Major patterns of cancer cure: Clinical implications.

INTRODUCTION: This review aimed to classify major patterns of cancer cure and discuss clinical implications. Patterns of cancer cure were identified, in terms of long-term survival and life expectancy, by means of two recently estimated indicators: cure fraction (CF) and time to cure (TTC). METHODS: We considered population-based studies reporting results for some cancer types on CF, defined as the proportion of patients who will reach the same life expectancy of the general population, or/and TTC, the time span necessary to experience a negligible excess mortality. TTC is obtained using conditional relative survival, which indicates the probability of surviving an additional y number of years, given that patients already survived x number of years. RESULTS: Four major patterns of cancer types emerged from published studies: (a) cancers with a CF > 60% and a TTC < 5 years (e.g., testicular, thyroid); (b) cancers with a CF between 20% and 50% and a TTC < 10 years (colon, rectum); (c) cancers showing a CF of approximately 50% and TTC > 10 years (breast, prostate and bladder); (d) cancers with a CF < 20% and uncertain TTC (lung or pancreas). CONCLUSION: Clinical and social impact of "cancer cure" categorisation are discussed in details. Recognising a cancer patient as cured represents an opportunity to improve their quality of life.

Culture and Palliative Care: Preferences, Communication, Meaning, and Mutual Decision Making.

Palliative care is gaining acceptance across the world. However, even when palliative care resources exist, both the delivery and distribution of services too often are neither equitably nor acceptably provided to diverse population groups. The goal of this study was to illustrate tensions in the delivery of palliative care for diverse patient populations to help clinicians to improve care for all. We begin by defining and differentiating culture, race, and ethnicity, so that these terms-often used interchangeably-are not conflated and are more effectively used in caring for diverse populations. We then present examples from an integrative literature review of recent research on culture and palliative care to illustrate both how and why varied responses to pain and suffering occur in different patterns, focusing on four areas of palliative care: the formation of care preferences, communication patterns, different meanings of suffering, and decision-making processes about care. For each area, we provide international and multiethnic examples of variations that emphasize the need for personalization of care and the avoidance of stereotyping beliefs and practices without considering individual circumstances and life histories. We conclude with recommendations for improving palliative care research and practice with cultural perspectives, emphasizing the need to work in partnerships with patients, their family members, and communities to identify and negotiate culturally meaningful care, promote quality of life, and ensure the highest quality palliative care for all, both domestically and internationally.

Physical Needs of Long-term Cancer Patients.

The enormous success in the therapeutic area of oncology has allowed achieving a number of long-term survival patients unthinkable until a few decades ago. The number of cancer survivors in the world has, in fact, almost tripled in the last decade alone. Anticancer therapies, including those of the latest generation, aimed at targeting also the chronicity of the disease, are not free from side-effects, especially when used in the long term. This scenario should lead to development of follow-up programs with the purpose of assessing long-term effects related to cancer treatments, in addition to the early detection of any relapse or a second tumor. Oncologists who take care of cancer survivors cannot ignore these effects; it is, therefore, essential to start a program of prevention and treatment of these sequelae, to meet patients' health needs.

Unequal cancer survivorship care: addressing cultural and sociodemographic disparities in the clinic.

The number of individuals diagnosed with cancer is growing worldwide. Cancer patients from underserved populations have widely documented disparities through the continuum of cancer care. As the number of cancer survivors (i.e., individuals who have completed cancer treatment) from underserved populations also continue to grow, these individuals may continue to experience barriers to survivorship care, resulting in persistent long-term negative impacts on health and quality of life. In addition, there is limited participation of survivors from underserved populations in clinical trials and other research studies. To address disparities and change practices in survivorship care, a better understanding of the roles of both socioeconomic status (SES) and of culture in cancer care disparities and the relevance of these to providing high-quality care is needed. SES and culture often overlap but are not identical; understanding the impact of each is especially relevant to survivorship care. To enhance health equity among cancer survivors, clinicians need to practice culturally competent care, address cultural beliefs and practices that may influence survivors' beliefs and activities, gain awareness of historical patterns of medical care in the survivor's community, and consider how barriers to cross-cultural communications may hinder communication in clinical settings. While the design and implementation of survivorship care programs emphasizing effectiveness and equity is complex and potentially time consuming, it is critical for providing optimal care for all survivors, including those from the most vulnerable populations.

ReCAP: ASCO Core Curriculum for Cancer Survivorship Education.

CONTEXT AND QUESTIONS ASKED: The number of cancer survivors is increasing exponentially. Currently there about 15 million cancer survivors, and by 2025, there will be nearly 20 million. Who will provide survivorship care, what are evidenced-based or best care practices, what are best methods to disseminate this information and assess its impact on physician practice, and what are the most cost-effective health care delivery models to serve the majority of survivors? SUMMARY ANSWER: The ASCO Survivorship Committee in collaboration with the ASCO Professional Development Committee developed a core curriculum and core competencies for physicians, allied health professionals, training programs, and policymaking organizations. Adapted from Institute of Medicine recommendations for survivorship care, the core curriculum and competencies include the following subheadings: surveillance for recurrence and second malignancies, long-term and late effects, health promotion and prevention, psychosocial well-being, special populations including adolescent and young adult survivors, older adult cancer survivors, caregivers of cancer survivors and communication and care coordination. METHODS: An environmental scan (a process that systematically surveys and interprets relevant data to identify opportunities and barriers) for survivorship was performed. Although survivorship content exists in various courses, conferences, guidelines, and Web-based applications, the information is incomplete and not easily found. Hence, there was a need for this content to be easy to access and available in one place. Content experts formulated the individual sections based on the environmental scan and their knowledge of the various subheadings. BIAS, CONFOUNDING FACTORS, DRAWBACKS: Both an environmental scan and a comprehensive literature review have standard methodologies. The differences are in scope; an environmental scan is more like an overview, and the standard literature review is more granular. For this article, we felt that environmental scan better served the purpose of developing a survivorship core curriculum and competencies. REAL-LIFE IMPLICATIONS: Survivorship care is one the most challenging problems oncologists face today and in the near future. Fundamental to the relatively new field of survivorship care is this core curriculum and competencies, which provide the framework necessary to generate appropriate referrals depending on local practices and expertise.

Addressing the psychosocial wellbeing of teenage children of cancer patients and survivors.

Thomas is 13 years old. His parents report a sharp decline in his school grades caused, according to his teachers' opinions, by listlessness and lack of concentration. The parents of Julia, 16 years old, describe her as restless, evasive, isolated, and withdrawn from others and from her usual activities. Linda, 18 years old, is described by her parents as indecisive, uncertain, and almost lethargic. Normally resolute and a high academic achiever, she appears locked in herself, unable to make choices. We first learned about them through the accounts of their concerned parents. Claire, 19 years old, lost weight and exercised hard enough to induce amenorrhea after her young mother underwent treatment for breast cancer, including antihormonal treatment. These four teenagers have in common a parent diagnosed with cancer, undergoing or having just completed treatment.

Quality of life profile in Italian long-term cancer survivors.

PURPOSE: Understanding the quality of life (QoL) of long-term cancer survivors is relevant to daily clinical practice as well as to healthcare policy. This study assessed QoL of Italian survivors and tested the association between QoL and the main clinical and socio-demographic sample's characteristics. METHODS: Two hundred and sixty-five Italian adult long-term cancer survivors (people free from cancer and its treatments for at least 5 years) were administered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, the Impact of Cancer, and the Short Form 36 questionnaires obtaining three different QoL profiles-cancer-specific, survivorship-specific, and generic. RESULTS: In both cancer-specific and generic QoL profiles, participants reported a lower general health and a higher social functioning than normative samples; in addition, they reported low emotional functioning and vitality, respectively, in the former and latter profile. In the survivorship-specific profile, participants scored higher on personal growth and altruism (p < 0.001) and lower on dissatisfaction and life interferences (p < 0.001). Males reported less dissatisfaction and life interferences (p < 0.001), and less pain (p < 0.001) than females. Employed participants reported higher physical functioning (p = 0.001) and fewer role limitations (p < 0.001) than unemployed participants. Differences according to cancer type were recorded only in survivorship-specific domains (p < 0.004). No association between survivorship length and any of the three QoL profiles was found. Finally, the absence of other reported health issues was associated to higher functioning in the majority of cancer-specific and generic QoL domains. CONCLUSIONS: Our data support the usefulness of multi-disciplinary follow-ups for long-term cancer survivors and the need to pay particular attention to the psycho-emotional long-term and late-presenting sequels of cancer and its treatment.

Universality of aging: family caregivers for elderly cancer patients.

The world population is aging, with the proportion of older people (65+ years) expected to reach 21% in 2050 and to exceed the number of younger people (aged 15 or less) for the first time in history. Because cancer is particularly a chronic disease of older people, a large increase in the number of elderly patients with cancer is anticipated. The estimated number of new cancer cases worldwide among people over 65 is expected to grow from about 6 million in 2008 to more than 11 million during the coming decade. By 2030, individuals over 65 are expected to account for 70% of all cancer patients in the Western world. Along with the increase in oncology patients, the number of older people caring for their ill spouses or other relatives is also growing, with the ensuing toll on these caregivers causing major concern, especially in western countries. In different societies the characteristics of family caregiver stressors, cultural norms concerning caregiving, and the availability of support have a huge impact on those providing care. Any study of older caregivers of older cancer patients requires an integrative evaluation of aging that takes into account cultural, social, psychological, and behavioral variables. This review proposes a critical discussion of the multidimensionality of the caregiving and of the impact that age, culture, and gender have on it.

Genetic counselling in ALS: facts, uncertainties and clinical suggestions.

The clinical approach to patients with amyotrophic lateral sclerosis (ALS) has been largely modified by the identification of novel genes, the detection of gene mutations in apparently sporadic patients, and the discovery of the strict genetic and clinical relation between ALS and frontotemporal dementia (FTD). As a consequence, clinicians are increasingly facing the dilemma on how to handle genetic counselling and testing both for ALS patients and their relatives. On the basis of existing literature on genetics of ALS and of other late-onset life-threatening disorders, we propose clinical suggestions to enable neurologists to provide optimal clinical and genetic counselling to patients and families. Genetic testing should be offered to ALS patients who have a first-degree or second-degree relative with ALS, FTD or both, and should be discussed with, but not offered to, all other ALS patients, with special emphasis on its major uncertainties. Presently, genetic testing should not be proposed to asymptomatic at-risk subjects, unless they request it or are enrolled in research programmes. Genetic counselling in ALS should take into account the uncertainties about the pathogenicity and penetrance of some genetic mutations; the possible presence of mutations of different genes in the same individual; the poor genotypic/phenotypic correlation in most ALS genes; and the phenotypic pleiotropy of some genes. Though psychological, social and ethical implications of genetic testing are still relatively unexplored in ALS, we recommend multidisciplinary counselling that addresses all relevant issues, including disclosure of tests results to family members and the risk for genetic discrimination.

Surprising results regarding MASCC members' beliefs about spiritual care.

BACKGROUND: Through our survey of Multinational Association of Supportive Care in Cancer (MASCC) members and its analysis, we sought to gain a broader, more inclusive perspective of physicians' understanding of patients' spiritual care needs and improve our approach to providing spiritual care to patients. METHODS: We developed a 16-question survey to assess spiritual care practices. We sent 635 MASCC members four e-mails, each inviting them to complete the survey via an online survey service. Demographic information was collected. The results were tabulated, and summary statistics were used to describe the results. RESULTS: Two hundred seventy-one MASCC members (42.7 %) from 41 countries completed the survey. Of the respondents, 50.5 % were age ≤50 years, 161 (59.4 %) were women and 123 (45.4 %) had ≥20 years of cancer care experience. The two most common definitions of spiritual care the respondents specified were "offering emotional support as part of addressing psychosocial needs" (49.8 %) and "alleviating spiritual/existential pain/suffering" (42.4 %). Whether respondents considered themselves to be "spiritual" correlated with how they rated the importance of spiritual care (p ≤ 0.001). One hundred six respondents (39.1 %) reported that they believe it is their role to explore the spiritual concerns of their cancer patients, and 33 respondents (12.2 %) reported that they do not feel it is their role. Ninety-one respondents (33.6 %) reported that they seldom provide adequate spiritual care, and 71 respondents (26.2 %) reported that they did not feel they could adequately provide spiritual care. CONCLUSIONS: The majority of MASCC members who completed the survey reported that spiritual care plays an important role in the total care of cancer patients, but few respondents from this supportive care-focused organization actually provide spiritual care. In order to be able to provide a rationale for developing spiritual care guidelines, we need to understand how to emphasize the importance of spiritual care and, at minimum, train MASCC members to triage patients for spiritual crises.

Professionalism in global, personalized cancer care: restoring authenticity and integrity.

Personalized medicine is revolutionizing cancer care and creating new expectations among oncologists and patients. At present the benefit is still marginal, however, and must be understood as incremental. In addition, cultural and resource disparities limit the sustainability of new cancer therapies on a global scale. Adequate instruments are needed to enable our exercise of sound and honest judgment in distinguishing breakthrough treatments from those that yield only marginal or doubtful improvements, and to develop strategies for formulation and correct application of balanced guidelines for sustainable cancer care. Professionalism requires that the acquisition of knowledge and skills go hand in hand with moral education in the intellectual virtues of humility, perseverance, adaptability, communicativeness, and commitment to resist self-deception or conflicts of interest. Hidden curricula undermine the moral values of medicine: these must be understood and uncovered. We should possess a special body of knowledge, skills, and values that allow us to change our practices when appropriate and to be stewards of society's limited resources through proper communication with our patients and families. In the era of personalized oncology and global issues of sustainability, professional authenticity and integrity in cancer clinical practice are key to bridging the gaps between true and false expectations of patients and the public.

Are oncologists accountable only to patients or also to their families? An international perspective.

In most societies, health professionals traditionally carry responsibility only toward their patients. However, this is not the case in all cultures. In the contemporary practice of oncology in Western cultures, there is a shift toward assuming broader responsibility for patients with cancer' families during the illness course, the grieving stage, and in cancer prevention and genetic counseling. Traditional family, community, and religious values play a central role in determining people's perceptions and attitudes toward life and death as well as toward caregiving for a sick relative. The meaning of cancer illness within the family culture is thus influenced not only by each individual's values and beliefs but also by the family's makeup and dynamics, as well as their taboos and secrets. Global cancer care should therefore be directed at the family as a unit, while respecting patient autonomy and privacy. This reappraisal of our traditional understanding of physicians' duty as solely directed at the patient is reflected in the recent US trend toward a patient- and family-centered care approach. An additional challenge for oncology professionals is to integrate and tailor interventions toward the needs of both care recipients and caregivers and relate it to this dyad as the basic and enduring unit of care.

Onclogists' difficulties in facing and disclosing medical errors: suggestions for the clinic.

Along with improved safety measures and changes in the culture of medicine, communication is key to reducing the effect of medical errors and to easing the medical, psychologic, and existential burdens they impose on all parties. Disclosure demonstrates respect for patients' autonomy and promotes patient's involvement in informed decision making about ways to correct or alleviate the effects of the error. It also enhances oncologists' integrity and helps restore trust in the patient-doctor relationship. Because of the complexity of cancer treatments and the uncertainty regarding outcomes in oncology, oncologists may rationalize nondisclosure as a way to avoid adding to the physical and existential suffering of their patients. Although there is broad agreement among professional and regulatory bodies, as well as medical ethicists, that physicians should disclose errors to patients-and physicians largely support disclosure of error to patients-studies show discrepancy between physicians' responses to hypothetical clinical scenarios of truth telling about medical errors and actual practices of withholding or tempering the truth. Among common reasons for avoiding disclosure are risk of malpractice lawsuits, fear of being exposed as incompetent, and feeling shame before patients and colleagues. Proper disclosure, however, including a sincere apology, should be part of the management of errors and of their long-term aftermaths. In disclosing medical errors, it is essential for oncologists to pay equal attention to the medical and the emotional aspects of the information they are giving and the reaction that it elicits in patients and families. Specific communication skills regarding disclosure of medical errors can be learned.