Palliation Of Symptoms Research Articles

An observational study of best supportive care with or without oral capecitabine in patients with metastatic gallbladder cancer.

521 Background: Patients with metastatic (M+) gallbladder cancer (GBC) have a median survival between 3 - 6 months and therefore palliation of symptoms without compromising quality of life (QoL) is the principal goal of treatment. This study aimed to compare overall survival (OS), toxicity and QoL in patients receiving best supportive care (BSC) with or without oral capecitabine (X). Methods: Patients with M+ GBC and a KPS of ≥70 were prospectively assigned to BSC + X - arm A or BSC alone - arm B, based on physician discretion. Arm A received BSC + X @1650 mg/m2 d1-14, repeated every 21 days for a maximum of 6 cycles. BSC measures included pain palliation; ascitic fluid drainage; jaundice mitigation and other palliative measures. Overall survival (OS) was computed by the Kaplan-Meier method from the date of histologic confirmation and compared using log-rank test. Qol was measured using FACT-Hep v4 administered at baseline, 3 and 6 months. Mean differences in scores were compared using Mann Whitney / Independent t-test and the linear mixed effects model was used for longitudinal analysis to determine the impact of treatment and time on QoL. Results: Between December 2020 to April 2022, 64 patients were assigned, 32 to each arm; data analysed August 2022. For the arms A vs B, the mean age (years) ± SD was 53.3±10.3 vs 54.5±10.3, p=0.21; females, 72% vs 73%, p=0.21; KPS 70, 9% vs 44%, p=0.008; pre-treatment biliary drainage, 9% vs 31%, p=0.06. In arm A, 78% and 21% completed 3 and 6 cycles of X. Median survival was 3.6 vs 2.0 mo, p=0.001; 26 and 27 patients succumbed (~83%), and at 6 months the survival probability was 28% vs 0% respectively; vomiting grade 1-2, 50% vs 78%, p=0.02; diarrhoea grade 1-2, 59% vs 9%, p=0.00; hand-foot syndrome – only arm A, grade 1, 2 & 3 were 32%, 6.5% & 3.2% p=0.001. Baseline QoL mean scores (Table) were significantly worse for most domains in arm B. However, there was no difference in the longitudinal QoL scores between the two treatment arms – FACTG total score (arm*time p=0.759). Conclusions: Not withstanding better prognosis patients of M+ GBC receiving X with BSC compared to BSC alone, a 2 month difference in median survival in favour of arm A was associated with worse diarrhoea and hand-foot syndrome and no discernable impact on longitudinal QoL scores between the two treatment arms.[Table: see text]

Palliative care symptoms and problems in a culturally and linguistically diverse population: large retrospective cohort study

ObjectivesMigrant Australians with cancer have higher unmet needs and poorer health-related quality of life. Less is known about their palliative care experience. We aimed to assess comparative symptom distress and...

Relationship between demoralization and quality of life in end-of-life cancer patients.

To examine the relationship between demoralization and health-related quality of life (HRQoL) in a sample of end-of-life cancer patients with a life expectancy of 4months or less undergoing palliative care, controlling for sociodemographic, clinical, and psychological variables. Sociodemographic, clinical, and psychological data from 170 end-of-life cancer patients were collected using the following scales: Edmonton Symptom Assessment System for palliative care patients' symptoms; Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms; Functional Assessment of Cancer Therapy Scale - General Measure (FACT-G) for HRQoL; Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being for spirituality (FACIT-Sp); Demoralization Scale - Italian Version (DS-IT) for demoralization. The DS-IT showed that 51.8% of cancer patients were severely demoralized. In addition, 36.5% of the sample had clinically significant depressive symptoms and QoL was severely impaired (FACT-G). The result of regression analysis showed that demoralization (especially "Disheartenment" and "Sense of failure") was the strongest contributor for HRQoL, followed by ESAS_Lack of Well-Being and depression (PHQ-9), with the final model explaining 66% of the variance of the FACT-G. The results highlight a very high prevalence of severe demoralization in end-of life cancer patients. Moreover, demoralization was not only associated with patients' HRQoL, but it was also the most important contributing factor. This finding underscores the need to identify preventive or therapeutic psychological interventions that focus on preventing existential distress, and thus improve the QoL of dying patients in their last days of life.

The potential impact of proxy reports for symptom experience and care quality and experience in advanced cancer.

As the US tests models of care for the seriously ill, patient perceptions of the quality of care are important. Proxies are often needed for this group. We sought to understand the potential impact of proxy reports for the assessment of care quality and experience in cancer. Secondary data analysis of a deidentified prospective study that included surveys of perceived care quality, including symptom management, from patients with advanced cancer receiving chemotherapy and their caregivers. Surveys were administered at diagnosis (time 1) and treatment (time 2), with top-box scoring used for analysis. Overall concordance was assessed using metrics including Gwet's AC1. The proportion of the highest scores by respondent type within 2 subgroups were examined: (1) symptom burden and (2) practice setting. Data from 83 dyads were analyzed. Proxies and patients frequently reported the highest scores for quality (time 1: proxies: 77% and patients: 80%). At time 1, 14% of proxies and 10% of patients reported an unmet need for symptom palliation. Most patients reporting an unmet need gave the top score for quality (75%), but fewer proxies did so (45%). Proxy and patient reports were similar within practice settings. Concordance was at least moderate (nearly all outcomes >0.5 and some >0.8) by Gwet's AC1. Findings of at least moderate concordance and similar experience outcomes within subgroups suggest the use of proxies may not change estimates substantially. However, consideration should be taken when evaluating symptom management, particularly if such evaluations inform assessment of provider performance.

BRACHY: A Randomized Trial to Evaluate Symptom Improvement in Advanced Non-Small Cell Lung Cancer Treated With External Beam Radiation With or Without High-Dose-Rate Intraluminal Brachytherapy

Uncontrolled studies suggest that the addition of high-dose-rate intraluminal brachytherapy (HDRIB) to external beam radiation therapy (EBRT) may improve palliation for patients with advanced non-small cell lung cancer (NSCLC). The purpose of this study was to evaluate the potential clinical benefit of adding HDRIB to EBRT in a multicenter randomized trial. Patients with symptomatic stage III or IV NSCLC with endobronchial disease were randomized to EBRT (20 Gy in 5 daily fractions over 1 week or 30 Gy in 10 daily fractions over 2 weeks) or the same EBRT plus HDRIB (14 Gy in 2 fractions separated by 1 week). The primary outcome was the proportion of patients who achieved symptomatic improvement in patient-reported overall lung cancer symptoms on the Lung Cancer Symptom Scale (LCSS) at 6 weeks after randomization. Secondary outcomes included improvement in individual symptoms, symptom-progression-free survival, overall survival, and toxicity. The planned sample size was 250 patients based on detection of symptomatic improvement from 40% to 60% with a 2-sided α of .05 and 80% power. A total of 134 patients were randomized over 4.5 years: 67 to each arm. The study closed early owing to slow accrual. The mean age was 69.8 years, and 67% of patients had metastatic disease. At 6 weeks, 19 patients (28.4%) in the EBRT arm and 20 patients (29.9%) in the EBRT plus HDRIB arm experienced an improvement in lung cancer symptoms (P=.84). When limited to patients who completed the LCSS, percentages were 40.4% versus 47.6%, respectively (P=.49). Between group differences in mean change scores (0.3-0.5 standard deviations) in favor of EBRT plus HDRIB were observed for overall symptoms, but only hemoptysis was significantly improved (P=.03). No significant differences were observed in progression-free or overall survival. Grade 3/4 toxicities were similar between groups. Small to moderate improvements were seen in symptom relief with the combined therapy, but they did not reach statistical significance. Further research is necessary before recommending HDRIB in addition to EBRT for palliation of lung cancer symptoms.

Role of addition of chemotherapy to palliative radiotherapy protocol: A review of literature and experience from a tertiary cancer center of India

Unresectable head-and-neck cancers (HNCs) pose a significant challenge to clinical oncologists. Radiotherapy (RT) has a pivotal role in palliation of symptoms in advanced unresectable stage. Palliative RT protocols generally employ hypofractionated regimes in an attempt to reduce the overall treatment time and acute toxicities. Concurrent chemoradiotherapy (CCRT) may improve local control facilitating faster palliation of symptoms. Yet the role of chemotherapy with hypofractionated schedules is unclear in palliative settings due to the fear of increased toxicities. The literature review was hence conducted to validate the tolerability and efficacy of CCRT in the palliative setting. The literature search was performed on electronic databases using appropriate keywords. Studies evaluating untreated patients, treated recurrent cancers, second primaries localized in the head and neck or metastatic HNC were all chosen. Five studies were selected which met our selection criteria. Palliation of symptoms, response rates, and toxicities of these studies was evaluated. Role of such concurrent regimes at other sites have also been discussed. All the evaluated studies demonstrated good rates of symptom palliation and response rates with tolerable adverse effects. In addition, our literature review has identified a paucity of evidence that warrants large-scale longitudinal studies to derive conclusive remarks on the use of palliative CCRT.

Endoscopic-Assisted Electrochemotherapy Versus Argon Plasma Coagulation in Non-Curable Esophageal Cancer – A Randomized Clinical Trial

Background: In this randomized clinical trial, we compared endoscopic-assisted electrochemotherapy (ECT) with argon plasma coagulation (APC) in patients suffering from esophageal cancer. We hypothesized that an initial, local tumor treatment could prevent or prolong the time to severe, obstructive dysphagia. Previous studies suggest that ablative therapies might have survival advantages compared with placing an esophageal stent. Methods: We aimed to include 50 patients with non-curable esophageal cancer. Patients were randomized to ECT or APC (1:1) as an upfront treatment and hereafter referred for standard treatment. The primary endpoint was the difference in time to interventional treatment demanding dysphagia. Secondary endpoints included side effects, symptom palliation, tumor response, and survival. Results: Ten patients were included (the study was prematurely terminated due to recruitment challenges), and the results are, therefore, mainly exploratory. Five patients received ECT, and four patients received APC. The median survival time among all patients was ten months. Two patients in the APC group and no patients in the ECT group had an esophageal stent placed during the follow-up period. One month after treatment, dysphagia relief was observed in five patients (two patients in the ECT group), and four patients had a partial response evaluated from CT imaging (three patients from the ECT group). No severe adverse events were registered in either group. Conclusion: ECT and ACP were administrated as initial therapy with few side effects, and none of the patients in the ECT group developed interventional treatment demanding dysphagia during their remaining lifetime. Future studies with ECT should focus on both symptom palliation, the need for re-intervention, and survival.

Wearable devices in palliative care for people 65 years and older: A scoping review.

The objective of this scoping review is to map existing evidence on the use of wearable devices in palliative care for older people. The databases searched included MEDLINE (via Ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Google Scholar, which was included to capture grey literature. Databases were searched in the English language, without date restrictions. Reviewed results included studies and reviews involving patients aged 65 years or older who were active users of non-invasive wearable devices in the context of palliative care, with no limitations on gender or medical condition. The review followed the Joanna Briggs Institute's comprehensive and systematic guidelines for conducting scoping reviews. Of the 1,520 reports identified through searching the databases, reference lists, and citations, six reports met our inclusion criteria. The types of wearable devices discussed in these reports were accelerometers and actigraph units. Wearable devices were found to be useful in various health conditions, as the patient monitoring data enabled treatment adjustments. The results are mapped in tables as well as a Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) chart. The findings indicate limited and sparse evidence for the population group of patients aged 65 years and older in the palliative context. Hence, more research on this particular age group is needed. The available evidence shows the benefits of wearable device use in enabling patient-centred palliative care, treatment adjustments and symptom management, and reducing the need for patients to travel to clinics while maintaining communication with healthcare professionals.

Integrating Patient and Expert Perspectives to Conceptualize High-Quality Palliative Cancer Care for Symptoms in the US Veterans Health Administration: A Qualitative Study.

Quality measurement is typically the domain of clinical experts and health system leaders; patient/caregiver perspectives are rarely solicited. We aimed to describe and integrate clinician and patient/caregiver conceptualizations of high-quality palliative symptom care for patients receiving care for advanced cancer within the US Veterans Health Administration in the context of existing quality measures. We conducted a secondary qualitative analysis of transcripts from prioritization discussions of process quality measures relevant to cancer palliative care. These discussions occurred during 2 modified RAND-UCLA appropriateness panels: a panel of 10 palliative care clinical expert stakeholders (7 physicians, 2 nurses, 1 social worker) and a panel of 9 patients/caregivers with cancer experience. Discussions were recorded, transcribed, and independently double-coded using an a priori logical framework. Content analysis was used to identify subthemes within codes and axial coding was used to identify crosscutting themes. Patients/caregivers and clinical experts contributed important perspectives to 3 crosscutting themes. First, proactive elicitation of symptoms is critical. Patients/caregivers especially emphasized importance of comprehensive and proactive screening and assessment, especially for pain and mental health. Second, screening and assessment alone is not enough; information elicited from patients must inform care. Measuring screening/assessment and management care processes separately has important limitations. Lastly, high-quality symptom management can be broadly defined if it is patient-centered; high-quality care takes an individualized approach and might include non-medical or non-pharmacological symptom management. Integrating the perspectives of clinical experts and patients/caregivers is critical for health systems to consider as they design and implement quality measures for palliative cancer care.

Perceptions and Reality of Antimicrobial Prescribing During the Transition to Comfort Measures Only at an Academic Medical Center.

Little is known about antimicrobial prescribing when patient care is transitioned to comfort measures only (CMO). We used a multidisciplinary survey and retrospective cohort study to gain insight into antimicrobial prescribing in this population at an academic medical center to inform future antimicrobial stewardship interventions. A survey focusing on antimicrobial prescribing during the transition to CMO was electronically distributed to providers in medical subspecialities and responses were compared across specialties. A retrospective chart review was performed of patients admitted to an academic medical center in 2020 who were on antimicrobials in the 48 hours prior to CMO. We investigated the percentage of patients who remained on antimicrobials after the transition to CMO and rationale for continuing antimicrobials. We received 113 survey responses (35% response rate). Forty-one percent of respondents indicated that they "sometimes" or "often" continued antimicrobials during the transition to CMO. Patient/family preference and symptom palliation were the most common factors cited by respondents when deciding whether to continue antimicrobials in this population. Of the 546 patient charts reviewed, 140 (26%) patients were alive 48 hours after CMO order, and 19 (14%) of those patients remained on antimicrobials. Five of 19 (26%) patients had documentation that antimicrobials were continued due to patient/family preference and 5 of 19 (26%) patients had documentation that antimicrobials were continued for palliation of symptoms. Patient/family preference and symptom palliation are important factors in prescribing antimicrobials when patient care is transitioned to CMO. More evidence is needed regarding palliative benefits of antibiotics to inform provider discussions of benefits and harms of antimicrobial use in this setting.

The Impact of Palliative Radiation Therapy on Patients With Advanced Gastric Cancer: Results of a Retrospective Cohort Study.

Aim In advanced gastric cancer, symptoms such as loss of appetite, stomach tightness, occasional pain, vomiting blood, and melena may occur. Palliative radiation therapy may be indicated in such cases. This study aimed to investigate the clinical outcomes of palliative radiotherapy in patients with advanced-stage gastric carcinoma. Methods From April 2018 to October 2022, consecutive patients with non-resected advanced gastric cancer who received radiation therapy for palliation of symptoms were included. Results A total of 23 patients with advanced-stage gastric carcinoma were analyzed in this study. Twelve male and 11 female patients were included. The median overall survival period was 3.9 months (95% confidence interval: 1.0-8.7 months). Sixteen patients required erythrocyte transfusion before radiotherapy; for 13 patients (83%), the required units of erythrocyte transfusion decreased after palliative radiotherapy. The mean erythrocyte transfusion units significantly decreased from 4.2 (standard deviation [SD]: 4.3) to 1.7 (SD: 3.6) (p = 0.02). No adverse events of grade ≥3 were observed in this study population. Conclusion Palliative radiation therapy for advanced gastric cancer yielded a good response rate and can be a useful treatment option.

1767. Because I Could Not Stop for Death, They Gave Me Antibiotics? Perceptions And Reality of Antibiotic Prescribing When Patient Care Is Transitioned to CMO at an Academic Medical Center

Abstract Background Little is known about antimicrobial prescribing when patient care is transitioned to comfort measures only (CMO). We used a multi-disciplinary survey and retrospective chart review to gain insight into antimicrobial prescribing in this population at an academic medical center. Methods A survey focusing on antimicrobial prescribing during the transition to CMO was electronically distributed to providers in Infectious Disease, Pulmonary/Critical Care, Hematology/Oncology, Palliative Care, and Hospital Medicine, and responses were compared across divisions. A retrospective chart review was performed of patients admitted to Beth Israel Deaconess Medical Center in 2020 who were on antimicrobials in the 48 hours prior to CMO. We investigated the frequency of patients on antimicrobials after the transition to CMO and provider rationale for continuing antimicrobials. Results We received 113 survey responses for a response rate of 35%; 111 were included for analysis. 41% of respondents indicated that they “sometimes” or “often” continued an antimicrobial during the transition to CMO. Of the 546 patient charts reviewed, 140 (26%) patients were alive 48 hours after CMO order, and 19 (14%) of those patients remained on antimicrobials (Figure 1). Patient/family preference was the most common factor when deciding whether to continue antimicrobials in patients on CMO, identified by 77% of respondents (Figure 2). 5/19 (26%) patients who were alive on antimicrobials 48 hours after CMO had documentation that antimicrobials were continued due to patient/family preference. Symptom palliation was the second most common factor when deciding whether to continue antimicrobials in patients on CMO, identified by 62% of respondents. For patients already on symptom directed medications, many providers perceived antibiotics to be helpful to palliate symptoms, though there were inter-division differences (Table 1). 5/19 (26%) patients who were alive on antimicrobials 48 hours after CMO had documentation that antimicrobials were continued for palliation of symptoms. Perceived Helpfulness of Antimicrobials for Specific Symptoms by Division Number/percentage of survey responses indicating antimicrobials were at least somewhat helpful for specified symptoms in patients already on symptom directed medications. Divisions compared using Kruskal-Wallis Tests. Conclusion Even after transition to CMO, a substantial number of patients remain on antimicrobials. Patient/family preference and symptom palliation are important factors when continuing antimicrobials in this population. Disclosures All Authors: No reported disclosures.

1786. Characterizing Antibiotic Use in Patients with Hematologic and Oncologic Malignancies Transitioned to Comfort Measures Only (CMO) During Hospital Admission

Abstract Background Antimicrobial treatment at the end of life is common. However, there is limited evidence on whether antimicrobial use during hospice care provides symptom palliation or contributes to discomfort. We sought to further investigate antimicrobial use at the transition to CMO in immunocompromised patients with active malignancies. Methods We conducted a retrospective cohort study of patients with active malignancies over 18 years of age admitted to Beth Israel Deaconess Medical Center from 3/1/2018 to 3/1/2021, who were transitioned to CMO. From hospital databases and from subsequent chart review, we examined: receipt of antimicrobials at any point in the admission; indication for antimicrobials; timing of CMO order; underlying hematologic/oncologic diagnosis; and concomitant COVID-19 diagnosis. Among the patients who received antimicrobials, we identified patients on antibiotics 48 hours prior to and after CMO order placement. Patients were excluded if CMO orders were reversed. Results 384 patients met study criteria. The mean age was 67 years, and 50.5% patients were female. 31.8% of patients carried a hematologic malignancy diagnosis while the remaining had solid tumor diagnoses. 88% patients received antimicrobials at any point during their hospitalization. Of the patients who received antimicrobials during their admission, 84% received them in the 48 hours prior to transition to CMO and 15.3% continued receiving antimicrobials after CMO transition. Patients received a mean of 5.7 antibiotics. Most common indications for antimicrobials included pneumonia (22.2%), intra-abdominal infections (13.6%), sepsis (13.3%), and prophylaxis (3.5%), but most (39.8%) received antimicrobials for more than one infection or indication. Conclusion Hospitalized patients with active malignancy at the end of life are heavily exposed to antimicrobials. The majority of patients transitioned to CMO receive antimicrobials during their last hospital admission, and a significant subset (15.3%) continue antimicrobials after placement on CMO. Further studies are needed to investigate the potential benefits and harms of continuing antimicrobials in CMO patients, as decisions are complex and individualized. Disclosures All Authors: No reported disclosures.

Palliative Care for Symptomatic Heart Failure: A New Paradigm

The nation’s largest, fastest growing, and costliest patient population are those living with symptomatic heart failure (HF). Patients with HF live, on average, for 5 years. Preventing the escalation of symptoms or an exacerbation is key when optimizing patient quality of life. Earlier integration of palliative symptom management can reduce exacerbation, prevent debility, maintain physical functioning, improve costly hospitalization, and improve patient quality of life. The current trends in policy and practice provide an important paradigm for the nurse practitioner when effectively managing the patient with HF.

Update on the palliative care approach at the pediatric intensive care unit.

Pediatric palliative care aims at improving the care and quality of life of children who are terminally ill or have a fatal prognosis. In the hospital setting, end-of-life decisions and treatments are common in intensive care units. This is why the integration of palliative care in these units is a logical evolution of the clinical approach to severely ill children. This study provides an update on the indications and characteristics of the palliative care approach in the context of pediatric intensive care. Here we describe palliative care approach initiation, decision-making, communicative aspects, drug treatment, symptom management, and palliative sedation.

Multi-Institutional Review of Bridging Radiotherapy Prior to Chimeric Antigen Receptor T-Cell Therapy for B-Cell Lymphomas

Introduction: Bridging radiotherapy (BRT) may be used prior to chimeric antigen receptor T-cell (CAR T) infusion for tumor cytoreduction, symptom palliation, and lymphodepletion. Case series on BRT are small and typically limited to single-institution reports. Herein, we report a multi-institutional analysis of the use of BRT prior to CD19-targeting CAR T therapy for relapsed/refractory B-cell lymphomas, with a focus on BRT characteristics, toxicity, and disease outcomes. Methods: We retrospectively analyzed 77 patients with diffuse large B-cell lymphoma (n=64, 83%), primary mediastinal B-cell lymphoma (n=11, 14%), mantle cell lymphoma (n=1, 1%), and T-cell/histiocyte rich large B-cell lymphoma (n=1, 1%) who underwent CAR T therapy between 2018 and 2020 at 4 academic institutions. All received BRT within 1 month prior to leukapheresis up until CAR T infusion. BRT toxicities were graded with CTCAE v5.0, cytokine release syndrome (CRS) per ASTCT, and immune effector cell-associated neurotoxicity syndrome (ICANS) using either ASTCT or CTCAE v5.0. PET/CT response post-CAR T therapy was determined according to Lugano criteria. Patterns of failure were classified with respect to both BRT fields (in field, out of field, or both) and immediate pre-CAR T sites of disease (prior site, new site, or both). Progression-free survival (PFS) and overall survival (OS), measured from CAR T infusion, were estimated using the Kaplan-Meier method and modeled using Cox regression. Results: Patients received axicabtagene ciloleucel (axi-cel; n=56, 73%), tisagenlecleucel (tisa-cel; n=20, 26%), and brexucabtagene autoleucel (n=1, 1%). Median age was 64 years (range, 24-81). Majority (n=41, 53%) were female and had advanced stage III/IV relapsed/refractory disease (n=60, 78%). ECOG performance status was 0/1/2/3 for 18 (24%), 41 (55%), 13 (17%), and 3 (4%), respectively. Median prior lines of therapy was 3 (range, 1-6). Extranodal disease was present in 49/75 (65%), central nervous system (CNS) involvement in 8 (10%), and bulky disease (lesion ≥7.5 cm) in 41/69 (59%). Systemic bridging therapy, excluding steroids, was given to 27 patients (35%). Median interval from leukapheresis to BRT start and from BRT end to CAR T infusion were 7 days (interquartile range [IQR], 3-12) and 12 days (IQR, 9-17), respectively. 19 patients (25%) received BRT to more than one anatomic site. BRT was delivered to the abdomen/pelvis (n=39, 51%), head/neck (n=18, 23%), thorax (n=11, 14%), extremity/soft tissue (n=10, 13%), CNS (n=6, 8%), spine/paraspinal region (n=6, 8%), and axilla (n=6, 8%). Median BRT dose was 26 Gy (range, 4-45), median fraction dose 3 Gy (range, 1.3-15), and most common regimen 20 Gy in 5 fractions. 26 patients (34%) received BRT to all active lesions. No grade ≥3 BRT toxicities were observed. Grade ≥3 CRS occurred in 5 patients (6%; 4 Grade 3 and 1 Grade 4). Grade ≥3 ICANS occurred in 17 patients (22%; 13 Grade 3 and 4 Grade 4), including 16/56 (29%) who received axi-cel and 1/20 (5%) who received tisa-cel. 25 patients (32%) received tocilizumab and 30 (39%) received steroids for CAR T toxicity. At a median of 33 days (IQR, 29-66) to first restaging PET/CT, overall response rate (ORR) was 83% (complete response 37/75, partial response 25/75). At a median follow up of 31.3 months (95% CI, 24.3 - 33.6), 44 patients (57%) had experienced disease progression and 41 (53%) had died. Patterns of failure were detailed for 41 patients and included within the BRT field only (n=4, 10%,) out of field only (n=25, 61%), and both (n=12, 29%). Failure occurred at immediate pre-CAR T sites only (n=5, 12%), new sites only (n=15, 37%) and both (n=21, 51%). 1- and 2-year OS rates were 59% and 48%. 1- and 2-year PFS rates were 41% and 35% (Figure 1). On multivariable analysis, age ≥65 (hazard ratio [HR] 1.9, p=0.040), CNS involvement (HR 4.5, p=0.0028), ≥3 prior lines of therapy (HR 2.1, p=0.0095), and bulky disease (HR 2.4, p=0.0063) were associated with inferior PFS. Conclusions: In this multi-institutional study, patients receiving BRT frequently had bulky disease yet experienced favorable ORR, PFS, and OS after CAR T therapy. There were no serious BRT toxicities and acceptable rates of CAR T toxicity. Isolated failure within the BRT field alone was uncommon. Future studies are needed to better define patient selection criteria for BRT versus other bridging therapies, as well as clarify the utility of "debulking” BRT prior to CAR T therapy. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The First Neuropalliative Care Unit in Germany-Characteristics of Patients.

We retrospectively analyzed the characteristics of patients treated in our NPC unit between February 2021-February 2022. Data were extracted from medical records and PC assessment including diagnosis, mode of admission and discharge, length of stay, and palliative symptoms. Data are presented as averages with a 95% confidence interval [lower limit; upper limit] or percentage (absolute number). We included 143 patients (52% (75) female, 67.9 years [65.6; 70.2]). Patients were admitted from general wards (48%; 68), their homes (22%; 32), intensive care units (16%; 23) or emergency departments (14%; 20). The main diagnoses were tumors of the nervous system (39%; 56), neurodegenerative diseases (30%; 43), neurologic complications (13%; 19) and cerebrovascular diseases (12%; 17). Complaints most frequently rated as severely to overwhelmingly burdensome were motor- or fatigue-associated problems, problems communicating, dysphagia and pain. The average length of stay was 13.7 days [12.2; 15.2]. Forty-five percent (64) of patients were discharged without further PC, 17% (24) were referred to a hospice and 13% (18) were discharged with outpatient PC. Five percent (7) were referred to neurorehabilitation and 21% (30) of patients died. Our NPC unit is a new model of care for neurological patients with substantial PC needs especially within the structures of a highly specialized and individualized medicine.

Optimal Management of Dysphagia in Patients with Inoperable Esophageal Cancer: Current Perspectives.

The majority of patients with esophageal cancer are diagnosed at an advanced, incurable stage. Palliation of symptoms, specifically dysphagia, is a crucial component to improve quality of life and optimize nutritional status. Despite multiple available treatment modalities, there is not one accepted or recommended to be the preferred treatment option. Palliative management is often decided by a multidisciplinary team considering factors including local availability, preference, patient life expectancy, and symptom severity. Systemic therapies such as chemotherapy are the most commonly used palliative modalities. Oncologists are most familiar with radiation for dysphagia palliation, especially for advanced metastatic cancer patients with good performance status. One common approach used by endoscopist is self-expandable metal stents. This is preferred for patients with short-term survival and poor functional status as it provides rapid relief of dysphagia. Cryotherapy is a relatively new endoscopic ablative modality and appears to be a promising option for dysphagia palliation, but more data is needed for wider adoption. This review summarizes the current literature on endoscopic and non-endoscopic treatment options for malignant dysphagia.

Free-text analysis of general practice out-of-hours (GPOOH) use by people with advanced cancer: an analysis of coded and uncoded free-text data.

People with advanced cancer frequently use the GP out-of-hours (GPOOH) service. Considerable amounts of routine GPOOH data are uncoded. Therefore, these data are omitted from existing healthcare datasets. To conduct a free-text analysis of a GPOOH dataset, to identify reasons for attendance and care delivered through GPOOH to people with advanced cancer. An analysis of a GPOOH healthcare dataset was undertaken. It contained all coded and free- text information for 5749 attendances from a cohort of 2443 people who died from cancer in Tayside, Scotland, from 2013-2015. Random sampling methods selected 575 consultations for free-text analysis. Each consultation was analysed by two independent reviewers to determine the following: assigned presenting complaints; key and additional palliative care symptoms recorded in free text; evidence of anticipatory care planning; and free-text recording of dispensed medications. Inter-rater reliability concordance was established through Kappa testing. More than half of all coded reasons for attendance (n = 293; 51.0%) were 'other' or 'missing'. Free-text analysis demonstrated that nearly half (n = 284; 49.4%) of GPOOH attendances by people with advanced cancer were for pain or palliative care. More than half of GPOOH attendances (n = 325; 56.5%) recorded at least one key or additional palliative care symptom in free text, with the commonest being breathlessness, vomiting, cough, and nausea. Anticipatory care planning was poorly recorded in both coded and uncoded records. Uncoded medications were dispensed in more than one- quarter of GPOOH consultations. GPOOH delivers a substantial amount of pain management and palliative care, much of which is uncoded. Therefore, it is unrecognised and under-reported in existing large healthcare data analyses.

Palliative Treatment of Esophageal Cancer Using Calcium Electroporation.

Calcium electroporation (CaEP) is a novel cancer therapy wherein high intracellular calcium levels, facilitated by reversible electroporation, trigger tumor necrosis. This study aimed to establish safety with CaEP within esophageal cancer. Patients with non-curable esophageal cancer were included at Copenhagen University Hospital Rigshospitalet in 2021 and 2022. In an outpatient setting, calcium gluconate was injected intratumorally followed by reversible electroporation applied with an endoscopic electrode. The primary endpoint was the prevalence of adverse events, followed by palliation of dysphagia. All patients were evaluated with CT and upper endoscopies up to two months after treatment. The trial was registered at ClinicalTrials.gov (NCT04958044). Eight patients were treated. One serious adverse event (anemia, requiring a single blood transfusion) and three adverse events (mild retrosternal pain (two) and oral thrush (one)) were registered. Initially, six patients suffered from dysphagia: two reported dysphagia relief and four reported no change. From the imaging evaluation, one patient had a partial response, three patients had no response, and four patients had progression. Six months after treatment, the patient who responded well was still in good condition and without the need for further oncological treatment. CaEP was conducted in eight patients with only a few side effects. This study opens the way for larger studies evaluating tumor regression and symptom palliation.