BMJ Supportive & Palliative Care最新文献

Background: Guidelines recommend early palliative care (PC) integration in advanced cancers. This remains a challenge in countries with high cancer burden and limited PC access. We report the quality improvement (QI) journey aimed at improving timely PC integration in patients with advanced gastric, colorectal and lung cancers at two centres in India.

Methods: Centre A, an academic institution, and Centre B, a standalone cancer centre, used the A3 methodology for the QI process. An audit was conducted prior to August 2023 to establish the baseline PC referral rate. Process mapping, root cause analysis and Pareto chart were done, and key drivers were identified and interventions were planned. The common interventions were to increase oncologists' awareness, ensure holistic symptom assessment and establish a referral process. The proportion of patients with advanced cancer referred timely to PC was measured and recorded. Sustainability of the QI projects was assessed until September 2024.

Results: There was an increase in the timely PC referral from 37% to 66% in Centre A, and from 30% to 60% in Centre B, from before August 2023 to April 2024.

Conclusion: QI projects are feasible and effective when supported by good stakeholder collaboration to achieve the target of early and timely PC referral within oncology settings.

Objective: To investigate whether initiating prehabilitation during neoadjuvant chemotherapy (NAC) is associated with postoperative recovery of functional exercise capacity in patients with oesophageal cancer.

Methods: In this multicentre observational study, we classified patients with oesophageal cancer into two groups based on the timing of prehabilitation: the early prehab (initiated during NAC) and late prehab (initiated after NAC) groups. Prehabilitation consisted mainly of an exercise programme combining supervised sessions with prescribed self-exercise. Functional exercise capacity was assessed using the 6 min walk distance (6MWD) before surgery (T0) and at 3 (T1) and 6 weeks (T2) postoperatively. Secondary outcomes included muscle strength, body weight, fatigue and health-related quality of life. Between-group differences in changes in 6MWD were analysed using a linear mixed-effects model, and secondary outcomes were descriptively summarised.

Results: 51 patients were analysed (early prehab group, n=17; late prehab group, n=34). Both groups showed a decline in 6MWD at T1 with partial recovery at T2. The early prehab group showed a smaller decrease in 6MWD at T2 (-13 m) compared with the late prehab group (-27 m), though the difference was not statistically significant (p=0.70). Trends favoured the early prehab group in muscle strength, fatigue and global health status scores.

Conclusions: This study observed a modest trend towards better postoperative recovery in patients who initiated prehabilitation during NAC, although no statistically significant differences were detected between groups. Further prospective trials are needed to refine intervention quality and identify patient populations most likely to benefit.

Trial registration number: UMIN000047895.

Objectives: Patients with advanced cancer may develop bacterial infections (BI) as their general condition worsens, but general blood tests often find it difficult to distinguish them from non-bacterial infections (NBI). The present prospective study was undertaken to investigate the effectiveness of serum procalcitonin levels in distinguishing between BI and NBI in patients with advanced urological cancer.

Methods: This study prospectively evaluated patients diagnosed with locally advanced or metastatic or recurrent urological cancer in our department from September 2013 to December 2019. Body temperature was measured in the axilla and the measurement results were recorded. Febrile episodes of ≥38.0°C were analysed, and written patient consent was obtained at the onset of the fever.

Results: Of 75 patients enrolled in the present study, 90 febrile episodes were analysed. A total of 34 of 90 febrile episodes were regarded as BI, and the remaining 56 febrile episodes as NBI. The median procalcitonin value was significantly higher in the BI group (p=0.0015), while no significant difference was found between the two groups for white blood cell count and C reactive protein. Additionally, a white blood cell count of less than 1.0×10ˆ9/L resulted in BI in all cases. The procalcitonin receiver operating characteristic area under the curve was 0.710 (95% CI 0.586 to 0.83), excluding cases with white blood cell counts of <1.0 × 10³/μL.

Conclusions: Procalcitonin is a rapid and affordable marker for differentiation between BI and NBI in patients with advanced urological cancer.

Objectives: To assess the feasibility, safety and preliminary efficacy of psilocybin-assisted therapy (PAT) for demoralisation in terminally ill patients receiving home hospice care.

Methods: In this open-label pilot trial, 4607 home hospice patients at a large community hospice were screened over 22 months; 66 were approached, 15 enrolled and 10 received psilocybin. Participants completed two home-based preparation sessions, a single 25 mg oral psilocybin session at an inpatient hospice facility, and two home-based integration sessions. Feasibility was assessed through recruitment, retention and acceptability. Safety was evaluated via adverse event monitoring, and preliminary efficacy was assessed using changes in demoralisation scores and other psychosocial measures.

Results: The intervention was well tolerated, with no serious adverse events attributed to psilocybin. At week 3, demoralisation scores significantly decreased (mean reduction: 8.8 points, p=0.0196), despite ongoing clinical decline. Grief- and peace-related themes were prominent during psilocybin sessions. While six participants rated the treatment favourably on the Reaction to Research Participation Questionnaire global evaluation factor, three rated neutral on one or more items, suggesting that the emotional intensity and demands of the intervention may influence acceptability.

Conclusion: This study provides initial evidence that PAT can be feasibly and safely integrated into hospice care for terminally ill patients. Further research is needed to optimise delivery and further assess therapeutic potential.

Objectives: To evaluate the incidence, pattern and risk factors of early cardiotoxicity and to assess the impact of undernutrition in children with Wilms tumour (WT) and hepatoblastoma receiving anthracycline-based therapy.

Methods: In this retrospective cohort study, 137 children treated between 2017 and 2022 were analysed. Cardiac function was monitored by serial echocardiography, and nutritional status was assessed using WHO and Pediatric Hematology-Oncology Association of Central America (AHOPCA) criteria. Multivariable logistic regression was performed to identify factors associated with early cardiac dysfunction.

Results: The incidence of early cardiotoxicity was 11.7%. Majority of patients who developed cardiotoxicity were asymptomatic. Undernutrition, assessed by WHO and AHOPCA criteria, was highly prevalent and significantly associated with cardiac dysfunction. Most affected patients showed recovery with medical management.

Conclusions: Undernourished children receiving anthracycline therapy for WT and hepatoblastoma are at increased risk of early cardiotoxicity. Routine nutritional assessment, early intervention and close cardiac monitoring may help mitigate acute cardiac toxicity in this vulnerable population.

Purpose: We sought to explore the lived experience of caregivers when communicating with doctors and nurses about their cancer-related information needs.

Methods: Semistructured interviews (n=20) were conducted with cancer caregivers. Data were collected as part of a broader study on caregiver health literacy needs. Interviews were analysed thematically.

Results: Seven themes emerged from the analysis. These themes were: (a) the importance of using everyday language and a variety of information delivery formats, (b) the need for sufficient time to discuss information, (c) the importance of creating a safe space for caregivers to participate during consultations, (d) health providers having a proactive approach to communication and being accessible, (e) access to health providers who recognised and included the caregiver during consultations, (f) health providers developing relationships with the caregiver and person with cancer and (g) caregiver recommendations for service improvement.

Conclusions: This study highlights how the quality of providers' communication with caregivers impacts their information needs. Caregivers perceive their information needs are met when providers engage in person-centred strategies. Difficulty acquiring and understanding cancer-related information occurs when providers block caregiver questioning about cancer. Caregiver understanding of cancer information is critical to support the caregiver's role in cancer care.

Objective: An effective tool for establishing concordant end-of-life (EOL) care in patients with cancer is advance care planning (ACP). However, various barriers, including psychological obstacles, hamper the access to ACP. Therefore, a new conceptual model combining a psycho-oncological approach with structured ACP was developed. The effectiveness and efficiency of this new concept of collaborative ACP (col-ACP) is evaluated in the present randomised controlled trial in patients with palliative cancer.

Methods: 277 patients with palliative cancer and their relatives were randomised into three groups (1) collaborative ACP (col-ACP) consisting of a psycho-oncological approach addressing barriers to EOL conversations followed by a standardised ACP procedure, (2) supportive intervention (active control) and (3) standard medical care.

Results: Patients in the col-ACP group completed advance directives (p<0.01) and healthcare proxies (p<0.01) significantly more often. Additionally, they felt better planned ahead for their future treatment (p<0.01) and were significantly more confident that their relatives were aware of their treatment wishes (p=0.03). In fact, their goals of care were known and highly fulfilled. However, patients' and caregivers' quality of life, patients' stress, depression and peace did not differ between the groups.

Conclusions: The new, well-received, concept of col-ACP improves readiness and access to ACP and results in more consistent EOL care. Further, even if no direct influence on quality of life could be proven, it supports patients in planning their treatment, making autonomous decisions and regaining self-efficacy in the face of life-limiting cancer. Therefore, a closer interlocking and information exchange between psycho-oncological and ACP services seems to be reasonable.

Trial registration number: NCT03387436.

Objective: Patients with metastatic gastric cancer (MGC) may require palliative surgery to manage complications such as obstruction or bleeding. While the role of stenting in MGC is clear, the role of palliative surgery in MGC shows conflicting results.

Methods: We retrospectively reviewed clinical data of patients with MGC treated at our institution between January 2007 and December 2021. The clinical outcomes of patients who underwent palliative surgery are analysed in this review.

Results: Gastrojejunostomy (GJ) and palliative gastrectomy were performed in 48 and 28 patients, respectively. The median overall survival in the GJ and palliative gastrectomy groups were 9.25 and 11.25 months, respectively (p=0.21). On subgroup analysis, we found that the patients who were diagnosed with MGC intraoperatively had better survival compared with preoperatively diagnosed patients even though it was statistically not significant. The complication rates following GJ and palliative gastrectomy were 6% and 7%, respectively.

Conclusion: Both palliative gastrectomy and GJ offer similar results to endoscopic stenting, as reported in the literature. Surgical palliative options continue to be relevant in selected cases due to lower rates of repeat interventions and reduced hospital visits, making them a one-time solution for patients, especially in resource-constrained settings.