Annals of palliative medicine最新文献

Background: Bone metastasis is the most common cause of cancer-related pain. Radiation therapy (RT) can provide successful palliation but there is currently no consensus for surveillance after palliative radiation. This study aimed to assess the feasibility of surveillance after RT for painful bone metastases.

Methods: The study took place in an academic cancer center. Patient feasibility measures included % of calls answered, ease of recruitment and study retention. Clinician measures included % of calls made within 3 days, call time and qualitative feedback. Patients were identified with a painful bone metastasis treated with RT. The bone metastasis had a worst pain score of at least 4 (0-10 scale), with pain localized to a radiographically confirmed lesion. Patients were called at weeks 1, 4 and 8 following RT. Pain response and opioid use were assessed. Quality of life was assessed using a validated questionnaire. Descriptive statistics were used to assess if these metrics were met for patients and clinicians over 8 weeks post-RT.

Results: Twenty patients were consented: 14 participants completed treatment and were not hospitalized or deceased prior to week 1. The patients were 50% male and 50% female. Recruitment was completed quickly, with no patients withdrawing. Response rate was week 1: 85% week 4: 83% and week 8: 83%. Six patients were referred back to their provider for pain management. Calls were made to patients within 3 days a median of 63% of the time (range, 40-82%), with a median call time of 16 (range, 8-42) minutes. Call lengths were longer for patients who required interpretation. Nurse feedback highlighted length of call and nursing time available as limitations.

Conclusions: All patient feasibility measures were met. Six patients required further pain management, highlighting a need for improved follow up post-RT for bone metastases. Staffing challenges for this intervention must be overcome.

Background and objective: Male breast cancer (MBC) accounts for nearly one percent of all diagnosed breast cancer (BC). In the United States alone, there were 2,670 MBC reported cases and 500 fatalities in 2019. In addition to the general challenges faced by patients to diagnose and treat cancer, MBC patients experience stigma from the medical community and their own feelings of embarrassment. The presence of stigma has a negative impact on the quality of life and psychological outcomes of MBC patients. This narrative review investigates current research on the presence of stigma in the diagnosis and care of MBC patients, and the role of stigma as a barrier to care.

Methods: Current literature on MBC and stigma was found through a search of PubMed and Google Scholar. The search strategy consisted of keywords related to "male breast cancer, stigma, awareness, experiences, and social support". Studies published from January 2005 to April 2024, that were retrievable and written in English, were included in this review.

Key content and findings: Several studies have supported that MBC patients experience stigma due to the lack of awareness in the medical community, and feelings of embarrassment felt by the patients. This stigma is seen through insufficient guidelines on MBC diagnosis and treatment and a lack of male-specific information for BC. These topics of stigma act as barriers to care, as they lead to psychological distress (e.g., anxiety and depression) and delayed diagnoses. Current studies suggest addressing the lack of information and awareness of MBC and implementing screening procedures to mitigate the negative impact of stigma.

Conclusions: This review highlights the presence of stigma in the care of MBC patients and its distressing effects on patients. There is a need for increased awareness among the medical community to improve diagnosis and treatment of MBC patients, to allow for more equitable care. Future therapies should focus on the viability of routine screening programs for male patients and addressing the gap of male-specific information.

Background and objective: Due to advances in early detection and treatment options, non-central nervous system (non-CNS) cancer survivors are living longer, even those with metastatic disease. Many of these survivors will experience enduring symptoms of breast cancer, such as cancer-related cognitive impairment (CRCI). Although CRCI is bothersome and, in some cases, potentially debilitating, little research has been done to address this symptom. Thus, the overarching goal of this narrative review is to provide both an overview of the problem of CRCI and its impact and focus on the latest research aimed at addressing CRCI in non-CNS cancer survivors.

Methods: A MEDLINE database (PubMed) search was conducted for terms related to non-CNS cancer, cognition, impacts of CRCI, and interventions. The English-language articles published until April 8th, 2024, were included in the search.

Key content and findings: CRCI includes self-reported cognitive complaints and/or impaired performance in multiple cognitive domains, including memory, processing speed, attention, and executive function. CRCI, in turn, can have a significant impact on everyday functioning, work ability, work engagement and productivity, and overall quality of life (QoL) of cancer survivors. While some researchers have examined pharmacological approaches, the vast majority of the interventional studies to date to address CRCI has focused on non-pharmacological approaches. Three of the most common non-pharmacological approaches are physical activity or exercise, mind-body approaches [e.g., mindfulness-based stress reduction (MBSR)], and cognitive rehabilitative approaches [e.g., cognitive training (CT) and cognitive behavioral therapy (CBT)].

Conclusions: Addressing the cognitive health of cancer survivors is imperative but has only recently been the focus of interventional research. More research in larger and more diverse samples of non-CNS cancer survivors is needed to identify effective ways to manage CRCI for all cancer survivors. Overall, maintaining cognitive health, especially in cancer survivors who are at increased risk for deficits, is a national health care priority that should not be ignored.

Background: Concurrent palliative care for patients with advanced cancer has been shown to reduce physical and psychological symptoms, and improve the quality of life of patients with advanced cancer. Underutilization of palliative care services, especially among African American patients with advanced cancer, remains an important public health problem. To address this gap, we developed a community health worker (CHW) palliative care intervention for African American patients with advanced cancer, which is being formally assessed through an ongoing effectiveness-implementation trial (NCT05407844). As part of the preparatory phase of this study, we conducted qualitative interviews with African American patients with advanced cancer and their caregivers. The objective of this analysis was to explore patient and caregiver attitudes and perceptions of the CHW palliative care intervention to support African American patients with advanced cancer in accessing palliative care.

Methods: We used purposive sampling to identify African American patients with advanced cancer and their informal caregivers from clinic lists and through referring oncologists. We conducted six individual and group semi-structured interviews with patients and caregivers between November 2022 and April 2023 at three enrollment sites: Johns Hopkins Hospital, TidalHealth Peninsula Regional, and University of Alabama at Birmingham Hospital. The interview guide was informed by the Consolidated Framework for Implementation Research, with a focus on the Innovation and Inner Setting domains. We used the framework method for thematic analysis.

Results: Overall, there was a lack of awareness and understanding of palliative care, due primarily to limited experiences with palliative care services among study participants. Despite this lack of familiarity, participants recognized the potential benefits of palliative care for patients with advanced cancer. All study participants were enthusiastic about the concept of patient navigation and the CHW palliative care intervention, with CHWs as lay patient navigators in palliative care. When reflecting on their own experiences, patients and their caregivers identified several areas where CHWs may have supported their cancer care, such as care coordination. Study participants viewed the CHW palliative care intervention as fulfilling a need within the African American community. Participants also made intervention delivery recommendations related to CHW characteristics, training and integration, and communication.

Conclusions: This study provides evidence for the acceptability of a CHW palliative care intervention for African American patients with advanced cancer and their caregivers. The findings of this study have led to intervention refinement, which will enhance implementation, delivery, and sustainability of the intervention.

Background and objective: The prevalence of chronic non-cancer pain (CNCP) in older adults is high. Opioids carry significant risk for harm in older adults. Yet, many older adults are established on long-term opioid therapy for the treatment of CNCP despite limited documented efficacy. Many of the non-opioid options to treat pain present challenges in this population. Since challenges with tapering patients off of opioids exist, older adults may remain established on long-term opioid therapy for CNCP. While opioid use is less scrutinized for older adults receiving palliative care, significant safety concerns exist. Therefore, efforts to mitigate risks for older adults receiving long-term opioids for CNCP and for palliative care are essential. Pharmacists as members of the interprofessional team are equipped to improve safety among older adults on chronic opioid therapy. Among patients receiving palliative care, collaboration with palliative care specialists is also key. The purpose of this narrative review is to describe risk mitigation strategies for opioid use among older adults with CNCP and those receiving palliative care.

Methods: Data were identified by searching PubMed (January 1, 1990 to February 21, 2024) using the following search terms: older adults, opioids, chronic pain, palliative care, and pharmacist. The search was repeated using terms geriatric, elderly, opiates, narcotics, and controlled substances. Non-English articles and observational studies with fewer than 100 patients were excluded. Major North American and European guidelines were reviewed. Additional literature was obtained through review of relevant references of identified articles.

Key content and findings: A variety of risk mitigation strategies to improve safety for older adults using opioids exist. They include risk assessment, tapering opioids, reducing high-risk concomitant medications, utilizing non-opioid therapies, screening for and treatment of opioid use disorder (OUD), toxicology testing, co-prescribing naloxone, utilizing controlled substance agreements, reviewing prescription drug monitoring program data, prescriber and patient education, and collaboration with pharmacists and palliative care specialists.

Conclusions: There are many opioid risk mitigation strategies for older adults. Collaboration with pharmacists and palliative care specialists can be an effective means for implementing strategies to optimize opioid safety for older adults with CNCP and those receiving palliative care.

Background and objective: The majority of palliative care provision occurs in general practice, yet only 9% of palliative care clinical trials were conducted in this setting. Evidence from hospital and specialist settings is not readily transferable to general practice, as the population, context and care processes are vastly different. Conducting interventional palliative care research in general practice settings is subject to many challenges and barriers. This narrative review aims to describe the factors influencing the conduct of interventional research in general practice settings for patients with palliative care needs.

Methods: A narrative review was performed to identify factors affecting the conduct of palliative care interventional studies in general practice. A literature search of MEDLINE was conducted on 26 September 2023, and data were synthesised utilising a narrative approach.

Key content and findings: Sixteen articles were identified. Five thematic groupings were identified from the literature that affected the interventions: factors related to health care professionals (HCPs), patients and carers, general practices, health systems, and research design. HCPs and practices were focused on providing clinical care and struggled to incorporate research into their workload. Staff and patients often had negative perceptions in palliative care combined with limited research experience, often resulting in unwillingness to engage in interventions and gatekeeping. Engaging with general practice staff to design, participate and champion research were key facilitators of successful interventions.

Conclusions: Palliative care interventions in general practice are invariably complex and challenging, yet acutely needed to address the care needs of patients in the community setting. Working together with patients, carers and clinicians to design and implement interventions appropriate for general practice settings is fundamental to their success.

Indications for re-irradiation are increasing both for palliation and potentially curative attempts to achieve durable local control. This has been in part driven by the technological advances in the last decade including image-guided brachytherapy, volumetric-modulated arc therapy and stereotactic body radiotherapy. These enable high dose focal irradiation to be delivered to a limited target volume with minimal normal tissue re-irradiation. The European Society for Radiotherapy and Oncology (ESTRO) and the European Organisation for Research and Treatment of Cancer (EORTC) have collaboratively developed a comprehensive consensus on re-irradiation practices, aiming to standardise definitions, reporting, and clinical decision-making processes. The document introduces a universally applicable definition for re-irradiation, categorised into two primary types based on the presence of geometric overlap of irradiated volumes and concerns for cumulative dose toxicity. It also identifies "repeat organ irradiation" and "repeat irradiation" for cases without such overlap, emphasising the need to consider toxicity risks associated with cumulative doses. Additionally, the document presents detailed reporting guidelines for re-irradiation studies, specifying essential patient and tumour characteristics, treatment planning and delivery details, and follow-up protocols. These guidelines are designed to improve the quality and reproducibility of clinical research, thus fostering a more robust evidence base for future re-irradiation practices. The consensus underscores the necessity of interdisciplinary collaboration and shared decision-making, highlighting performance status, patient survival estimates, and response to initial radiotherapy as critical factors in determining eligibility for re-irradiation. It advocates for a patient-centric approach, with transparent communication about treatment intent and potential risks. Radiobiological considerations, including the application of the linear-quadratic model, are recommended for assessing cumulative doses and guiding re-irradiation strategies. By providing these comprehensive recommendations, the ESTRO-EORTC consensus aims to enhance the safety, efficacy, and quality of life for patients undergoing re-irradiation, while paving the way for future research and refinement of treatment protocols in the field of oncology.

Background: Dedicated palliative radiation oncology programs (PROPs) within radiation oncology (RO) practices have been shown to improve quality and decrease costs of radiation therapy (RT) in advanced cancer patients. Despite this, relatively few PROPs currently exist, highlighting an unmet need to understand characteristics of the few existing PROPs and the potential barriers and facilitators that exist in starting and maintaining a successful PROP. We sought to assess the attributes of existing PROPs, the facilitators and barriers to establishing these programs, and the resources needed to create and maintain a successful program.

Methods: A 15-item online survey was sent to 157 members of the Society of Palliative Radiation Oncology (SPRO) in July 2019.

Results: Of the 157 members, 48 (31%) responded. Most practiced in an academic center (71% at main center and 15% at satellite) and 75% were from a larger group practice (≥6 physicians). Most (89%) believed the development and growth of a dedicated PROPs was either important (50%) or most important (39%) to the field of RO. Only 36% of respondents had a PROP, 38% wanted to establish one, and 13% were currently developing one. Of those with PROPs (N=16), 75% perceived an increase in the number of referrals for palliative RT since starting the program. A majority had an ability to refer to an outside palliative care specialist (64%), an outpatient RO service (53%), and specialized clinical processes for managing palliative radiotherapy patients (53%), with 41% having an inpatient RO consult service. Resources considered most essential were access to specialist-level palliative care, advanced practice provider support, a radiation oncologist with an interest in palliative care, having an outpatient palliative RO clinic, an emphasis on administering short radiation courses, and opportunities for educational development. Of those with a PROP or those who have tried to start one, the greatest perceived barriers to initiating a PROP were committed resources (83%), blocked out clinical time (61%), challenges coordinating management of patients (61%), and support from leaders/colleagues (61%). Perceived barriers to sustaining a PROP were similar. For those without a PROP, the perceived most important resources for starting one included access to palliative care specialist by referral (83%), published guidelines with best practices (80%), educational materials for referring physicians and patients (80%), educational sessions for clinical staff (83%), and standardized clinical pathways (80%).

Conclusions: PROPs are not widespread, exist mainly within academic centers, are outpatient, have access to palliative care specialists by referral, and have specialized clinical processes for palliative radiation patients. Lack of committed resources was the single most important perceived barrier for initiating or maintaining