Current Opinion in Supportive and Palliative Care最新文献

Purpose of review: Abdominal pain due to cancer is a significant and debilitating symptom for cancer patients, which is commonly undertreated. Radiotherapy (RT) for the management of abdominal cancer pain is underused, with limited awareness of its benefit. This review presents a discussion on current precision RT options for the management of cancer pain in the abdomen.

Recent findings: Precision RT focuses on delivering targeted and effective radiation doses while minimizing damage to surrounding healthy tissues. In patients with primary or secondary liver cancer, RT has been shown to significantly improve liver related cancer pain in the majority of patients. Also, symptom sequelae of tumour thrombus may be relieved with the use of palliative RT. Similarly, single dose, high precision stereotactic RT to the celiac plexus has been shown to significantly improve pain in patients with pancreatic cancer. Pain response for adrenal metastases has been less commonly investigated, but small series suggest that stereotactic body RT may reduce or alleviate pain.

Summary: RT is an effective option for the treatment of abdominal cancer pain. RT should be considered within the multidisciplinary treatment armamentarium, and may be successfully integrated, alone or in conjunction with other treatment modalities, in abdominal cancer related pain.

Purpose of review: Globally, breast cancer is the most commonly diagnosed cancer in women. Locally advanced breast cancers (LABCs) may necessitate palliative radiation therapy (RT) due to the severity of the patients' symptoms, inoperability, or other reasons precluding curative-intent treatment such as poor performance status and patient comorbidities. This review aims to discuss current evidence on palliative RT in LABC.

Recent findings: Advanced targeted RT techniques have led to improvements in local control with reduced treatment-related toxicities. Emerging short-course palliative RT prescriptions offer feasible options that avoid delay in systemic therapy. Additionally, recent studies also highlight approaches for integrating palliative RT with systemic therapies.

Summary: Palliative RT plays a vital role in managing symptoms and enhancing quality of life for LABC patients. However, there is currently no consensus on the optimal prescriptions for palliative RT in these patients. Standardized reporting of palliative RT studies is needed for robust comparison of efficacy and toxicity between various treatment regimens. Furthermore, future research on the optimal integration of RT with novel systemic agents is needed.

Purpose of review: The impacts of early palliative care for patients with advanced cancer are well described. This has led to endorsement of early palliative care, alongside cancer treatment, by leading cancer organisations. The aim of this review is to consider how best to adopt and integrate the learning from studies of early palliative care into an effective, sustainable service that is offered as part of routine cancer care.

Recent findings: 'Timely', 'targeted' and 'precision' approaches have been proposed to ensure that limited palliative care resources are available to those who are most likely to benefit. Triage and referral based on individual patients' needs has been shown to be both efficient and effective. Standardised referral criteria and the use of tools to assess complexity may support equitable service development. A specialist multidisciplinary approach is a common factor underpinning successful integration between palliative care and oncology but does not negate the importance patient-centred considerations such as advance care planning, which can be facilitated by non-specialist teams.

Summary: The challenge is no longer whether early palliative care should be provided, but how. Evidence-based strategies about how best to implement early palliative care are needed to inform appropriate resourcing, funding, and delivery.

Purpose of review: Breathlessness is a common, distressing and limiting symptom in people with advanced disease, but is challenging to assess as the symptom intensity depends on the level of exertion (symptom stimulus) during the assessment. This review outlines how to use recently developed normative reference equations to evaluate breathlessness responses, accounting for level of exertion, for valid assessment in symptom research.

Recent findings: Published normative reference equations are freely available to predict the breathlessness intensity response (on a 0-10 Borg scale) among healthy people after a 6-minute walking test (6MWT) or an incremental cycle cardiopulmonary exercise test (iCPET). The predicted normal values account for individual characteristics (including age, sex, height, and body mass) and level of exertion (walk distance for 6MWT; power output, oxygen uptake, or minute ventilation at any point during the iCPET). The equations can be used to (1) construct a matched healthy control dataset for a study; (2) determine how abnormal an individual's exertional breathlessness is compared with healthy controls; (3) identify abnormal exertional breathlessness (rating > upper limit of normal); and (4) validly compare exertional breathlessness levels across individuals and groups.

Summary: Methods for standardized and valid assessment of exertional breathlessness have emerged for improved symptoms research.

Purpose of review: This review aims to address the gap in radiation therapy (RT) care for elderly cancer patients. It will discuss the barriers to implementing effective RT in elderly and frail patients with a focus on breast cancer and metastatic settings.

Recent findings: Recent studies indicate that SBRT provides better pain control for bone metastases compared to cEBRT, but elderly patients are underrepresented in these trials. Evidence on the effectiveness of geriatric assessment tools in predicting RT tolerance and toxicity is mixed, with some studies showing a correlation while others do not. Comprehensive geriatric assessments, though promising, are often impractical due to time and resource constraints.

Summary: There is a critical need for more inclusive research to better understand the risks and benefits of RT in elderly patients. Developing streamlined geriatric assessment tools and integrating them into clinical practice can enhance treatment personalization. Future studies should prioritize elderly populations to generate robust data, thereby improving RT outcomes and quality of life for this growing patient group.

Purpose of review: Palliative care in Latin America is evolving, but training for informal caregivers remains underexplored. This review summarizes recent interventions to educate or train caregivers in end-of-life care.

Recent findings: The literature search identified three interventions published by 2023, two with reception evaluations, all with small sample sizes and no control groups. Needs of caregivers have been more frequently described and include training on aspects of the disease, nursing skills, how to handle patients´ and own emotions; help in navigating the complex healthcare systems in Latin America; help in conversations about the end of life and dying, still taboos in the region; help in finding additional caregivers or other types of support to make the caregiving role sustainable over time for the caregiver. Interventions mainly focused on emotional support and identifying additional caregivers without guilt; two included nursing skills training.

Summary: There are very few formal interventions described and evaluated to assist caregivers in end-of-life care in Latin America described in the literature. This illustrates the rather invisible but very important role of these important stakeholders in the care for patients. Multidimensional interventions should be developed and evaluated to support caregivers.

Purpose of review: Dementia is a chronic progressive terminal condition. Most care is provided by family caregivers (including close friends); their wellbeing is a public health priority. Caregivers manage increasingly complex needs with disease progression, and declining cognitive and physical function. This can impact the well-being of caregivers, and meaningful support is essential. This review article aims to understand what the benefits and challenges of digital health interventions are and provide considerations for future development of digital health interventions for family caregivers for people with dementia, to improve quality of life.

Recent findings: Benefits include the valuable source of support from connective platforms; 24/7 accessibility; and opportunity for remote monitoring. However, this needs to balance with challenges, including the privacy of data concerns; and the digital divide driving inequalities in care provision for family caregivers with no access to internet devices.

Summary: Digital health interventions can positively impact the overall well-being of family caregivers for people with dementia. If challenges are addressed and digital health interventions are designed to meet priorities for family caregivers, this can help improve the quality of life for family caregivers of people with dementia.

Purpose of review: Breathlessness remains a common and distressing symptom among people with serious illness, particularly in advanced disease. This review synthesises recent advances in the development, characteristics, and outcomes of breathlessness support services.

Recent findings: The expanding body of evidence regarding breathlessness support services has broadened and strengthened our understanding of clinical and cost-effectiveness. The expansion of these services, into diverse settings and including digital delivery, has augmented their reach and accessibility to a wider population. Additionally, there is increasing attention to the psychological aspects of breathlessness and its management, including the challenges of optimising breathlessness support services for long-term benefit.

Summary: Recent studies have made substantial progress in enhancing our knowledge of breathlessness support services and their impact on people with serious illness. Innovations extending services into new countries and settings, including use of digital platforms for intervention delivery, plus increased recognition of psychological mechanisms, have the potential to support more people with serious illness to live as best as possible with breathlessness.

Purpose of review: This review aims to synthesise contemporary research on symptom management for people with advanced dementia who are thought to be in the final year of life. It highlights the unique challenges faced by palliative care and dementia care specialists, offering insights into the clinical decision-making required to support those with advanced dementia in various care settings.

Recent findings: Recent studies indicate that people with advanced dementia often experience significant unmet palliative care needs, particularly regarding symptom management. Pain, breathlessness, and psychological distress are frequently mismanaged, which contributes to suboptimal care. Moreover, the unpredictable trajectory of dementia complicates the identification of end-of-life needs, which can result in fragmented care. Caregivers, both professional and family, struggle with managing complex symptoms, while family caregivers in home settings face added burdens in providing care without sufficient support.

Summary: Palliative care for people with advanced dementia is currently inadequate due to a lack of tailored interventions, poor symptom management, and disjointed care systems. Enhancing training for caregivers, fostering interdisciplinary collaboration, and focusing on integrated care approaches across home and institutional settings are crucial to improving quality of life and symptom control for people with advanced dementia.

Purpose of review: The importance of the gut microbiome for human health and well-being is generally accepted, and elucidating the signaling pathways between the gut microbiome and the host offers novel mechanistic insight into the (patho)physiology and multifaceted aspects of healthy aging and human brain functions.

Recent findings: The gut microbiome is tightly linked with the nervous system, and gut microbiota are increasingly emerging as important regulators of emotional and cognitive performance. They send and receive signals for the bidirectional communication between gut and brain via immunological, neuroanatomical, and humoral pathways. The composition of the gut microbiota and the spectrum of metabolites and neurotransmitters that they release changes with increasing age, nutrition, hypoxia, and other pathological conditions. Changes in gut microbiota (dysbiosis) are associated with critical illnesses such as cancer, cardiovascular, and chronic kidney disease but also neurological, mental, and pain disorders, as well as chemotherapies and antibiotics affecting brain development and function.

Summary: Dysbiosis and a concomitant imbalance of mediators are increasingly emerging both as causes and consequences of diseases affecting the brain. Understanding the microbiota's role in the pathogenesis of these disorders will have major clinical implications and offer new opportunities for therapeutic interventions.