plan, due to the use of actual patient geometry and density.

The Palliative Treatment Plan as a Bone of Contention between Attending Physicians and Nurses.

Acute vital crisis in end-of-life situations may result in hospitalization and intensive care without recognizable benefit in many cases. Advance directives regarding indications for resuscitation, hospitalization, and symptomatic treatment help ensure that acute complications can be managed quickly and satisfactorily in the patient’s customary surroundings. A plan was designed and implemented in Austrian nursing homes to provide emergency physicians with rapidly obtainable information on the patient’s current situation, and whether resuscitation attempts and hospitalization are advised or not. This palliative treatment plan is arranged by a physician together with caregivers, close relatives, and the patient or his court-appointed health care guardian or holder of power of attorney. Four years after implementation of the plan, a user satisfaction survey was carried out. The majority of participating nurses, emergency physicians and family doctors judged application and design of the palliative treatment plan positively. However, the low response rate of family doctors indicates nonconformity. In particular, the delegation of symptomatic treatment to nurses proved to be controversial. There is still a need to provide up-to-date information and training for health professionals in order for them to understand advance directives as extended autonomy for patients who have lost their ability to make their own decisions.

An Unusual Case: Gastric Metastasis of Hepatocellular Carcinoma

Introduction: Gastrointestinal tract involvement of hepatocellular carcinoma (HCC) is a rare entity with a poor prognosis and can occur via hematogenous route or direct invasion. Here we report a case with de novo HCC after liver transplantation who had rising alfa-fetoprotein (AFP) levels and was found to have gastric metastases incidentally. Case: A 62 year old man underwent liver transplantation with a diagnosis of hepatocellular carcinoma Three years after the liver transplantation, bone and liver metastasis developed and palliative treatment plan was made. During follow-up AFP levels began to rise subsequently and computed tomography of chest and abdomen revealed stable liver lesions and a suspicious gastric luminal nodule. Upper endoscopy showed polypoid lesions in stomach and the pathology of the biopsies taken from these lesions were consistent with HCC metastasis. Discussion: Patterns of metastases in patients with recurrent HCC after liver transplantation might be different. Immunsuppressive treatment in transplant patients might have a negative effect on disease biology and may result in more disseminated disease and atypical sites of metastases as in our case. In patients with rising AFP in the absence of progressive disease on radiologic evaluation, gastrointestinal system metastases via hematogenous route should be kept in mind and upper endoscopy should be considered even in the absence of gastric symptoms, particularly if the presence of extrahepatic disease will change treatment decisions.

Early detection of disease progression after palliative chemotherapy in NSCLC patients by (18)F-FDG-PET.

We investigated whether 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is capable of detecting renewed disease progression earlier than computed tomography (CT) in patients with inoperable non-small cell lung cancer (NSCLC) who have undergone chemotherapy as part of a palliative treatment plan. 18 patients were studied retrospectively. Three FDG-PET/CT scans for initial and follow-up diagnostic purposes were evaluated. Palliative chemotherapy was administered between the first FDG-PET/CT scan (t0) and the second (t1), followed by a treatment-free interval between the second FDG-PET/CT scan (t1) and the third (t2). Maximum standardized uptake values (SUVmax) and largest diameters of lesions were determined for PET scans and the corresponding CTs. Lesion-based and patient-based assessments were performed, as were assessments according to RECIST/PERCIST. 82 lesions were identified in 18patients. In interval t1-t2, the increase in diameter in the lesion-based evaluation was 5.0% (non-significant), while the patient-based evaluation showed a non-significant reduction of 2.8%. Considering PET, both the lesion-based and patient-based evaluations found a significant increase in SUVmax by a median of 30.4% and 45.8%, respectively. PERCIST criteria at time point t2 identified ten more patients with progression than did RECIST. In patients with NSCLC, renewed progression during the treatment-free interval after palliative chemotherapy can be detected earlier with PET than with CT. Thus, FDG-PET appears to be a useful diagnostic imaging procedure regarding this aspect. Its clinical relevance should be investigated in further studies.

Is educating community nurses about end-of-life care a waste of resources?

British Journal of Community Nursing Vol 18, No 2 77 The health system—and palliative care in particular— are facing difficult financial times due to spending cuts. It seems that when times are this hard one of the first things to go is staff education, which is disturbing considering that it takes years to train community palliative care nurses to function at specialist level. Attendance at courses, conferences and study days/seminars are all affected, which leaves one asking whether palliative care education among community nurses still has currency needed to enhance patient experience. However, despite these negative outcomes the Government has confidently stated that a positive patient experience is an important quality health outcome. The financial situation and the Government’s aspiration create tension, in that, to create a positive patient experience, there must be a well trained workforce to deliver the best services and care possible. But the Willis report (2012) concurs that there are no ‘major shortcomings’ in nursing education to affect the quality of care given to patients. The report goes on to recommend under theme 4: continuing professional development that all relevant bodies including employers and universities should recognise, fund, promote and support nurses development. This would include community nurses as a way of investing for the future. The issue may be how education is translated into practice to benefit patients. It was encouraging when, in January, the prime minster pledged £40million funding for ward managers, community team leaders and senior nurses to gain necessary skills to provide compassionate care. For community team leaders, compassionate care is even more crucial to patients at the end of their lives. However, considering the number of groups this money is intended for, one wonders whether it will be enough to see real change for all patients. Education of community nurses in palliative care is crucial if all patients are to be afforded a dignified and unique death. Education of community nurses ensures that patient experience can be enhanced at point of care delivery. Community nurses need to understand the patient’s needs, concerns, wishes and fears. Community nurses need to be equipped with skills that help them support the patient physically and emotionally. When death is impending, most patients want information so informational care is vital. The national cancer patient experience survey (2010) reported 43% of patients want more information about their diagnosis than what they are given (Department of Health, 2010). Informational care helps patients understand better their disease, its progression and palliative treatment plan where possible. Educated community nurses can provide evidence-based information, which has been tested for validity. However, in order to do so they need to be able to understand the evidence to decide on its clinical relevance. Education is one sure way of achieving this. The knowledge that death is imminent often evokes emotional responses for patients, and a community nurse may be the first professional to visit them at home, following confirmation of the diagnosis. Patient experience would be enhanced if the nurses recognise and address the emotions being expressed in a non-judgemental way. Emotions are expressions of feelings and at times a cry for help, which can be managed through information or a platform to talk and alleviate anxiety, worries and fears. Evidence from Armes et al (2009) suggests 50% of people (150 000 per year) experience anxiety and depression following a diagnosis of cancer. In order to support patients with emotional needs, community nurses’ communication skills need to be effective and this can be enhanced through training and refresher workshops. Some employers afford their staff sufficient education and training and demonstrate continual professional development. However, in some organisations—and I have experienced it personally—it is quite frustrating for nurses who are funded to attend palliative care courses, conferences and seminars to find that when they return, there is no appetite from management to implement the new evidence or facilitate knowledge exchange with other staff. Putting this into the context of real cost and time, it translates to a waste of resources, educating these nurses in this way. Similarly, when community nurses have completed a research project as part of their degree, there is no incentive to disseminate findings and implement changes in practice. A clear strategy is essential to ensure that such vital knowledge is put to good use that will benefit patients at the end of their life. One in five people develop significant long-term emotional difficulties (Macmillan Cancer Support, 2012), seriously affecting their quality of life, so it is vital community nurses are supported to improve the patient experience and do it right first time. BJCN

Der palliative Behandlungsplan als Entscheidungsbasis zwischen palliativer und notfallmedizinischer Behandlung

Acute vital crisis in end-of-life situations may result in a person being hospitalized and thus, expelled from his intimate environment, which aggravates the continuity of care. This entails a heavy burden for patients and necessitates an emergency medical services (EMS) call without recognizable benefit in many cases. Crisis episodes frequently mark the beginning of the dying process. Advance care planning or end-of-life care in elderly patients can help prevent such situations and ensure high contentment of patients, families and caregivers. Frequently, the question arises whether the burden arising from further hospitalization or from certain medical treatment options is reasonably balanced by the potential benefits of the steps taken. In such comprehensive care settings a custom-tailored palliative treatment plan may serve as an instrument for advance care planning. A palliative treatment plan set up by a physician together with a caregiver helps ensure that acute problems can be solved quickly and satisfactorily in the patient's customary surroundings. If EMS assistance is still needed, the emergency physician has written information on the patient's situation and can act quickly to meet the patient's immediate needs. This also means that EMS personnel must be properly trained in providing palliative care. In this way the palliative treatment plan can help caregivers continue to care for patients in their intimate surroundings.

Medication Can Induce Severe Ulcerations

Nonsteroidal antiinflammatory drugs can cause oral ulcers. In this case, discontinuing piroxicam, a nonsteroidal anti-inflammatory drug, and starting a palliative treatment plan helped resolve a patient's ulcers.