Current Opinion in Supportive and Palliative Care最新文献

Purpose of the review: Pulmonary fibrosis (PF) is characterized by relentless scarring of the lungs, declining lung function, and increasing symptom burden. In PF, dyspnea and cough are the most common symptoms, severely impacting quality of life. This review highlights recent advances in understanding their mechanisms and explores evolving strategies for management of these symptoms.

Recent findings: Advances in non-pharmacologic approaches, including hand-held fans, dyspnea services and pulmonary rehabilitation are playing a vital role in dyspnea management. Opioids, while effective in reducing exertional dyspnea in controlled settings, show limited benefit for daily life breathlessness and are associated with significant adverse events, highlighting the need for cautious, individualized use. For refractory cough, promising studies are investigating the role of opioids and neuromodulatory therapies. Non-pharmacologic approaches, including speech therapy, and behavioral interventions, provide complementary approaches. A multidisciplinary approach and individualized care plans to address the multifactorial nature of dyspnea and cough are key.

Summary: Effective management of dyspnea and cough can importantly improve patients' quality of life. Further research is required to refine treatment protocols, optimize palliative care interventions, and identify and test novel therapeutics. Translation of these findings into clinical practice requires a focus on evidence-based, patient-centered care.

Purpose of review: Chronic breathlessness is distressing and debilitating, yet often under-recognised. This review summarises recent insights into the visibility of breathlessness and delineates potential contributing factors to its invisibility.

Recent findings: Chronic breathlessness' invisibility is multi-faceted and often leads to avoidance behaviour by patients. The symptom's presence, severity and impacts can be hidden from patients, caregivers, clinicians and the public due to its insidiousness, supposed subjectivity, stigma and the ability to be modulated by reducing exertion. This leads to patients' under-reporting of their breathlessness in clinic and low levels of public unawareness. Other contributing factors can include clinicians' failure to initiate conversations about breathlessness at times because of lack of knowledge about assessment and treatment, or prioritising disease management over symptom management.

Summary: There is robust evidence that chronic breathlessness is often missed, unacknowledged or misunderstood by patients, caregivers, clinicians and society. Optimised clinical recognition and response may help to reverse these trends. Longitudinal studies are needed to explore whether such perceptions can be changed. Intervention studies should address every aspect of invisibility - from clinical improvements to minimising stigma and validating the subjective experience of patients.

Purpose of review: Skeletal metastases occur in approximately 80% of advanced breast, 70% of advanced prostate, and 30% of lung cancers, and place patients at increased risk of skeletal related events (SRE). Bone modifying agents (BMAs) have been shown to prevent or delay SRE development. Our objective was to summarize the role of these agents in the management of these three cancers.

Recent findings: Total 52 studies met our inclusion criteria. These highlighted the benefit of BMAs in reducing SREs in metastatic breast and castrate resistant prostate cancer (mCRPC), with less clear impact on reducing SRE in lung cancer, or on improving progression-free and overall survival due to significant heterogeneity in trial design and outcomes. Benefits in SRE reduction occurred with bisphosphonates and denosumab, however when compared, denosumab was superior. Denosumab however is not more cost effective, and multiple trials support potential de-escalation to either 12 weekly dosing or other reduced duration.

Summary: There is a large body of evidence to support the role of BMAs in reducing SREs in metastatic breast and mCRPC. Impact on survival outcomes is heterogeneous, and future large database trials would be helpful in identifying which subgroups of patients truly have survival benefit from BMAs.

Purpose of review: Diagnosis and management of patients with suspected or confirmed cancers often require procedures which can cause significant anxiety, discomfort and pain. While intravenous sedation and strong opioids are effective, they could be risky in frail cancer patients with multiple comorbidities. Inhaled methoxyflurane (IMF) (Penthrox®) has been utilised as an analgesic for moderate to severe trauma pain for decades in emergency departments. This review article evaluates the latest evidence for the use of IMF in cancer-related procedures.

Recent findings: IMF has been recently shown to be effective in reducing pain and discomfort in patients receiving transrectal ultrasound-guided prostate biopsy and removal of gynaecological brachytherapy applicators. Side effects of IMF are mild and transient. No recent report of severe toxicities such as cardiopulmonary suppression was observed.

Summary: IMF is a safe drug device combination that can reduce discomfort and improve treatment compliance with repeat procedures in cancer patients. Real-world studies should be performed to further evaluate its safety and quality of life in diverse cancer patient populations and guide patient selection.

Purpose of review: Long COVID affects approximately 6% of the population after SARS-CoV-2 infection commonly involving persistent respiratory symptoms such as breathlessness and cough. This review provides an update on the latest evidence regarding post-COVID condition/Long COVID and respiratory sequelae, focusing on persistent symptoms, respiratory complications, and therapeutic approaches to date.

Recent findings: Post-COVID interstitial lung abnormalities are estimated to persist in approximately 11% of patients hospitalized with acute COVID-19. However, breathlessness is common in adults (non-hospitalized) with Long COVID, suggesting aetiologies beyond pneumonitis. The risk of venous thromboembolic disease in Long COVID remains uncertain and trial results of anti-coagulation in Long COVID are awaited.

Summary: Long COVID presents complex respiratory challenges, and careful assessment is crucial to differentiate Long COVID symptoms from exacerbations of pre-existing respiratory conditions. Current management includes a symptom-based multidisciplinary approach, with ongoing research into effective treatments including immune modulating agents.

Purpose of review: Two widely validated health-related quality of life (HR-QoL) tools, specifically designed for patients with advanced cancer, are the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 15 Palliative Care (EORTC QLQ-C15-PAL) and the Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal-14). This systematic review aims to evaluate the use of EORTC QLQ-C15-PAL and FACIT-Pal-14 in prospective studies in patients with advanced cancer, focusing on study types, clinical settings, additional HR-QoL tools used, and completion rates.

Recent findings: Sixty studies were included in the analysis. Both EORTC QLQ-C15-PAL and FACIT-Pal-14 are used in a variety of studies. Given that EORTC QLQ-C15-PAL was developed 9 years before FACIT-Pal-14 PAL, most studies utilized the EORTC tool. Both tools were shown to be successfully used in a variety of clinical settings, including in various advanced tumour types or different study designs, depending on the investigator and study needs.

Summary: This review demonstrates the wide range of utilization of EORTC QLQ-C15-PAL and FACIT-Pal-14 in prospective studies to assess the HR-QoL issues in patients with advanced cancers.

Purpose of the review: This review summarises high-level evidence for fan therapy and adds a commentary on the relatively-neglected question of how to optimise benefits based on qualitative evidence, clinical experience and broader research and theory.

Recent findings: Recent high-level evidence suggests the fan reduces time to recovery from episodic breathlessness rather than reduces daily levels over a longer period. Lower grade evidence suggests the fan can also help people increase their physical activity. Experimental evidence for physiological mechanisms suggests that airflow reduces inspiratory neural drive and perceived unpleasantness through facial cooling of the trigeminal and olfactory nerves. Faster airflow elicits a stronger effect, with the optimal balance between efficacy and comfort proposed to be 2.85 metres per second. Research on clinician perspectives highlights the need for targeted strategies to drive fan implementation.

Summary: Fan therapy contributes to all three domains of the Breathing, Thinking, Functioning model of breathlessness management. Given it is affordable, portable, and has no known harms, the fan should be recommended as first-line therapy for anyone with breathlessness. Future research should evaluate how best to integrate fan therapy as a complex intervention alongside other strategies and supports.

Purpose of the review: Breathlessness is a prevalent symptom that significantly affects physical and mental health. While commonly associated with respiratory and cardiovascular diseases, breathlessness is increasingly recognised as a concern in the general population. This review summarises recent research on the prevalence, risk factors, assessment methods, and clinical and societal impact, with a focus on findings from the past 18 months.

Recent findings: Recent studies indicate that breathlessness affects a substantial proportion of adults worldwide, with prevalence varying across populations and regions. Identified risk factors include older age, female sex, high body mass index, smoking, and comorbidities such as respiratory and cardiovascular diseases. Novel approaches in assessing breathlessness are looking beyond unidimensional scales to improve diagnostic accuracy. However, breathlessness remains underdiagnosed in clinical practice. Recent publications also show that breathlessness has a substantial impact on health outcomes of the affected person, but also imposes a burden on their informal caregivers, health care systems and the economy.

Summary: Despite progress in understanding chronic breathlessness, knowledge gaps persist, particularly regarding its assessment in large-population samples. Longitudinal studies are needed to understand risk factors for breathlessness and its impact on health outcomes and society.

Purpose of review: Respiratory symptoms often co-occur as a symptom cluster in lung cancer patients, which can be detrimental to clinical outcomes. This review synthesizes recent evidence on respiratory symptom clusters and their management.

Recent findings: The expanding body of evidence on respiratory symptom clusters in lung cancer patients has grown significantly. These clusters, primarily comprising cough, shortness of breath, and expectoration, remain prevalent and persistent, regardless of treatment modalities. Cough is highlighted as the sentinel symptom. Recent advancements, including both multimodal and single-component non-pharmacological interventions, such as the Respiratory Distress Symptom Intervention and acupuncture, have shown promise in alleviating respiratory symptoms.

Summary: Recent studies have significantly advanced our understanding of identifying and managing respiratory symptom clusters in lung cancer patients. Longitudinal studies tracking respiratory symptoms could provide valuable insights into their progression. This could be achieved by integrating advanced technologies, such as mobile health applications, which have the potential to revolutionize real-time symptom monitoring. Furthermore, understanding the biological mechanisms underlying these clusters is essential for developing targeted therapies that address symptoms more comprehensively.

Purpose of review: Breathlessness is a prevalent and distressing symptom in palliative and supportive care, with limited licensed pharmacological options once disease-directed therapies are no longer effective. Antidepressants have been proposed as a potential treatment, even in the absence of comorbid mood disorders, due to their modulation of neural circuits and serotonin pathways involved in breathlessness perception. Despite their off-label use in clinical practice for managing refractory or chronic breathlessness, robust evidence supporting their efficacy is needed. This review critically evaluates the latest evidence on their potential benefits and safety in breathlessness management.

Recent findings: Breathlessness is influenced by at least three interrelated axes: lung-brain, behavioural-functional, and psycho-social-spiritual. These mechanisms operate across diseases, making them relevant in palliative and supportive care. Despite promise from early case reports and small trials, two recent large, randomised studies of mirtazapine and sertraline found no benefit in alleviating breathlessness or improving other outcomes. The mirtazapine trial also reported more adverse events than placebo. Earlier trials were small with design limitations, reducing reliability. A 2016 trial of sertraline found benefits for depression in stable COPD. Recent concerns over increased morbidity associated with antidepressant use in respiratory disease highlight the need for early detection of people at risk of worsening breathlessness or depression and a holistic, individualised approach.

Summary: Current evidence does not support antidepressants for breathlessness in respiratory disease. Non-pharmacological approaches should be first line, given their proven benefits and low risk. Off-label medicine use requires caution and should ideally be offered within a trial or evaluation. Given the complex nature of breathlessness, future research should focus on innovating and then testing treatments and therapies in well-designed trials with appropriate outcome measures and reporting of adverse events, health care use and informal carer effects.