Integration of the geriatric palliative care in oncological care of elderly patient with cancer.

OBJECTIVES: The objective of this article is to describe the profile of the population attended to by the palliative geriatrics clinic and to evaluate the symptomatic control derived from the care provided. METHODS: During 2017 a model based on a holistic approach was implemented, in this model the team geriatric palliative care plays a fundamental role by being part of the palliative care team and functioning as a liaison with the oncology team and other required services. We outlined the profile of 100 patients aged 70 and older seen between 2017 and 2019 at our geriatric palliative care clinic. Descriptive statistics were used. In addition, the symptoms and the care clinic model effect on the symptomatic control were analyzed, as well as the complexity of patients in palliative care with IDC-Pal. RESULTS: The patients median age was 83.5 years. Patients were classified by type of management: 47% within the supportive care group and 53% with palliative care only; 58% had metastatic disease and 84% presented at least 1 comorbidity. Frailty was observed in 78% and a Karnofsky scale of 60 or less was observed in 59% of the overall population. SIGNIFICANCE OF RESULTS: Elderly cancer patients have a complex profile and may have multiple needs. Integrating geriatric palliative care can help to provide better and personalized care along with symptomatic control. Further studies are required to establish the ideal care model for these patients. Importantly, a personalized treatment with a geriatric palliative care specialist is a key element.

Utilization of medical interventions in hospitalized Mexican adults with cancer at the end of life in a referral hospital: The importance of early palliative care.

OBJECTIVES: To investigate the impact of early vs. late palliative care (PC) on the frequency of admissions to acute hospital settings and the utilization of end-of-life (EoL) interventions in cancer decedents. METHODS: In this single-center, cross-sectional study, we examined the frequency of intensive care unit (ICU) and emergency department (ED) admissions among adult cancer decedents between 2018 and 2022 in a referral hospital in México. Additionally, we assessed EoL medical interventions, categorizing patients into 3 groups: those who received early PC (EPC), late PC (LPC), and those who did not receive PC (NPC). RESULTS: We analyzed data from 1762 patients, averaging 56 ± 16.3 years old, with a predominant representation of women (56.8%). PC was administered to 45.2% of patients, but EPC was limited to only 12.3%. The median time from the initiation of PC to death was 5 days (interquartile range: 2.0-31.5). Hematological malignancies were the most prevalent, affecting 21.5% of patients. EPC recipients demonstrated notable reductions in ICU and ED admissions, as well as diminished utilization of chemotherapy, radiotherapy (RT), antibiotics, blood transfusions, and surgery when compared to both LPC and NPC groups. EPC also exhibited fewer medical interventions in the last 14 days of life, except for RT. SIGNIFICANCE OF RESULTS: The findings of this study indicate that a significant proportion of EoL cancer patients receive PC; however, few receive EPC, emphasizing the need to improve accessibility to these services. Moreover, the results underscore the importance of thoughtful deliberation regarding the application of EoL medical interventions in cancer patients.

Assessment of emotional distress in palliative care: Edmonton Symptom Assessment System-revised (ESAS-r) vs Distress Thermometer.

OBJECTIVES: To evaluate the sensitivity and specificity of the Distress Thermometer (DT) as a screening tool for emotional distress in oncological palliative care patients and to compare the DT with the Edmonton Symptom Assessment System-revised (ESAS-r) and the gold standard to determine the most appropriate assessment method in palliative psychological care. METHODS: Data were collected from psychological screening tests (ESAS-r and DT), and clinical interviews (gold standard) were conducted by a clinical psychologist specialist in palliative oncology from January 2021 to January 2022 in an oncology palliative care service. RESULTS: The sample consisted of 356 first-time patients with a diagnosis of advanced cancer in palliative care. The most frequently reported oncological diagnoses were gastrointestinal tract (49.3%) and breast (18.3%). Most patients were female (n = 206; 57.9%), 60.4% were married/with a partner, 55.4% had between 6 and 9 years of schooling, and a median age of 57 (range, 46-65) years. The cutoff of the DT was 5, with a sensitivity of 75.88% and specificity of 54.3%. Emotional problems (sadness and nervousness) had a greater area under the curve (AUC) when measured using the DT than the ESAS-r; however, only in the case of the comparative sadness and discouragement was the difference between the AUC marginally significant. SIGNIFICANCE OF RESULTS: The use of the DT as a screening tool in oncological palliative care is more effective in the evaluation of psychological needs than the ESAS-r. The DT, in addition to evaluation by an expert psychologist, allows for a more comprehensive identification of signs and symptoms to yield an accurate mental health diagnosis based on the International Classification of Diseases-11th Revision and/or Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition.

Validation of the Mexican version of the Schedule of Attitudes Toward Hastened Death in patients undergoing palliative care in Mexico.

OBJECTIVES: The Schedule of Attitudes Toward Hastened Death (SAHD) has emerged as a valid and reliable tool to assess the wish to hasten death (WTHD) among patients diagnosed with advanced cancer; however, the instrument has never been culturally adapted and validated for patients in Mexico. This study sought to validate and abbreviate the SAHD tool for use among patients attending the Palliative Care Service of the Instituto Nacional de Cancerología in Mexico. METHODS: The SAHD was culturally adapted from a previously published validation in patients from Spain. Eligible patients included Spanish literate subjects treated as outpatients in the Palliative Care Service, with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-3. Patients were asked to answer the Mexican version of SAHD (SAHD-Mx) instrument and the Brief Edinburgh Depression Scale (BEDS). RESULTS: A total of 225 patients were included in the study. Median positive response in the SAHD-Mx was 2 (range 0-18). Positive correlation was identified between the SAHD-Mx scale and ECOG performance status (r = 0.188, p = 0.005), as well as BEDS (r = 0.567, p < 0.001). SAHD-Mx displayed strong internal consistency (alpha = 0.85) and adequate reliability from test-retest phone interviews (r = 0.567, p < 0.001). Using the confirmatory factor analysis model, a factor was identified and the number of items was reduced to 6, including items 4, 5, 9, 10, 13, and 18. SIGNIFICANCE OF RESULTS: The SAHD-Mx emerges as an adequate tool, with appropriate psychometric characteristics, for assessing WTHD among patients diagnosed with cancer undergoing palliative care in Mexico. .

Clinical effects of hydration, supplementary vitamins, and trace elements during end-of-life care for cancer patients.

Introduction: Introduction: current data regarding the decision on rehydration of patients with terminal-stage cancer remain controversial. Objective: the present study was to evaluate the effect of intravenous hydration and supplementary vitamins and trace elements on clinical symptoms and biochemical parameters in palliative cancer patients. Methods: a randomized clinical trial including 72 palliative cancer patients aged 18 years and older was performed at the National Cancer Institute in Mexico. Patients were divided into two groups: intervention and control, both receiving intravenous saline solution weekly for 4 weeks, but the former was also supplemented with vitamins and trace elements. Symptoms were assessed at baseline and 4 weeks after with the Edmonton Symptom Assessment Scale. Same measurements applied to biochemical parameters. Results: the mean age of the patients was 58.75 years. The most frequent cancer diagnoses were gastrointestinal (32 %). In the between-groups analysis significant improvements were found for the intervention group in anorexia (p = 0.024), pain (p = 0.030), chloride (p = 0.043), phosphorus (p = 0.001), potassium (p = 0.006), and total proteins (< 0.0001). Conclusion: we highlight the improvement in the control of most symptoms and some biochemical parameters in the intervention group receiving vitamins and oligoelements along with intravenous hydration. Further studies are needed.

Introducción: Introducción: los datos actuales sobre la decisión de rehidratación de pacientes con cáncer en fase terminal siguen siendo controvertidos. Objetivo: el presente estudio fue evaluar el efecto de la hidratación intravenosa y la suplementación con vitaminas y oligoelementos sobre los síntomas clínicos y parámetros bioquímicos en pacientes con cáncer paliativo. Métodos: en el Instituto Nacional del Cáncer de México se realizó un ensayo clínico aleatorizado que incluyó a 72 pacientes con cáncer paliativo de 18 años o más. Los pacientes se dividieron en dos grupos: intervención y control, ambos recibieron solución salina intravenosa semanalmente durante 4 semanas, pero el primero también se complementó con vitaminas y oligoelementos. Los síntomas se evaluaron al inicio del estudio y 4 semanas después con la escala de evaluación de síntomas de Edmonton. Mismas medidas aplicadas a los parámetros bioquímicos. Resultados: la edad media de los pacientes fue de 58,75 años. El diagnóstico de cáncer más frecuente fue el gastrointestinal (32 %). En el análisis entre grupos se encontraron mejoras significativas para el grupo de intervención en anorexia (p = 0,024), dolor (p = 0,030), cloro (p = 0,043), fósforo (p = 0,001), potasio (p = 0,006) y proteínas totales (< 0,0001). Conclusión: destacamos la mejoría en el control de la mayoría de los síntomas y algunos parámetros bioquímicos en el grupo de intervención que recibió vitaminas y oligoelementos junto con hidratación endovenosa. Se necesitan más estudios.

Palliative Care in Patients With Hematological Malignancies. We Have a Long Way to Go .

Background: Patients with hematological malignancies have significant and diverse palliative care needs but are not usually referred to specialist palliative care services in a timely manner, if at all. Objective: To identify the characteristics of patients with hematological malignancies referred to the palliative care service in a tertiary hospital in Mexico City. Patients: Retrospective study including consecutive patients with hematological malignancies referred to palliative care services at Mexico's National Cancer Institute. Results: Between 2011 and 2019, 5,017 patients with hematological malignancies were evaluated for first time at Mexico's National Cancer Institute. Of these, 9.1% (n = 457) were referred to palliative care. Most were male (53.4%), with a median age of 58 years. The most frequent diagnosis was non-Hodgkin lymphoma (54.9%). The primary indication for referral to palliative care was for cases wherein chemotherapy was no longer an option (disease refractory to treatment, 42.8%). The median time of referral to the palliative care service occurred 11.2 months after the first evaluation at the National Cancer Institute and death occurred on median 1.1 months after the first palliative care evaluation. Conclusion: Patients with hematological neoplasms are infrequently referred to Palliative Care at the Institute (9.1%). We found no clear referral criteria for Palliative Care referral and note that hematologists' optimism regarding a cure can delay referrals. Clearly, we have a long way to go in improving the number of patients referred, and we still saw frequent referrals near the end of life, but the high rate of outpatient referrals is encouraging.

Performance status and survival in cancer patients undergoing palliative care: retrospective study.

OBJECTIVE: Accurate forecasting the life expectancy of patients with cancer is adamantly needed for adequate decision-making in the Palliative Care Services (PCS) context. Nonetheless, physician forecast is often inaccurate, hindering end of life (EOL) decisions. In this study, we determined the prognostic value of two oncology performance status (PS) scales at first referral to PCS. METHODS: Retrospective analysis of 6310 patients consecutively admitted to PCS at the Instituto Nacional de Cancerología (2012-2018). Demographic and PS (as per Karnofsky (KPS) and Eastern Cooperative Oncology Group (ECOG) scales) information was retrieved and the overall survival of patients calculated according to PS. Concordance of each scale was assessed in the overall population and according to age. RESULTS: Overall survival was significantly associated with ECOG and KPS (p<0.05). A total of 2278 (36.1%) and 2296 (36.4%) patients were referred to PCS in their last month of life and most had a poor PS (ECOG 3-4, 59.1%; KPS <50, 54.4%). Both PS scales had high concordance in the overall population (K=0.6189 (KPS); K=0.6058 (ECOG)), but a higher value was observed among the subgroup of patients aged ≥65 (K=0.6339 (KPS); 0.6252 (ECOG)). Concordance was lowest among younger (≤39) patients. CONCLUSIONS: PS as assessed by the most widely known tools is strongly associated with overall survival of patients with cancer attending PCS. No large differences were observed among the scales, though results slightly favour the use of KPS. Early referral to PCS and accurate survival prediction can aid in relevant decision-making for patients approaching EOL.

Lecciones aprendidas y retos en la integración de cuidados paliativos en oncología. Experiencia en el Instituto Nacional de Cancerología.

No disponible.

Suicide in cancer patients undergoing palliative care: A report of two cases / Suicidio en pacientes con cáncer que recibe cuidados paliativos: reporte de dos casos

Abstract Introduction Suicide represents a major public health problem worldwide, and cancer patients might have vulnerability factors which increase suicide risk. There are multiple factors associated with this tragic outcome, including those stemming from the disease itself, mental illness and social, personal and spiritual factors. Although previous reports have identified a suicide rate which ranges from .03-7% among cancer patients undergoing palliative care, this has not been studied in Mexico. Objective This study sought to report the cases of suicide in patients with cancer undergoing palliative care at a large cancer reference center. Method A retrospective review of records was performed between 2018-2019 for patients treated at the Palliative Care Service of the Instituto Nacional de Cancerología in Mexico City. Records for patients who committed suicide were reviewed to describe factors associated with this outcome. Results Among all deaths identified during the record review, two were due to suicide (.09%). The patients were one female and one male, 60 and 42 years of age, diagnosed with breast cancer and gastroesophageal junction cancer, respectively, associated with tobacco and alcohol consumption, as well as several economic, social, and familial stress factors. One of the patients was identified as likely having major depressive disorder. Discussion and conclusion Deaths might be underreported in our population. A systematic evaluation is required in order to establish and detect suicidal behavior risk factors, and a follow-up plan for all these patients.

Resumen Introducción El suicidio representa un problema de salud pública en todo el mundo. Los pacientes con cáncer pueden tener factores de vulnerabilidad para presentar conducta suicida. Hay múltiples factores asociados con este fenómeno, incluidos los derivados de la enfermedad en sí, enfermedades mentales y factores sociales, personales y espirituales. Aunque hay reportes previos que describen una tasa de suicidio que va del .03 al 7% entre los pacientes con cáncer que reciben cuidados paliativos, esto no se ha estudiado en México. Objetivo Reportar los casos de suicidio en pacientes oncológicos que reciben cuidados paliativos en un centro oncológico de referencia. Método Se trata de un estudio retrospectivo, donde se revisaron los expedientes de los pacientes atendidos en el Servicio de Cuidados Paliativos del Instituto Nacional de Cancerología entre 2018-2019. Se revisaron los expedientes de los pacientes que se suicidaron para describir los factores de riesgo que presentaban. Resultados Entre todas las muertes identificadas durante la revisión de expedientes, dos se debieron a suicidio (.09%). Los pacientes fueron una mujer y un hombre, de 60 y 42 años, diagnosticados de cáncer de mama y de una unión gastroesofágica, respectivamente. Los factores asociados fueron el consumo de tabaco y alcohol, así como varios factores de estrés económico, social y familiar. Se identificó, asimismo, que uno de los pacientes padecía trastorno depresivo mayor. Discusión y conclusión Es posible que los suicidios estén infrarreportados en nuestra población. Se requiere una evaluación sistemática para establecer y detectar factores de riesgo de conducta suicida, y un plan de seguimiento para todos estos pacientes.

Venous Thromboembolism in Patients with Cancer Receiving Specialist Palliative Care.

CONTEXT: The prevalence of venous thromboembolism (VTE) in patients with cancer is particularly high at disease progression and during relapse. Patients cared for in specialized palliative care units (SPCU) are rarely included in VTE studies. Objective: We sought to study the prevalence, clinical characteristics, and survival of individuals with VTE in an SPCU setting. METHODS: We retrospectively included 2707 consecutive individuals with active cancer managed at a SPCU. Data were summarized using descriptive statistics and frequency for categorical variables. Overall survival was estimated by Kaplan-Meier and comparisons by log-rank test. Thrombotic events were confirmed by imaging. RESULTS: We studied 1984(73.3%) women and 723 (26.7%) men. The overall prevalence of thrombosis was 22.2% with only 6.2% occurring after initiating SPCU care, and was higher in women (24.6% vs 15.8%), particularly with gynecological tumors (cervical: 30.5%, ovarian: 29.2%). Median survival was slightly longer for patients without VTE (80 days [IQR21-334] and 69 days [IQR 25-235]; p = 0.03). CONCLUSIONS: Prevalence of VTE was high and varied by tumor origin. VTE may impact survival. Though median survival is short, some patients are followed over months, suggesting that in the absence of high bleeding risk, treatment for thrombosis in an attempt to decrease the morbidity of re-thrombosis should be considered. On the other hand, few patients developed symptomatic VTE during SPCU care, making generalized primary prophylaxis probably unwarranted. Customizing anticoagulation for the risk of hemorrhage and physical performance is essential.

Profile, Treatment, and Survival of Palliative Cancer Patients in a Middle Income Country's Cancer Center.

BACKGROUND: Data describing the characteristics, treatment, and survival of oncological patients referred to PCS remains scarce. Aim: To establish the characteristics of oncological patients referred to PCS, including their profile, treatment, and survival within a 7-year period. DESIGN: Retrospective review of medical records. Clinical variables such as treatment and dates were included. Ji2 or Wilcoxon tests were used accordingly; Kaplan-Meier and log rank test were used to estimate survival. SETTING/PARTICIPANTS: Consecutive oncological patients diagnosed between 2012 and 2018 sent to PCS were included. RESULTS: We studied 5,631 patients, 58% female and 59% at advanced stage. Median age was 59 years, with 6 years or less of formal education and low monthly income ($152.4 USD). Neoplasms included breast (12%), stomach (12%), colorectal (10%) and cervical cancer (9%). Median referral time was 5.1 months; pain was the main reason for referral. Morphine was the most prescribed opioid with 47%. Median overall survival was 3.1 months. CONCLUSIONS: Morphine remains the paradigm of treatment making necessary to emphasize information on its optimal use. Additional measures such as education for cancer prevention and early referral to PCS are vital to improve survival and quality of life.

Validation of the Patient Dignity Inventory in Mexican Cancer Patients.

Introduction: The Patient Dignity Inventory (PDI) is a reliable screening instrument for a variety of problems (physical, existential, and social) that affect the dignity of patients during their end of life. The PDI has been translated into several different languages and has been validated in different settings. As such, it is important to validate the instrument in patients with cancer in Mexico to assess dignity in this population. The aim of this study was to translate and validate the Spanish version of the PDI in Mexican patients with cancer. Methods: This is a cross-sectional study that included patients with cancer, both those enrolled and not enrolled in palliative care, at the Instituto Nacional de Cancerología in Mexico City from September 2018 to August 2019. A translation and back translation were performed to obtain the Mexican version of the PDI (PDI-Mx) instrument. Patients completed the PDI-Mx, the Hospital Anxiety and Depression Scale (HADS), and functional scales (Eastern Cooperative Oncology Group [ECOG] and Karnofsky). Psychometric properties were evaluated by determining internal consistency, exploratory and confirmatory factor analysis (CFA), and concurrent validity with the HADS. Results: We included 290 participants with cancer (145 in palliative care and 145 not enrolled in palliative care). The Cronbach's alpha of the PDI-Mx was 0.95. There was a significant correlation with the HADS (rs = 0.757, p < 0.0001). The factor analysis showed four factors that explain 64.7% of the model. The CFA presented adequate indicators, which show the adjustment of the structure that indicates a balanced and parsimonious model. Conclusions: The Mexican version of the PDI shows adequate psychometric properties in patients with cancer. We suggest the use of PDI-Mx in clinical care and research. The study was approved by the Institutional Review Board and Ethics Committee with numbers (016/063/CPI) and (CEI/1115/16) respectively.

Comparing the hospital anxiety and depression scale to the Brief Edinburgh Depression Scale for identifying cases of major depressive disorder in advanced cancer palliative patients.

OBJECTIVE: This study sought to compare the Hospital Anxiety and Depression Subscale (HADS-D) and Brief Edinburgh Depression Scale (BEDS) as case-finding tools of major depressive disorder in patients with advanced cancer in a palliative care service. METHODS: An observational study was performed which included patients with advanced cancer who attended the palliative care service at the National Institute of Cancer in Mexico. Patients were asked to fill out the Hospital Anxiety and Depression Scale (HADS) and BEDS and were then assessed by a psychiatrist to evaluate major depressive disorder (MDD) as per the DSM-5 criteria. The case-finding capability of each scale was determined using receiver operating characteristic curves, assessing the area under the curve (AUC) in comparison to the clinical diagnosis. RESULTS: Eighty-nine patients were included; median age was 57 years, and 71% were female. Among these, 19 patients were diagnosed with MDD during the interview. When comparing the self-reported scales, BEDS had a better performance compared with HADS-D (AUC 0.8541 vs. 0.7665). Limitations include a heterogeneous population and a limited sample size. SIGNIFICANCE OF RESULTS: The BEDS outperformed the HADS-D tool in discriminating patients with and without depression. A BEDS cutoff value of ≥5 is suggested as a case-finding score for depression in this population.

Snapshot of symptoms of advanced cervical cancer patients referred to the palliative care service in a cancer center in Mexico.

OBJECTIVE: To report the clinical and demographic characteristics of patients with advanced cervical cancer referred to the palliative care service (PC) at a major cancer center in Mexico. METHODS: This is a retrospective cohort study of patients with advanced cervical cancer referred to the PC of INCan, between January 2011 and December 2015. Demographic and clinical characteristics at the time of admission to the INCan, time to referral to PC, initial Edmonton Symptom Assessment System evaluation, and follow up were recorded. RESULTS: In all, 359 patients were included, median age 51 years, predominantly poor with low education. Most patients 322 (90%) received tumor-specific treatment; presence of nephrostomies and other tumor-related complication was frequent. Median time to referral was 335 days, more than 180 (50%) had five or more symptoms, pain and fatigue were the most prevalent. CONCLUSION: Women with advanced cervical cancer have a high burden of symptoms; PC is only considered at the end of life. Efforts for an early referral to PC should be made.

Associated factors of distress in patients with advanced cancer: A retrospective study.

OBJECTIVE: The objective of this study was to assess the psychosocial distress and associated factors in advanced cancer patients consulting at the outpatient Palliative Care Unit at the National Cancer Institute in Mexico City. DESIGN: A retrospective study was conducted using electronic records (June 2015 to December 2016). SAMPLE: A total of 646 patients with advanced cancer during their first visit to the outpatient palliative care unit at the National Cancer Institute in Mexico were evaluated using the Distress Thermometer (DT) and ECOG performance status scores. FINDINGS: Overall, 62% were women, with a median age of 57 years, and married (54.8%). The most frequent diagnosis was gastrointestinal cancer (28.6%), and 38.9% had a functional performance status of ECOG 2. The median DT score was 4.0 (IQR = 2-6), with 56% reporting DT scores ≥4. The three most frequent problems ≥4 were sadness (82.6%), feeling weak (81.2%), worry (79.6%), and <4 were feeling weak (57.7%), fatigue (55.6%), and financial security (52.1%). The variables associated with distress according to the multiple logistic regression analysis were problems with housing (OR = 2.661, 95% CI = 1.538-4.602), sadness (OR = 2.533, 95% CI = 1.615-3.973), transportation (OR = 1.732, 95% CI = 1.157-2.591), eating (OR = 1.626, 95% CI = 1.093-2.417), nervousness (OR = 1.547, 95% CI = 1.014-2.360), and sleep (OR = 1.469, 95% CI = 1.980-2.203). CONCLUSION: The principal factors were related to distress levels, housing problems, transportation issues, and emotional problems such as sadness, nervousness, lower functionality, and younger age. Therefore, psychosocial support is of considerable relevance in palliative care. These findings will help clinicians understand the distress of patients with advanced cancer in palliative care in Latin American countries.