Annals of palliative medicine最新文献

Background and objective: Breast cancer is the most prevalent cancer among women worldwide, with 45% of them over 65 years old. Older breast cancer patients tend to be underrepresented and understudied in major clinical trials. This narrative review provides a comprehensive overview of the current evidence regarding treatment decision-making, treatment toxicities, and proposed survivorship management recommendations for geriatric cancer patients.

Methods: A literature search was conducted on PubMed and Google Scholar. The search strategy included a combination of keywords related to clinical management and treatment toxicities of older cancer breast cancer patients. English articles published between May 1990 to May 2024 were included.

Key content and findings: Older breast cancer patients represent a heterogeneous group with specific needs and treatment considerations. Treatment decisions for geriatric cancer patients should be based on a comprehensive geriatric assessment (CGA), which considers the patient's functional status, comorbidities, and preferences, rather than relying solely on chronological age. Breast cancer surgery is generally well tolerated in older patients, with a low rate of systemic complications and 30-day post-surgery mortality. In selected elderly patients, axillary surgery may be omitted to minimize side effects. The choice of endocrine therapy should take into account the side effect profile, patient's comorbidities, concomitant medications, and preferences. While aromatase inhibitors provide better efficacy, musculoskeletal side effects and osteoporosis may be a concern for older patients. CDK4/6 inhibitors have a similar efficacy in elderly patients as younger patients, but the incidence of neutropenia and dose modifications or interruptions are more frequent. Reported radiotherapy side effects are similar across age groups, although the occurrence of radiationinduced pulmonary toxicities was found to be associated with old age. Chemotherapy is reserved for triplenegative and HER2-positive disease in elderly patients due to known side effects. such as neutropenia, cardiotoxicity, and cognitive impairment. Data on the efficacy and safety of immunotherapy use in older patients are limited.

Conclusions: Physicians should make additional efforts to evaluate age-specific treatment efficacy and treatment-induced toxicities. Further efforts to enhance the representation of older patients in breast cancer trials are warranted.

Hepatobiliary malignancies (HBMs), primarily hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), share the common traits of having a generally poor prognosis, late presentation, and high symptom burden related to both the disease process itself and underlying poor liver function. The incidences of both malignancies have been rising in recent decades for unclear reasons. Curative options remain limited given the general aggressive disease course despite advances in diagnosis, therapies, and surgery. Early integration of palliative care into the routine care of patients with HBMs is an essential, but underutilized, component of care to improve the functional and symptomatic quality of the lives of patients and their families. While formal guidelines for its integration are currently lacking, palliative care can and should be provided in parallel to disease specific care at any stage to address the physical, emotional, and spiritual needs of patients with HBMs. In this review, the special needs of this patient population are examined ranging from early symptom management at the time of diagnosis all the way through to end-oflife care. Key barriers that prevent the early provision of palliative care for patients with HBMs are identified and discussed and recommendations provided on how to improve early integration.

Background and objective: Breast cancer (BC) is the most prevalent cancer among women worldwide. With a growing number of BC survivors (BCSs), the number of survivors who require highquality survivorship care is increasing. Various recommendations have been proposed for survivorship care plans (SCPs). However, globally, limited progress has been made to implement these recommendations consistently in cancer care centers. This review explores the gaps and challenges that exist in BC survivorship care (BCSC) and proposes future directions for improving survivorship care for patients and the healthcare system.

Methods: Current literature on BCSC was searched using PubMed and Google Scholar. The search strategy utilized a combination of keywords related to BCSC, gaps in survivorship care, and health promotion. Retrievable and English articles from January 2000 to March 2024 were included in the review.

Key content and findings: Despite the large number of guidelines and recommendations on best BCSC practices, only a small number of these have been translated into clinical practices that help streamline patient care. There are many gaps to the provision of high-quality survivorship care, all of which negatively affect patient outcomes. Some of these gaps include but are not limited to: the limited role of primary care providers (PCPs), lack of coordination of care, lack of evidence-based research, insufficient data on health promotion, and challenges implementing comprehensive care.

Conclusions: These findings indicate the need for a holistic and personalized approach to BCSC. The importance of implementing a multi-disciplinary and coordinated approach to survivorship care has been emphasized. This includes further involvement of PCPs, through increased training for PCPs in survivorship care. Despite available models of survivorship care, further research is needed to determine optimal BCSC that improves patient outcomes while decreasing the strain on the healthcare system. Additionally, technology can play a beneficial role in survivorship care, especially through telehealth and artificial intelligence (AI). Nonetheless, further research is needed on BCSC.

Palliative surgery is defined as an operation or procedure performed with the primary intention of relieving symptoms or improving quality of life. Gastrostomy tubes are often employed with palliative intent but, like many palliative interventions, there is insufficient data to facilitate surgical decision-making. This can be challenging for healthcare professionals as caring for palliative patients often encompasses end of life care, severe life-altering symptoms, and poor prognosis. Thus, we have gathered available data for the appropriate use of gastrostomy tube in palliative surgery and propose our mini-review as a primer to aid in medical and surgical decision-making. We first provide the background for palliative surgery and the definition, brief history and techniques pertinent to palliative gastrostomy tube (PGT). Then we review the data relevant to two common indications-head/ neck cancer and malignant bowel obstruction-for PGT. As our deliverable, we present an effective paradigm for delivering the data to patients and families utilizing known palliative communication and decision-making frameworks such as the Palliative Triangle, Best Case/Worst Case and Defining Value. Moreover, we highlight the necessity of conducting more palliative care research that involves palliative outcome measures in addition to traditional metrics such as overall survival. We end our discussion by emphasizing the importance of multidisciplinary team, individualized decision-making, and relationship-based care for palliative patients.

Background: Integration of palliative care has been shown to be beneficial and is therefore recommended. However, the specific methods for arranging such care remain unclear. Systematic referral and regular visits with a multi-professional palliative care team have appeared most beneficial. This study aimed to study how integrated palliative care is currently carried out in relation to which patients are referred to an integrated visit and what occurs during the visit, along with lifespan after the first integrated visit.

Methods: A retrospective chart review of all patients with an incurable cancer receiving integrated palliative care with ongoing oncologic therapy, who were treated in Tampere University Hospital, Finland, between January 1, 2018 and June 30, 2021.

Results: Altogether 207 patients were referred to an integrated palliative care visit, which covers 4% of the incurable cancer patients in the department of oncology at the same time. The most common reasons for referral were symptom burden and limited anti-cancer treatment possibilities. The need for advance care planning was seldom identified. During the first year after the integrated visit, 99 (48%) patients died. Approximately one-third of the patients received anti-cancer treatment in the last month of their life.

Conclusions: Based on the results of the study, the need for palliative care might be unmet, since so few patients are referred to integrated palliative care visits. Emphasis should be placed on identification of palliative care needs and advance care planning. The follow-up models of outpatient clinics should be examined and developed to better meet the needs of the patients.

Planning for future medical treatment, and care, referred to as advance care planning (ACP), has evolved to a focus on conversations that explore values and preferences in a broad sense. Given diverse practices internationally, we examined how international experts would define ACP themselves and whether this differs by medical profession. In an explorative study embedded in a Delphi study on ACP in dementia, experts in ACP in persons with dementia and other diseases reported at baseline how they would define ACP "in one sentence, off the top of your head". We analyzed the text of the reported definitions with content analysis, created codes to identify small definition elements, then merged them into categories. We assessed phrasing from a patient, healthcare professional, or neutral perspective. Almost half (45%) of 87 experts from 30 countries phrased ACP from a patient perspective (29% neutral, 26% professional). Codes (n=131) were merged into 19 categories. Five categories appeared in more than half of the definitions: 'Choosing between options', 'Care and treatment', 'Planning for the future', 'Individual person' and 'Having conversations'. Other categories, including 'End of life' and 'Documentation' were mentioned by a minority of experts. The categories and perspectives did not appreciably differ between physicians and other professionals. In conclusion, international experts from 30 countries typically defined ACP as person-centered conversations to choose future care and treatment, without focusing on end of life or documentation. Future research should evaluate the extent to which such conceptualization of ACP is present within clinical programs and practice recommendations and our work may serve as a starting point to monitor changes over time. Registration: World Health Organization Clinical Trial Registry Platform (NL9720).

Radiofrequency ablation (RFA) is a neuromodulation technique that uses electrocautery to damage nerves with thermal energy and interrupt nociception and has primarily been used to treat patients with chronic back pain. While the use of RFA to modulate neuronal innervation of cervical and lumbar facet joints is well studied, research on the applications of RFA to target the thoracic spine is limited despite these facet joints accounting for pain in over 25% of patients with chronic mid-back and upper-back pain. The purpose of this paper is thus to describe RFA and its utilization in the thoracic spine for chronic back pain. A review of the literature on PubMed was conducted to identify primary evidence for RFA with a focus on only the thoracic spine. Nine papers were identified and reviewed in this article. Primary literature published on RFA-naive patients with thoracic facet joint pain has provided evidence in support of RFA for short-term and long-term pain relief in this spinal region. However, all but two of these studies utilized a cohort study design. Future studies with larger patient cohorts or that utilize a randomized control trial study design are crucial to better establish the effectiveness and long-term utility of this neuromodulation technique.