BMJ Supportive & Palliative Care最新文献

Background: In oncology, early palliative care enhances quality of life and may increase survival; yet, because of resource limitations and overestimation of prognosis, referrals frequently happen late. Due to a shortage of specialised workers, this issue is made worse in low- and middle-income countries (LMICs).

Key evidence: Referral systems powered by artificial intelligence (AI) (such as electronic health record-based triggers and machine learning risk models) have the potential to identify individuals who might benefit from earlier palliative integration. According to preliminary research, AI interventions resulted in more timely referrals. In a large cancer cohort, a machine learning model, for example, could increase access to early palliative treatment by approximately 8-15% without requiring more consultations. Although algorithm-based default referrals in a randomised experiment greatly increased consultation rates (44% vs 8%), patient-reported outcomes were not improved.

Global relevance: By giving referrals priority, such technologies have the potential to revolutionise LMICs, where specialised palliative care is limited. Nevertheless, there is a lack of evidence from LMIC contexts, and context-specific adaptation is required.

Conclusion: Globally, AI-powered referral systems have a great deal of promise to enable earlier integration of palliative care in oncology. Among the main drawbacks are algorithmic bias, problems with data quality and the requirement for ethical supervision and clinical workflow integration. Although preliminary data appear promising, further prospective validation is necessary to guarantee that more referrals result in significant patient benefits. With a focus on patient-centred care, AI systems should support clinical judgement rather than replace it.

Objectives: To evaluate factors associated with high-dose opioid use in patients with advanced cancer and examine the effect of high-dose opioid use on patients' survival.

Methods: This study retrospectively searched the medical records of 416 patients with advanced cancer in a home-based hospice in central China. Age, sex, type of cancer, type of pain, the maximum oral morphine equivalent daily dose, type of opioid, preadmission oral morphine equivalent daily dose, lung cancer or not, bone metastases, opioid switch and survival time were assessed.

Results: There were 416 subjects included from the 455 eligible participants (91.4%). 80 patients (19.2%) received high-dose opioids at home. Male (OR 2.471; 95% CI 1.054 to 5.792; p=0.037), preadmission morphine equivalent daily dose (OR 1.022; 95% CI 1.016 to 1.028; p=0.000) and the use of morphine at maximum morphine equivalent daily dose (OR 5.123; 95% CI 1.249 to 21.014; p=0.023) were positively predicted high-dose opioid use. No difference in survival was found when comparing the high-dose and very high-dose opioid use groups.

Conclusions: Male home-based patients with advanced cancer who use morphine and have greater preadmission opioid doses should be aware of the necessity for high-dose opioid use. Regulated opioid use in adequate amounts does not shorten survival.

Objectives: Patients with advanced malignancies spend a considerable proportion of their limited survival time on healthcare. However, it is not usual practice to consider 'time spent for therapy' when making treatment decisions. This study aimed to calculate the time toxicity associated with systemic therapy in advanced malignancies.

Methods: The study was a prospective (CTRI/2023/05/053281) single-centre study that included adult patients with advanced malignancies receiving palliative intravenous systemic therapy. The time spent away from home for the hospital visit was considered time toxicity. Time toxicity over the 2-month period, divided by total follow-up duration, was calculated to derive the time toxicity index. The time taken for the different activities determined the components of time toxicity. Time toxicity was correlated with patient quality of life.

Results: Of the 92 recruited patients, the median age was 57 (35-88) years, 39 (42%) were women and 34 (37%) patients had gastrointestinal cancers. The median survival time was 7.6 (95% CI 5.6 to not reached) months. The mean time toxicity over the study period was 226 hours (95% CI 194 to 258.7) and time toxicity index was 17% (95% CI 14% to 20.5%). The major components of time toxicity were travel time and hospital formalities. Mean proportion of necessary to non-value-added activities was 8 (SD 9.4). The time toxicity index correlated with QoL.

Conclusions: The study highlights that time toxicity is an important factor in decision-making for patients planned for palliative therapy. Further studies are needed to understand the impact of time toxicity and the meaning patients attach to this.

Trial registration number: CTRI/2023/05/053281.

Objectives: Pancreatic and lung cancer are associated with cancer cachexia (CC), which negatively impacts patients' quality of life, treatment outcomes and prognosis. This study aimed to evaluate the feasibility and effectiveness of a 24-week eccentrically overloaded resistance training (ERT) in patients with CC.

Methods: 22 patients with pancreatic or lung cancer and CC were randomised (2:1) to either supervised ERT (n=14) and usual care (UC, n=8). ERT was performed twice weekly for 24 weeks. Feasibility was assessed through recruitment rate, dropouts, adverse events (AEs) and exercise adherence. Secondary outcomes included body composition, physical performance and patient-reported outcomes (PROs) in quality of life, fatigue, anxiety and depression, anorexia-cachexia symptoms and physical activity levels. Assessments were conducted at baseline, 12 weeks (ITT1) and after 24 weeks (ITT2).

Results: The recruitment rate was 21.8%. 10 dropouts (45.5%) were recorded (ERT: n=7, UC n=3). Clinical AEs were comparable between the groups. Two AEs occurred during or after an exercise session, but resolved completely. The exercise adherence was 63.7%. After 12 weeks, the ERT group improved significantly in aerobic capacity, functional strength and several PROs, while the UC group improved in PROs depression and physical activity levels. After 24 weeks, body composition worsened in the UC group compared with the ERT group (p=0.026). Intragroup analysis showed improvements in PRO domains in the ERT group and decreases of the phase angle in the UC group.

Conclusions: Supervised ERT seems feasible in cachectic cancer patients and may preserve or enhance physical performance, constitution and PROs.

Objectives: As a leading cause of morbidity and mortality worldwide, cancer imposes psychological, physical and functional burdens. Recent paradigms focus on integrative treatment approaches in patients with cancer, which include psychological and spiritual care. While spirituality has been shown to have a potential role in alleviating disease burdens, both psychological and physical, this effect has not yet been fully elucidated in the Middle East. Our study examines the impact of spirituality on the quality of life (QoL), depression, anxiety and cancer symptom severity in patients with cancer within the Lebanese population.

Methods: Our cross-sectional study followed 200 adults with solid tumours in a tertiary care centre in Beirut, Lebanon. Data were mainly collected through questionnaires: Hospital Anxiety and Depression Scale, Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being 12 Item Scale, MD Anderson Symptom Inventory and 36-item Short Form Survey Instrument. Multivariable logistic regression analyses were conducted to predict anxiety and depression. Interaction terms between spirituality and each of symptom severity levels, physical QoL and mental QoL were assessed.

Results: Higher spirituality significantly reduced the odds of anxiety (adjusted OR (aOR)=0.89, 95% CI (0.84 to 0.94), p<0.001) and depression (aOR=0.9, 95% CI (0.85 to 0.95), p<0.001) in patients with cancer, independent of symptom severity or QoL measures.

Conclusions: Our findings shed the light on the role that spiritual care plays in alleviating cancer burden despite physical symptoms severity-and pave the way to potentially modify cancer treatment protocols in the Middle East.

Objectives: This substudy investigated whether medicinal cannabis causes an elevation in alanine aminotransferase (ALT) or aspartate aminotransferase (AST) in patients with advanced malignancy and determined whether different cannabis formulations (cannabidiol (CBD) alone vs tetrahydrocannabinol (THC)/CBD combination) had differing effects on enzyme levels.

Methods: This analysis used data from two multicentre, randomised, placebo-controlled trials of escalating doses of CBD (MedCan1) or THC/CBD (MedCan2), including 287 patients with advanced cancer. Participants received escalating doses of CBD, THC/CBD or placebo. ALT and AST levels were measured at baseline, day 14 and day 28.

Results: Medicinal cannabis did not cause elevation of ALT or AST in patients with advanced malignancy at the doses studied (up to 600 mg CBD/day). No clinically meaningful differences in liver enzyme levels were observed between CBD-only and CBD/THC combination products. Furthermore, no patients in the cannabis groups exceeded the predefined thresholds of 3× upper limit of normal (ULN) (or 5× ULN in those with liver metastases) for ALT or AST.

Conclusions: In patients with advanced malignancy enrolled in two clinical trials, medicinal cannabis products did not have a significant adverse impact on ALT or AST levels during the first 4 weeks of use at the doses studied.

Objective: At the end of life, some patients with refractory suffering require deep continuous sedation. Based on the pharmacological properties, we hypothesised that sodium oxybate may offer advantages in these particular situations by preventing sedation lightening, a limitation reported with midazolam, the currently recommended agent.This trial aimed to compare the efficacy of sodium oxybate and midazolam for deep continuous sedation at the end of life.

Methods: This single-centre, single-blind, parallel-group, randomised trial tested sodium oxybate versus midazolam for this indication. The primary outcome was the treatment success defined as the ability to achieve and maintain a Richmond agitation-sedation scale less than or equal to -4.Patients, admitted to the acute palliative care unit, were randomly assigned to receive one standard dose of sodium oxybate followed by the maintenance or a titration dose of midazolam with subsequent maintenance. Patients were blinded to group assignments. Analysis was performed using an intention-to-treat approach. This study was registered at ClinicalTrials.gov (NCT05085873).

Results: Between 14 October 2021 and 9 October 2023, 22 patients were included. Treatment success was 100% (95% CI 71.5% to 100%) in the sodium oxybate group versus 0% (95% CI 0% to 28.5%) in the midazolam group (p<0.0001). No severe adverse events were reported.

Conclusion: This first end-of-life randomised controlled trial comparing midazolam with another sedative suggests that sodium oxybate may offer more stable continuous deep sedation, with fewer fluctuations in sedation depth. These findings support the potential for improving patient comfort in this specific context.

Objective: This study aimed to investigate the factors for increasing sedentary time during neoadjuvant chemotherapy (NAC) in older patients with locally advanced oesophageal cancer (LAEC) and to elucidate potential clinical mechanisms.

Methods: We conducted a single-centre exploratory prospective cohort study. Between October 2021 and December 2023, consecutive 80 patients with LAEC aged ≥65 years were scheduled for curative oesophagectomy after NAC. The change in sedentary time (Δ=after NAC - before NAC; expressed in min/week) was calculated from sedentary time measured by the Global Physical Activity Questionnaire. Factors associated with the change in sedentary time were investigated using a multivariate regression model. Two-tailed statistical significance was accepted at p<0.05.

Results: A total of 69 patients were included in the analysis. The mean age was 72.9 years, and docetaxel+cisplatin + fluorouracil, cisplatin+fluorouracil and oxaliplatin+leucovorin + fluorouracil regimens were administered to 46 (67%), 4 (6%) and 19 (27%) patients, respectively. The mean sedentary times before and after chemotherapy were 3235±1477 min/week and 3557±1598 min/week, and the mean change in sedentary time during chemotherapy was 322±736 min/week. Worsening fatigue was a significant factor influencing increased sedentary time during chemotherapy (vs non-worsening fatigue, adjusted coefficient 531.111, 95% CI 104.960 to 957.261, p=0.015).

Conclusions: The clinical mechanism of increasing sedentary time during chemotherapy may be associated with worsening fatigue. In older adults with LAEC, a physical activity intervention during NAC may improve clinical outcomes.

Background: Cancer-related fatigue (CRF) is a common side effect in patients with breast cancer. Various non-pharmacological interventions are employed to alleviate CRF; however, current research lacks evaluations of their efficacy. This study compared the effectiveness of different non-pharmacological interventions on CRF in patients with breast cancer and to provide references for future research and clinical practice.

Methods: We systematically searched multiple databases, including the China National Knowledge Infrastructure (CNKI), Wanfang, VIP Database for Chinese Technical Periodicals (VIP), China Biology Medicine (CBM), PubMed, Web of Science, Cochrane Library and EMBASE, covering the period from the inception of each database to August 2024. The quality of the included studies was assessed via the AMSTAR-2 scale (a measurement tool to assess systematic reviews 2), and evidence mapping was used to summarise the characteristics of included studies.

Results: 52 systematic reviews/meta-analyses were included. The types of non-pharmacological interventions included 34 exercise interventions, 6 multidimensional interventions (a multimodal intervention approach involving three or more non-pharmacological therapies), 4 psychosocial interventions, 2 massage or acupuncture therapies, 2 art therapies, 1 moxibustion, 1 dietary supplement, 1 continuity of care and 1 systemic care. The conclusions of these studies were categorised as 'beneficial' for 41 studies, 'may be beneficial' for 9 studies and 'inconclusive' for 2 studies.

Conclusions: The evidence mapping revealed that exercise interventions are the most widely used and effective interventions for CRF in patients with breast cancer. However, owing to the variety of non-pharmacological interventions and the fact that some of them are less common in studies, more large-sample, high-quality, prospective randomised trials and systematic reviews/meta-analyses involving different interventions are needed to further validate them in the future.