Current Opinion in Supportive and Palliative Care最新文献

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.

Purpose of review: The evidence supporting geriatric assessment (GA) in cancer care is well established, and GA is recommended by the American Society of Clinical Oncology, the International Society of Geriatric Oncology, and other oncology bodies. However, effective implementation of GA remains inadequate. Using selected papers indexed in Medline from the most recent 18 months to July 2024, including two outstanding interest papers, this review aimed to describe enablers and barriers to GA implementation in oncology and contrasts implementation with and without an implementation science framework. Finally, we make recommendations on applying an implementation science framework to facilitate integrating GA in oncology.

Recent findings: Implementation science frameworks have been widely employed in health services research, but their use in geriatric oncology, particularly to guide GA implementation and evaluation, is limited. Lack of time in busy practices coupled with workforce shortages adds to the challenges of GA implementation and adoption. A variety of screening and assessment tools such as the G8, electronic rapid fitness assessment, and Eastern Cooperative Oncology Group are often used in lieu of geriatrician review and to streamline GA. When effectively implemented in oncology, GA informs care and treatment decisions for improved outcomes.

Summary: Despite the benefits for older adults, embedding GA into routine clinical practice is critical yet not common practice. The variety of available GA tools, logistics, and individual beliefs are some of the identified barriers to GA adoption in oncology. Enablers include organization readiness, adaptability, communication, and the use of multidisciplinary teams. Further research is needed to examine how implementation science frameworks could provide guidance and structure for successful GA implementation in oncology.

Purpose of review: The survival rate of patients with a cancer or palliative care diagnosis has improved over the years although pain remains a debilitating symptom that many patients still require treatment with opioids. Compared to full mu-opioid receptor agonists such as morphine and oxycodone, buprenorphine continues to remain a second- or third-line choice in this group of patients.We have reviewed the pharmacology and clinical utility of buprenorphine to stimulate debate around the first-line use of buprenorphine in the management of pain in cancer patients.

Recent findings: Buprenorphine has a pharmacological profile that is unique and unlike any other opioid. It is associated with many immediate and long-term benefits, with lower risks of adverse effects that make it an ideal first-line choice in the management of cancer pain.

Summary: Buprenorphine appears to be a promising choice of opioid for cancer patients. Studies have found that buprenorphine is a safe and effective choice for many patients, making it a suitable first-line option for the management of cancer pain.

Purpose of the review: Today, two-thirds of all cancer survivors are at least 65 years old. Older cancer survivors have complex care needs, and addressing their social determinants of health (SDoH) is critical for improving and managing survivorship outcomes for this uniquely vulnerable population, yet research specifically examining these associations remains limited and emergent. To this end, we describe the emergent body of evidence on the associations between SDoH domains and older cancer survivors' outcomes.

Recent findings: Despite the limited investigations of SDoH on the health outcomes of older cancer survivors, there were measures representing all domains of SDoH - health care access and quality, education access and quality, neighborhood and built environment, social and community context, and economic stability. We reviewed another determinant, Digital Environment and Engagement, as they are highly relevant to older cancer survivors' care. Studies primarily investigated outcomes such as the use of or delays in treatment and variables related to care coordination. Generally, poorer access to resources such as income, social networks, and quality health care facilities predicted poorer health outcomes.

Summary: We reviewed studies that revealed that SDoH significantly impacts older cancer survivors' health outcomes. Our description informs future interventions and policies to improve their care.

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: Palliative radiotherapy is frequently applied for various indications, with hemostasis being a quite common one. However, while bleeding can occur at different sites and arise from various primary tumor types, clear guidelines for administering hemostatic radiotherapy are lacking. Additionally, most available data on hemostatic radiotherapy are retrospective, and often studies do not focus on hemostasis specifically. This review provides an overview of the most recent data on hemostatic radiotherapy to identify any research trends and focus areas for this specific topic.

Recent findings: This review confirms the value of radiation for tumor bleeding. Unfortunately, research in hemostatic radiotherapy predominantly continues to focus on retrospective analyses of treated patients. However, at least two prospective trials specifically investigating hemostasis have been published recently, both conducted in low-income countries.

Summary: Radiotherapy is an effective and well-tolerated treatment for bleeding tumors. As the incidence of advanced cancer rises in low- and middle-income countries, where resources are limited, further research should focus on hypofractionated regimens. Additionally, there is a need for comprehensive descriptions of contouring and treatment planning to optimize outcomes in these settings.

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: This review raises awareness regarding the lack of data available for healthcare professionals caring for older adults with cancer when using supportive care medications.

Recent findings: Guidelines for supportive cancer care lack concrete recommendations on the appropriate use of medications in older adults with cancer. Some guidelines, such as the National Comprehensive Cancer Network Older Adult Oncology guideline, contain vital information for prescribers to consider when choosing a supportive care medication. Information at present in most guidelines is generally vague, identifying areas where caution is required in older adults, without specific details.

Summary: Research is needed to assess the efficacy and safety of supportive cancer care medications in older adults.