Supportive Care Options Research Articles

Exploring the experience of adhering to a prescribed pre-surgical exercise program for patients with advanced rectal cancer: A phenomenological study

ObjectivesThe aim of this study was to explore the lived experience of patients with advanced rectal cancer as they attempted to adhere to a prescribed, hospital-based pre-surgical exercise program. Design/MethodsTen patients took part in three semi-structured in-depth interviews prior to (week 0), midway (week 3), and at completion (week 6) of the exercise program. Data were analysed using a phenomenological approach. ResultsMain themes that were deemed important for remaining enrolled in the program included: (1) building camaraderie and peer support, (2) experiencing a sense of structure and control, and (3) feeling safe and encouraged. Patients also reported engaging in further exercise outside the program and feeling motivated to continue exercising in the future. ConclusionsThis study shows the potential to integrate exercise prior to surgery as it was viewed as acceptable and feasible by patients with advanced rectal cancer. Moreover, it provides much needed information into the possible mechanisms that underpin patient's continued participation in exercise programs during treatment for advanced rectal cancer. Prescribed, hospital-based program should be implemented to promote opportunities for exercise and provide on-going supportive care options for patients awaiting surgery.

Ceritinib: Breakthrough treatment for ALK-positive metastatic non–small cell lung cancer

FDA has granted accelerated approval to ceritinib (Zykadia— GlaxoSmithKline), a new oral therapy targeting anaplastic lymphoma kinase–positive (ALK+) metastatic non–small cell lung cancer (NSCLC) in patients who have progressed on or are intolerant to crizotinib (Xalkori—Pfizer), the only other approved ALK inhibitor.

Supportive care for women with recurrent miscarriage: a survey to quantify women's preferences

Supportive care is regularly offered to women with recurrent miscarriages (RMs). Their preferences for supportive care in their next pregnancy have been identified by qualitative research. The aim of this study was to quantify these supportive care preferences and identify women's characteristics that are associated with a higher or lower need for supportive care in women with RM. A questionnaire study was conducted in women with RMs (≥ 2 miscarriages) in three hospitals in the Netherlands. All women who received diagnostic work-up for RMs from January 2010 to December 2010 were sent a questionnaire. The questionnaire quantified supportive care options identified by a previous qualitative study. We next analysed associations between women's characteristics (age, ethnicity, education level, parity, pregnancy during questionnaire and time passed since last miscarriage) and their feelings about supportive care options to elucidate any differences between groups. Two hundred and sixty-six women were asked to participate in the study. In total, 174 women responded (response rate 65%) and 171 questionnaires were analysed. Women with RM preferred the following supportive care options for their next pregnancy: a plan with one doctor who shows understanding, takes them seriously, has knowledge of their obstetric history, listens to them, gives information about RM, shows empathy, informs on progress and enquires about emotional needs. Also, an ultrasound examination during symptoms, directly after a positive pregnancy test and every 2 weeks. Finally, if a miscarriage occurred, most women would prefer to talk to a medical or psychological professional afterwards. The majority of women expressed a low preference for admission to a hospital ward at the same gestational age as previous miscarriages and for bereavement therapy. The median preference, on a scale from 1 to 10, for supportive care was 8.0. Ethnicity, parity and pregnancy at the time of the survey were associated with different preferences, but female age, education level and time passed since the last miscarriage were not. Women with RM preferred a plan for the first trimester that involved one doctor, ultrasounds and the exercise of soft skills, like showing understanding, listening skills, awareness of obstetrical history and respect towards the patient and their miscarriage, by the health care professionals. In the event of a miscarriage, women prefer aftercare. Women from ethnic minorities and women who were not pregnant during the questionnaire investigation were the two patient groups who preferred the most supportive care options. Tailor-made supportive care can now be offered to women with RM.

Low Testosterone Levels Are Associated with Shorter Progression Free Survival in Multiple Myeloma

Abstract 4978 Introduction:Testosterone (T) is important for maintenance of bone mineral density and muscle mass, stimulation of erythropoiesis, energy level, mood, and libido. Androgen deprivation therapy, i. e. near-complete hypogonadism, for prostate cancer is associated with type 2 diabetes, myocardial infarction, and overall mortality. In a study of male cancer patients with prostate and germ cell tumors, the prevalence of low T was 48–78% with opioid use, obesity, and being Caucasian as statistically significant covariates. Obesity increases T in women, with an associated increased breast cancer risk, and lowers T in men while raising estradiol levels. As fatigue and depression are common in multiple myeloma, we conducted a review of T in myeloma patients. None of the published literature has looked for an association between free testosterone and either characteristics of disease biology or concrete endpoints such as age of diagnosis, performance status, progression free survival, or overall survival. Methods:We retrospectively reviewed consecutive patients with plasma cell dyscrasias referred to Ohio State University that signed consent for the IRB-approved Ohio Myeloma Registry (www. ohiomyeloma. org). 343 patients were initially identified with either a total or free testosterone level available for evaluation, 171 patients with active myeloma. Results:168 patients had a diagnosis of active myeloma and low or normal T – 44/171 (25%) were receiving opiates, 29/171 (17%) were taking anti-depressants, and 135/171 (79%) were male. 37/171 (22%) had type 2 diabetes and 92/171 (54%) had hypertension. The BMI median was 28. 9 (range 16. 9–53. 1) with 32 (19%) patients normal, 48 (28%) overweight, and 60 (35%) obese. The median time from diagnosis to T assessment was 49 days. In the entire cohort, the median free testosterone was 4. 17 (range 0. 11–16. 17) with 45 (26%) patients below the normal range, 123 (72%) within normal limits, and 3 (2%) with high T. In the subset of male patients (n=135), the median age was 61 y. o. (range 18–80).We designated two groups of male patients – 44 with low T and 91 with normal T. When comparing the two groups across hemoglobin, creatinine, calcium, stage, BMI, renal insufficiency, and anemia, there were no statistically significant differences. There was a difference between the presence or absence of lytic bone disease (p<0. 036) – less detectable bone disease on skeletal survey in the normal testosterone group. The median PFS in the low free T group was 23 months (16 events) and 35 months in the normal T group (27 events), p<0. 28. If we repeated this analysis but included women, the median PFS in the low free T group was 23 months compared to 35 months in the normal T group (p<0. 39). If we expand to include patients that had total as well as free testosterone, the median PFS was 24 months compared to 34 months with normal T (p<0. 23) (see figure). Conclusions:With approximately 30% of the cohort with severe hypogonadism (free testosterone below normal range) in a population predisposed to fractures, anemia, and depression, increased awareness of the prevalence of this diagnosis may change supportive care options for a population that often has a poor quality of life. There is a trend towards shorter PFS in patients with low free T. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Myeloma:diagnosis complications and supportive care

A key approach to current treatment is the rapid reduction of the myeloma clone to minimal disease levels. This approach has significantly improved outcomes but it remains critical to manage the side effects of the disease and of treatment emergent side effects. While these supportive care options are directed towards improving patient quality of life, they also have significant effect against the disease and can improve survival.

Recent Developments in Treatment Stratification for Metastatic Breast Cancer

The modern approach to management of metastatic breast cancer (MBC) is centred on individualizing treatment to best suit the patient's breast cancer characteristics (molecular subtype, disease burden and prognostic markers), as well as the patient's clinical history (co-morbidities, prior therapies and social factors). The wealth of treatments available has heightened the complexity of tailored patient care that in turn allows better optimization of treatment efficacy and quality of life. There are promising developments in the management of estrogen receptor (ER)-positive breast cancer, particularly with respect to overcoming resistance with dual targeting of the phosphoinositide-3 kinase/AKT/mammalian target of rapamycin and ER-signalling pathways. A central focus in the management of triple negative breast cancer has been through efforts to identify novel therapeutic targets in this disease subgroup. Next-generation sequencing approaches have begun to reveal how breast cancer somatic mutational heterogeneity between tumours with the same histopathological subtype is likely to impede efforts to identify novel common therapeutic targets. The most successful example of targeted therapy in MBC is the targeting of human epidermal growth factor receptor 2 (HER2) by trastuzumab. Dual and irreversible HER2/epidermal growth factor receptor targeting and attenuation of downstream resistance pathways also appear promising in HER2-positive trastuzumab-refractory breast cancer. Targeted therapy with antiangiogenic agents shows clinical activity, but the balance between efficacy, toxicity and cost remains a topic of debate, emphasizing the unmet need for a predictive biomarker of response to this class of drug. Poly(ADP ribose) polymerase(PARP) inhibitors appear to have clinically meaningful activity in BRCA germline mutant breast cancer. Activity of PARP inhibitors in other breast cancer subgroups is yet to be clearly defined. Novel chemotherapy agents show marginally superior efficacy, at a cost of a moderate increase in toxicity. Bone-modifying drugs expand supportive care options; again, better permitting individualization of treatment choice. The future management of MBC will increasingly focus on stratifying therapeutics based on individualized-tumour molecular aberrations.

Supportive care for women with unexplained recurrent miscarriage: patients’ perspectives

BACKGROUND Supportive care is currently the only 'therapy' that can be offered to women with unexplained recurrent miscarriage (RM). What these women themselves prefer as supportive care in their next pregnancy has never been substantiated. Therefore the aim of this study was to explore what women with unexplained RM prefer as supportive care during their next pregnancy. METHODS We performed explorative, semi-structured, in-depth interviews. The interviews were performed with 15 women with unexplained RM who were actively seeking conception. All interviews were conducted by telephone. The interviews were fully transcribed and two researchers independently identified text segments from the transcribed interviews and categorized them in the appropriate domain. RESULTS Women identified 20 different supportive care options; 16 of these options were preferred for their next pregnancy. Examples of the preferred supportive care were early and frequently repeated ultrasounds, βHCG monitoring, practical advice concerning life style and diet, emotional support in the form of counselling, a clear policy for the upcoming 12 weeks and medication. The four supportive care options that were not preferred by the women were admittance to a hospital ward at the same gestational age as previous miscarriages, Complementary Alternative Medicine, ultrasound every other day and receiving supportive care from their general practitioner. CONCLUSIONS Our study identified several relevant preferences for supportive care in women with unexplained RM. Many of these can be offered by the gynaecologist and will help in guaranteeing high-quality patient-centred care.

American Society of Clinical Oncology Statement: Toward Individualized Care for Patients With Advanced Cancer

Patients with advanced incurable cancer face complex physical, psychological, social, and spiritual consequences of disease and its treatment. Care for these patients should include an individualized assessment of the patient's needs, goals, and preferences throughout the course of illness. Consideration of disease-directed therapy, symptom management, and attention to quality of life are important aspects of quality cancer care. However, emerging evidence suggests that, too often, realistic conversations about prognosis, the potential benefits and limitations of disease-directed therapy, and the potential role of palliative care, either in conjunction with or as an alternative to disease-directed therapy, occur late in the course of illness or not at all. This article addresses the American Society of Clinical Oncology's (ASCO's) vision for improved communication with and decision making for patients with advanced cancer. This statement advocates an individualized approach to discussing and providing disease-directed and supportive care options for patients with advanced cancer throughout the continuum of care. Building on ASCO's prior statements on end-of-life care (1998) and palliative care (2009), this article reviews the evidence for improved patient care in advanced cancer when patients' individual goals and preferences for care are discussed. It outlines the goals for individualized care, barriers that currently limit realization of this vision, and possible strategies to overcome these barriers that can improve care consistent with the goals of our patients and evidence-based medical practice.

469 Vitamin D signalling and metabolic pathways expression in breast cancer progression

With current treatments, men usually survive many years after being diagnosed with prostate cancer. However, without supportive care, the systemic effects of prostate cancer and therapies such as androgen deprivation therapy (ADT) can undermine skeletal integrity, resulting in skeletal complications that may erode quality of life (QOL). Prostate cancer patients are at risk for fractures from cancer treatment-induced bone loss. In addition, they are also at risk for pathologic fractures, severe bone pain, and other sequelae from bone metastases, which almost invariably occur during the progression of prostate cancer. This review investigates the incidence and pathophysiology of bone loss and skeletal morbidity in prostate cancer patients and reviews available treatment options for maintaining skeletal health throughout the continuum of care for these patients.Studies were identified through MEDLINE searches, review of bibliographies of relevant articles, and review of abstracts from national meetings.Several supportive care options are available to prevent generalized and localized bone loss, including calcium and vitamin D supplements and bisphosphonates. Oral calcium and vitamin D supplementation alone, however, appears to be insufficient to prevent bone loss during ADT. Zoledronic acid administered every 3 months during ADT or every 3 to 4 weeks for patients with bone metastases can reverse bone loss and reduce skeletal morbidity, respectively, in patients with prostate cancer.Skeletal complications contribute to the erosion of QOL in prostate cancer patients. Palliative care can provide important benefits to these patients. Some agents, such as zoledronic acid, may provide skeletal health benefits throughout the course of prostate cancer progression. Further investigations of the QOL impact of these benefits are warranted.

Recent Time Trends in the Epidemiology of Stage IV Prostate Cancer in the United States: Analysis of Data From the Surveillance, Epidemiology, and End Results Program*

To describe recent epidemiologic trends in stage IV prostate cancer. Although advances in screening and diagnostic techniques have led to earlier detection of prostate cancer, a portion of patients still present with late-stage disease. Population-based cancer registry data from the Surveillance, Epidemiology, and End Results Program (cases from 1988 to 2003, follow-up through 2005) were used to calculate annual age-adjusted incidence rates of stage IV prostate cancer (overall and for the subset presenting with distant metastases) and to assess time trends in patient, tumor, and treatment characteristics and survival. From 1988 to 2003, the age-adjusted incidence of stage IV prostate cancer significantly declined by 6.4% each year. The proportion of men diagnosed at younger ages, with poorly differentiated tumors, or who underwent a radical prostatectomy significantly increased over time. Five-year relative survival improved across the study period (from 41.6% to 62.3%), particularly in those diagnosed at younger ages or with moderately to well-differentiated tumors. Later years of diagnosis were independently associated with a decreased risk of death (from all causes and from prostate cancer specifically) after controlling for important patient, tumor, and treatment characteristics. Tumor grade and receipt of radical prostatectomy appeared to be the strongest independent prognostic indicators. Temporal trends were similar in the subset presenting with distant metastases, except that no significant improvement in survival was observed. As younger men may expect to live longer with advanced prostate cancer, there remains a need to widen the range of therapeutic and supportive care options.

Update on the therapy for myelodysplastic syndrome

The myelodysplastic syndromes (MDS) are a diverse group of clonal hematopoietic stem cell disorders characterized by cytopenias. Patients have a risk of developing acute leukemia though most succumb to complications of low blood counts. Over the past decade many novel treatments have been developed and investigation of new agents is ongoing. In this article, we discuss the classification and prognostic systems that are used in MDS, the agents available for treatment of MDS as well as review supportive and palliative care options for patients who are not candidates for, or opt against, newer treatment strategies.

Improvement in survival of breast cancer patients with synchronous metastases

1063 Background: Less than 10% of breast cancer patients are diagnosed with metastatic disease upon initial diagnosis. Once metastases are detected, median survival ranges between 18 and 24 months. Many new chemotherapy agents, hormonal therapy, monoclonal antibodies and supportive care options were presented during the last decade. Although a few randomized trials have demonstrated improvement in survival for various agents, it has not been clear whether the overall survival of these patients has improved. In this study, we analyzed the survival of patients diagnosed with metastatic breast cancer in during the 1990’s Methods: We have analyzed 874 patients diagnosed with breast cancer at our Institute in the years 1991–1994 and 1102 patients in 1996–1999. Tumor characteristics, treatments, and the outcomes of these patients were compared. We used Kaplan-Meier, Wilcoxon test and Cox proportional hazard in order to investigate variants between the 2 groups. Results: After excluding all women with no evidence of metastatic disease at diagnosis, we analyzed 96 patients. No major difference in tumor characteristics was found between the group of patients diagnosed in the early 1990’s and the group diagnosed in the late 1990’s. We found a significant relationship between the period of diagnosis of metastatic breast cancer and survival: median survival was 19 months for the first group and 35 months for the second group (p=0.0398, 95% C.I), with 5-year overall survival rates 8% for patients diagnosed in the early 1990’s and 25% for patients diagnosed in the late 1990’s, p=0.0497. Two years survival was 25% and 60% respectively, although insignificant, p = 0.0941. Although there was no significant difference in number of chemotherapy courses given in the 2 groups, many more new generation treatments were used for the late 90th group. The Hazard of death within 5 years for patients treated with at least one new generation protocol was 0.53, p= 0.004. Conclusions: This study suggests that there has been significant survival improvement in breast cancer patients diagnosed with synchronous metastasis during the second half of the 1990’s. This improvement can be explained by the introduction of new treatments agents and strategies during the last decade No significant financial relationships to disclose.

Major Progress for a Less Common Cancer

Major Progress for a Less Common Cancer

Skeletal Morbidity in Men with Prostate Cancer: Quality-of-Life Considerations throughout the Continuum of Care

With current treatments, men usually survive many years after being diagnosed with prostate cancer. However, without supportive care, the systemic effects of prostate cancer and therapies such as androgen deprivation therapy (ADT) can undermine skeletal integrity, resulting in skeletal complications that may erode quality of life (QOL). Prostate cancer patients are at risk for fractures from cancer treatment-induced bone loss. In addition, they are also at risk for pathologic fractures, severe bone pain, and other sequelae from bone metastases, which almost invariably occur during the progression of prostate cancer. This review investigates the incidence and pathophysiology of bone loss and skeletal morbidity in prostate cancer patients and reviews available treatment options for maintaining skeletal health throughout the continuum of care for these patients. Studies were identified through MEDLINE searches, review of bibliographies of relevant articles, and review of abstracts from national meetings. Several supportive care options are available to prevent generalized and localized bone loss, including calcium and vitamin D supplements and bisphosphonates. Oral calcium and vitamin D supplementation alone, however, appears to be insufficient to prevent bone loss during ADT. Zoledronic acid administered every 3 months during ADT or every 3 to 4 weeks for patients with bone metastases can reverse bone loss and reduce skeletal morbidity, respectively, in patients with prostate cancer. Skeletal complications contribute to the erosion of QOL in prostate cancer patients. Palliative care can provide important benefits to these patients. Some agents, such as zoledronic acid, may provide skeletal health benefits throughout the course of prostate cancer progression. Further investigations of the QOL impact of these benefits are warranted.