Cancer Pain and Patient Education: Strategy, Implementation, Difficulties and Opportunities of EFFADOL, a Regional Collaborative Programme.

While pain remains a burden for many cancer patients, their active involvement in dealing with it through therapeutic patient education (TPE) has proved effective in overcoming hurdles to pain management. This article describes how a regional TPE programme devoted to cancer pain was set up, as well as the difficulties and opportunities encountered during its implementation. Ten nurse-doctor pairs from the chronic pain units of Lower Normandy, after being trained in TPE, designed and built the EFFADOL (Ensemble Faire Face A la DOuLeur [Cope together with pain]) programme. They collaboratively developed the pedagogical, evaluation and communication tools used in the programme. After the educational diagnosis step, patients are able to follow three sessions in order to acquire the following skills: (1) understanding the different types of pain, (2) understanding pain treatments and their adverse reactions and (3) optimally managing pain on a daily basis. Patients can ask a relative to join the sessions and can choose their preferred modality (individual and/or collective sessions). Programme implementation and the importance of communicating with oncologists and independent health professionals are discussed. The programme, which is available to patients close to home, meets their needs as previously assessed through a regional prospective survey. Difficulties to include patients and opportunities to address them are identified. The programme's limitations mainly concern its organization, structure and communication issues. The main challenge remains the overhaul of care practices and the role of the caregiver to allow patient autonomy.

Effectiveness of a therapeutic patient education program in improving cancer pain management: EFFADOL, a stepped-wedge randomised controlled trial.

BACKGROUND: Despite numerous guidelines, nearly one of two patients with cancer pain remains undertreated, thereby affecting their quality of life. Active patient involvement through Therapeutic Patient Education (TPE) is considered as a relevant strategy to overcoming hurdles in pain management. The aim of the EFFADOL study is to assess the effectiveness of a TPE program in improving cancer pain management. METHODS/DESIGN: The EFFADOL study is a stepped-wedge randomised controlled trial. A total of 260 cancer patients with unbalanced background pain will be randomised over the institutional level, i.e. stepped-wedge cluster design. Six clusters will be formed, one at the regional level of "Basse-Normandie" for patients receiving the educational approach by health providers already trained to TPE. Then, five additional centers will be gradually included at the national level, making it possible to compare the "conventional" management of pain (before medical staff training to TPE) with the educational approach (after being trained). The main study parameter is pain interference on daily life assessed with the self-administrated and validated Brief Pain Inventory questionnaire. Secondary objectives comprised the evaluation of patients' adherence to pain education program, the description of pain intensity, pain relief, analgesic adherence and pain emotional impact. Educational dimension of the program will be evaluated through the patients' acquisition of knowledge and skills about their pain and treatment as well as their self-efficacy to participate actively in pain management. The patient's feeling of pain changes will be measured. Finally, the satisfaction of participants and educators will be reported. We hypothetise active involvement of patients in TPE will lead to an improved pain management compared to standard care. DISCUSSION: Analyzing the impact of a TPE program in cancer pain patients will improve their pain management and quality of life. We expect that the dissemination of our project educational approach through the French territory will be accompanied by long term change in clinical practices with mutual benefit to patients and caregiver-educators. TRIAL REGISTRATION: NCT03297723 , registered: 09/28/2017. Protocol version: Version n°1.1 dated from 2016/09/08.

Therapeutic Patient Education in Cancer Pain Management: from Practice to Research: Proposals and Strategy of the French EFFADOL Program.

In the field of cancer pain, therapeutic patient education (TPE) allows patients to develop skills to better manage their pain. In the Lower Normandy region of France, the management of pain is based on networking, thus allowing proximity and accessibility for all concerned. We have thus designed and initiated a broad five-stage research program that includes the following: (1) training for caregivers in TPE; (2) identifying the educational expectations of patients and their relatives with regard to cancer pain; (3) the design of a TPE program; (4) the evaluation of its quality; and (5) the evaluation of its effectiveness by comparative randomization. This article presents this approach and more particularly the research phases (stages 2, 4, 5) for which the objectives, the methodology, and the expected results are justified. Among the key points, particular attention is paid to the evaluation of the educational dimension that provides patients with self-efficacy to participate actively in the management of their pain, their perception of changes in relation to it and its impact. The choice of a specific assessment criterion (subscale 9 of the Brief Pain Inventory) and of the step-wedge design are thus argued. This approach, which is based on a partnership between health care professionals and researchers, aims to demonstrate the benefits provided by TPE to patients in order to enable them to better manage their pain on a daily basis.

Oral antineoplastic agents: how do we care about adherence?

AIMS: Oral therapies, including hormone-based or targeted therapies, have recently taken an increasing place in cancer treatment. In this context, a state of the art of the available studies dealing with the adherence of adult patients to oral anticancer treatment is warranted. The purpose of this review is to address (i) the association between assessment methods and measured adherence, (ii) the putative factors related to adherence and (iii) new ways of improving adherence to oral cancer therapies. METHODS: We conducted a literature-based narrative review of studies obtained from Pubmed using medical subject heading terms and free-text terms combining concepts related to oral anticancer medication and adherence. RESULTS: The analysis is based on 48 studies published since 1990, mostly assessing hormone-based therapy in breast cancer and targeted therapies in chronic myeloid leukaemia. Various methods of adherence were reported including self-report, medication measurement or combinations of methods. Adherence rates were found to vary from 14% to 100%. Beside patient related-factors, adherence rate discrepancies were found to be dependent on the method used. Furthermore, there was no consensual definition of adherence even regarding the same methods, some of them tolerating a period of interruption during the treatment period. Finally, several studies addressing persistence found a progressive decrease in adherence with time. CONCLUSION: Adherence to novel oral therapies is a major issue and further research is warranted to standardize adherence assessment in clinical studies better and to define better the most appropriate approaches to improve long term adherence in oncology practice.

Shared Meditation Involving Cancer Patients, Health Professionals and Third Persons: Perceptions of Participants Through a Focus Group Study.

People with cancer often experience psychological distress and in addition, the practice of oncology is one of the most stressful areas of medicine for health professionals. Mindfulness meditation has been used to alleviate stress-related symptoms. We therefore ran a pilot study to assess the feasibility of a mindfulness intervention involving cancer patients, health professionals, and third persons together, as part of a comprehensive project aiming to evaluate the added value of 'meditating together'. Following on from our quantitative analyses of the project, we investigated its qualitative aspects through focus groups to explore the perceptions of participants regarding their experience. Focus groups conducted in 7 patients, 7 health professionals, and 8 third persons after the intervention showed that 'meditating together' was generally appreciated, particularly by patients, who found it motivating and a way to relieve their feelings of loneliness in the face of illness. All participants reported better stress management. They also shared benefits and difficulties concerning the practice of meditation and the programme's modalities. In addition, they all stated that the programme should be lasting. The opinion of the patients (our target population) will be decisive in building an optimized programme that will suit them the best. In conclusion, the protocol and the qualitative findings of the present study validate the rationale for conducting a fully powered randomized trial to demonstrate the potential added value of shared meditation and how it improves well-being by promoting bridge-building between cancer patients, health professionals and others.Trial Registration: ClinicalTrials.gov. NCT04410185. Registered on June 1, 2020.

[Development of a targeted educational activity in addictology: From design to use in specialized structures in the Normandy region]. / Élaboration d'une activité éducative ciblée en addictologie : de la conception à l'utilisation dans les structures spécialisées de la région Normandie.

OBJECTIVE: Risk and damage reduction is a public health issue and allows to consider addiction as a chronic pathology in which patients have the opportunity to become actors of their own care, a philosophy shared with Therapeutic Education. In this context, our objective is to develop a tool adapted to the populations of patients/users in specialized structures, meeting the criteria of a Targeted Educational Activity, to allow them a better understanding and management of their addiction to opiates on a daily basis. METHOD: In a multi-professional setting, involving pharmacists, doctors and nurses, an exploratory phase was conducted in order to identify the theme, the target population and the tool format. Then, the tool was built and validated with the ambition of responding pedagogically to the problems encountered daily by patients/users. RESULTS: The pedagogical tool, called "Le QUIZZ à moindre risque", contains 51 questions categorized in 2 structured parts on the reduction of risks related to opiate consumption and substitution drugs. Focused on the problems of patients/users, it helps them achieve greater autonomy in their health and a better quality of life, with and despite the illness. The proposed format makes it a tool that can be freely consulted by patients/users according to their practices and needs; it can also be used in group workshops conducted with the caregivers. CONCLUSION: The tool developed aims to (i) enable opiate users to acquire skills to improve the management of their consumption and the risks involved and (ii) strengthen communication between patients/users and caregivers by offering them the opportunity to be actors of their care. The tool is currently being tested and evaluated in many cities in Normandy and its optimization will allow for an improvement in care that meets the challenges and needs.

Shared meditation involving cancer patients, health professionals and third persons is relevant and improves well-being: IMPLIC pilot study.

BACKGROUND: Alleviating suffering and improving quality of life are universally shared goals. In this context, we implemented a pilot study to assess the feasibility and acceptability of a mindfulness intervention in the form of meditation involving together cancer patients, health professionals, and third persons. METHODS: Two groups of 15 participants equally composed of patients, health professionals and third persons were constituted. A dedicated programme on mindfulness and compassion was constructed, including 12 weekly sessions of 1.5 h and a half-day retreat. Adherence and satisfaction with the programme were evaluated. All participants completed questionnaires on perceived stress, quality of life, mindfulness, empathy, and self-efficacy. Burnout was assessed in health professionals. RESULTS: Shared meditation was feasible as 70% of participants attended ≥ 80% of the 13 meditation sessions. Satisfaction with the programme was high (median satisfaction score: 9.1 out of 10) and all participants expressed positive attitudes towards shared meditation and a benefit on their global quality of life. Participants reported significant improvement in stress (p < 0.001), global quality of life (p = 0.004), self-efficacy (p < 0.001), and mindfulness skills (p < 0.001) from baseline to post-programme. CONCLUSIONS: This study demonstrated the feasibility of a shared dedicated meditation programme in terms of participation and acceptability of participants. The measured benefits observed among participants furthermore justify the interest of a subsequent randomized study aiming to demonstrate the potential added value of shared meditation by promoting bridge-building between cancer patients, health professionals and others. TRIAL REGISTRATION: ClinicalTrials.gov. NCT04410185 . Registered on June 1, 2020.

Detection of extracellular 8-oxo-7,8-dihydro-2'-deoxyguanosine as a biomarker of oxidative damage in X-irradiated fibroblast cultures: optimization of analytical procedure.

We have developed a simple methodology, based on single-step solid-phase extraction followed by isocratic high-performance liquid chromatography coupled with electrochemical detection (HPLC-ECD), to determine extracellular 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) in culture supernatants of normal human dermal fibroblasts. A standard addition method, using externally added 8-oxodG (0.5 and 1 pmol) was employed to eliminate matrix effects arising from the chemically complex, protein-rich medium. Secondly, applying this procedure to X-ray irradiated fibroblasts, we report a significant twofold increase in the levels of 8-oxodG at the radiobiologically relevant dose of 6 Gy. This suggests that extracellular 8-oxodG might be a useful biomarker for oxidative stress following moderate doses of X-irradiation.

[Elaboration and evaluation of a therapeutic education program in cancer pain management]. / Construction et évaluation d'un programme d'éducation thérapeutique du patient dans le domaine de la douleur liée au cancer.

Pain, one of the most feared symptoms for patients with cancer, remains insufficiently alleviated and impairs quality of life. Therapeutic patient education (TPE) is a relevant approach to this problem while allowing patients to develop skills to better manage their pain. In the "Basse-Normandie" French region, the management of pain relies on two organized networks, thus allowing proximity and accessibility for all concerned. In this context, our team has begun a broad five-step research program that is part of a regional health policy: (1) training in TPE of 10 doctor/nurse pairs; (2) identification of educational expectations of patients and their relatives in the field of cancer pain; (3) design and optimization of a TPE program dedicated to cancer pain; (4) regional pilot study aiming to assess the feasibility, quality and transferability of the program; (5) evaluation of the TPE program by interventional comparative randomization at the national level. This article aims to present the program which originality and strengths are based on collaborative work between health stakeholders. Objectives, methodology and expected results of the research phase (stages 2, 4, 5) are notably developed. The main expected outcomes are to prove the effectiveness of the program in improving the knowledge and skills of patients in the field of pain cancer in order to promote their adherence to treatment and, consequently, to enable them to better manage it. The long-term objective is to disseminate the educational approach by modifying practices that provide a mutual benefit for caregivers and patients.

Therapeutic Education in Improving Cancer Pain Management: A Synthesis of Available Studies.

This literature review aims to synthesize available studies and to update findings in order to obtain a current, comprehensive estimate of the benefits of pain education. Forty-four original articles obtained from the PubMed database were analyzed to investigate which protocols could be most effective in improving pain management. Recent studies indicate a growing interest in evaluating patients' skills and attitudes; these include satisfaction with cancer pain treatment, patient-reported improvement, and patient participation-all of which could be dependable benchmarks for evaluating the effectiveness of educational programs. Besides pain measurement, recent studies advance support for the importance of assessing newly developed outcome criteria. In this sense, patients' active participation and decision making in their pain management are probably the most relevant goals of pain education.

Measurement of 8-oxo-7,8-dihydro-2'-deoxyguanosine in peripheral blood mononuclear cells: optimisation and application to samples from a case-control study on cancers of the oesophagus and cardia.

8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) is a widely used biomarker to evaluate the level of oxidative stress. This study describes in its first part the optimisation of our analytical procedure (HPLC/electrochemical detection). Particular care was exercised to avoid artefactual oxidation and in the precision of measurement, which was evaluated with blood bags from hemochromatosis patients. The best results were obtained with a DNA extraction step using the "chaotropic method" recommended by the European Standards Committee on Oxidative DNA Damage (ESCODD). Other approaches such as anion exchange columns gave ten times as much 8-oxodG as this method. Moreover, a complete DNA hydrolysis using five different enzymes allowed improved precision. The optimised protocol was applied to peripheral blood mononuclear cells (PBMC) sampled during a case-control study on cancers of the oesophagus and cardia. With 7.2 +/- 2.6 8-oxodG/10(6) 2'-deoxyguanosines (2'-dG) (mean +/- SD), patients (n = 17) showed higher levels of 8-oxodG than controls (4.9 +/- 1.9 8-oxodG/10(6) 2'-dG, n = 43, Student's t-test: p < 0.001). This difference remained significant after technical (storage, sampling period, 2'-dG levels) and individual (age, sex, smoking, alcohol) confounding factors were taken into account (p < 0.0001, Generalised Linear regression Model). To our knowledge, this is the first report to demonstrate an increase of 8-oxodG in PBMCs of patients suffering from a cancer of the upper digestive tract. This elevated level of DNA damage in patients can raise interesting issues: is oxidative stress the cause or the result of the pathology? Could this biomarker be used to evaluate chemoprevention trials concerning digestive tract cancers?

[Quality of life and supportive care in head and neck cancers]. / Qualité de vie des patients et soins de support en cancérologie des VADS.

The quality of life of patients treated for head and neck cancers and their carers is part of the current concerns of health care teams. Assessment tools were created and helped to highlight the severe physical effects (pain, mucositis…) and chronic (mutilation, post-radiation complications…) related to the disease or to different treatments but also to consider the psychosocial impact of this disease. Improving the quality of life through a thoughtful and comprehensive support that must be associated with somatic care, mental health care, rehabilitation and inclusion of social difficulties and suffering relatives. Supportive care shall ensure a good quality of life for patients treated and their families but also reduce the physical effects associated with the disease and treatment. They rely on coordination of care including the cancer networks established in the cancer plan to ensure comprehensive and continuous care for these patients.

Dramatic increase in oxidative stress in carbon-irradiated normal human skin fibroblasts.

Skin complications were recently reported after carbon-ion (C-ion) radiation therapy. Oxidative stress is considered an important pathway in the appearance of late skin reactions. We evaluated oxidative stress in normal human skin fibroblasts after carbon-ion vs. X-ray irradiation. Survival curves and radiobiological parameters were calculated. DNA damage was quantified, as were lipid peroxidation (LPO), protein carbonylation and antioxidant enzyme activities. Reduced and oxidized glutathione ratios (GSH/GSSG) were determined. Proinflammatory cytokine secretion in culture supernatants was evaluated. The relative biological effectiveness (RBE) of C-ions vs. X-rays was 4.8 at D0 (irradiation dose corresponding to a surviving fraction of 37%). Surviving fraction at 2 Gy (SF2) was 71.8% and 7.6% for X-rays and C-ions, respectively. Compared with X-rays, immediate DNA damage was increased less after C-ions, but a late increase was observed at D(10%) (irradiation dose corresponding to a surviving fraction of 10%). LPO products and protein carbonyls were only increased 24 hours after C-ions. After X-rays, superoxide dismutase (SOD) activity was strongly increased immediately and on day 14 at D(0%) (irradiation dose corresponding to a surviving fraction of around 0%), catalase activity was unchanged and glutathione peroxidase (GPx) activity was increased only on day 14. These activities were decreased after C-ions compared with X-rays. GSH/GSSG was unchanged after X-rays but was decreased immediately after C-ion irradiation before an increase from day 7. Secretion of IL-6 was increased at late times after X-ray irradiation. After C-ion irradiation, IL-6 concentration was increased on day 7 but was lower compared with X-rays at later times. C-ion effects on normal human skin fibroblasts seemed to be harmful in comparison with X-rays as they produce late DNA damage, LPO products and protein carbonyls, and as they decrease antioxidant defences. Mechanisms leading to this discrepancy between the two types of radiation should be investigated.

8-oxo-7,8-dihydro-2'-deoxyguanosine as a biomarker of oxidative damage in oesophageal cancer patients: lack of association with antioxidant vitamins and polymorphism of hOGG1 and GST.

BACKGROUND: The present report was designed to investigate the origins of elevated oxidative stress measured in cancer patients in our previous work related to a case-control study (17 cases, 43 controls) on oesophageal cancers. The aim was to characterize the relationship between the levels of 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG), antioxidant vitamins and genetic susceptibility. METHODS: 8-oxodG was analysed in peripheral blood mononuclear cells (PBMCs) by High Performance Liquid Chromatography with Electrochemical Detection (HPLC-ED). Analysis of gene polymorphisms in GSTM1 and GSTT1 was performed by multiplex PCR and in GSTP1 and hOGG1 by a PCR-RFLP method. Reversed-phase HPLC with UV detection at 294 nm was used to measure vitamins A and E in serum from the same blood samples. RESULTS: We observed that in our combined population (cases and control, n = 60), there was no statistically significant correlation between the levels of 8-oxodG and (i) the serum concentration of antioxidant vitamins, vitamin A (P = 0.290) or vitamin E (P = 0.813), or (ii) the incidence of the Ser326Cys polymorphic variant (P = 0.637) of the hOGG1 gene. Also, the levels of 8-oxodG were not significantly associated with polymorphisms in metabolite-detoxifying genes, such as GSTs, except for the positive correlation with Val/Val GST P1 allele (P < 0.0001). CONCLUSIONS: The weakness of our cohort size notwithstanding, vitamins levels in serum and genetic polymorphisms in the hOGG1 or GST genes do not appear to be important modulators of 8-oxodG levels.