Current Opinion in Supportive and Palliative Care最新文献

Purpose of review: This review examines the role of pragmatic clinical trials (PCTs) in addressing the underrepresentation of older adults with cancer (OAC) in clinical trials. Focusing on real-world evidence (RWE), it aims to provide a comprehensive overview of PCT utilization, emphasizing their potential to enhance treatment decisions and patient outcomes. Existing knowledge gaps in PCT implementation are also discussed.

Recent findings: PCTs are identified as effective tools to include OACs with comorbidities and complex conditions in research, bridging the representation gap. Despite their proven value in healthcare provision, their application in OAC contexts remains limited, hindering comprehensive understanding and inclusivity in clinical trials.

Summary: While randomized controlled trials (RCTs) are considered the gold standard in oncology research, OACs have historically been excluded, perpetuating underrepresentation. Furthermore, even in current oncology clinical development trials, this demographic continues to be underrepresented. PCTs offer a valuable avenue for the identification and evaluation of therapies within authentic RW contexts, encompassing various healthcare settings, such as hospitals, clinics, and physician practices. RCTs and PCTs complement one another, and the utilization of PCTs has the potential to inform clinical decision-making across the OACs entire treatment trajectory.

Purpose of review: Since SARS-CoV2 pandemic, many specialties have introduced virtual assessments within clinical practice. Conducting an online geriatric assessment, or relying on self-reported questionnaires, may be more challenging than a conventional medical appointment. This review aims to discuss the state of research on virtual assessment and self-reported questionnaires in the general geriatric population and specifically in Oncology.

Recent findings: Virtual assessment of older adults has been the focus of two separate position papers. Aside from videoconferences or phone appointments, self-reported questionnaires have emerged in recent years as reliable tools to screen for frailty and triage patients who would benefit from a comprehensive in-person assessment, with adequate correlation with in-person tests, good acceptance by the respondents and being well received by healthcare providers. Although some have been tried in geriatric oncology, many still lack validation, and their widespread use may be limited by digital literacy, cognitive impairment, and social supports.

Summary: The development, validation and adoption of self-reported questionnaires and virtual assessment in the care of older adults with cancer may overcome the staffing limitations and time constrains that frequently hampers the widespread evaluation of this population to improve their care.

Purpose of the review: Chronic post-treatment pain in breast cancer affects a high proportion of patients. Symptom burden and financial costs are increasingly impacting patients and healthcare systems because of improved treatments and survival rates. Supporting long-term breast cancer symptoms using novel methodology has been examined, yet few have explored the opportunity to utilise these interventions for prevention. This review aims to explore the need for, range of, and effectiveness of such interventions.

Recent findings: Three papers describe risk factors for chronic pain, with six recent papers describing the use of interventions for acute pain in the surgical setting. The evidence for the effectiveness of these interventions to improve pain management in this setting is limited but tentatively positive. The results have to take into account the variation between systems and limited testing.

Summary: Multiple types of intervention emerged and appear well accepted by patients. Most assessed short-term impact and did not evaluate for reduction in chronic pain. Such interventions require rigorous effectiveness testing to meet the growing needs of post-treatment pain in breast cancer. A detailed understanding of components of web-based interventions and their individual impact on acute pain and chronic pain is needed within future optimisation trials. Their effectiveness as preventative tools are yet to be decided.

Purpose of review: Improvements in cancer treatment have led to more people living with and beyond a cancer diagnosis but survivors may have increased health problems as they age. The purpose of this review is to critically evaluate population data exploring incidence of late effects for cancer survivors.

Recent findings: 18 studies were identified between 2013 and 2023 that explored the impact on survivors' physical and emotional health. Patients who had been treated at least 2 years previously for cancer had significant cardiovascular risk factors compared with age-matched controls. Women with breast cancer were more likely to have cardiovascular disease, including hypertension, arrythmias and congestive heart failure. This was associated with anthracyclines and/or trastuzumab as part of systemic anti-cancer therapy. Survivors of colorectal cancer were three times more likely to have acute kidney injury than age-matched controls. Stress and mood disorders were higher in survivors of testicular cancer and prostate cancer.

Summary: Population studies are important to identify the 'real world' consequences of cancer and its treatment beyond clinical trials. Knowledge is critical for managing an ageing cancer population. Data to personalise cancer survivorship care, not only helps determine potential health risks, but can improve secondary prevention, emotional health, recovery, and long-term outcomes.

Purpose of review: There is a growing movement towards person-centred, age-friendly healthcare in the care of older adults, including those with cancer. The Age-Friendly Health Systems (AFHS) initiative uses the 4Ms framework to enable this change. This review documents the utility and implications of 4Ms implementation across different settings, with a particular focus on cancer care.

Recent findings: The AFHS initiative 4Ms framework uses a set of core, evidence-based guidelines (focussing on What Matters, Medication, Mentation and Mobility) to improve person-centred care. The successful implementation of the 4Ms has been documented in many different healthcare settings including orthopaedics primary care, and cancer care. Implementation of the 4Ms framework into existing workflows complements the use of geriatric assessment to improve care of older adults with cancer. Models for implementation of the 4Ms within a cancer centre are described. Active engagement and education of healthcare providers is integral to success. Solutions to implementing the What Matters component are addressed.

Summary: Cancer centres can successfully implement the 4Ms framework into existing workflows through a complex change management process and development of infrastructure that engages healthcare providers, facilitating cultural change whilst employing quality improvement methodology to gradually adapt the status quo to age-friendly processes.

Purpose of review: Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases).

Recent findings: Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated.

Summary: This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.