Contribution of collegial support meetings (CSM) in the management of complex situations of patients with advanced cancer.

PURPOSE: Collegial support meetings (CSM) have been set up in the Gustave Roussy Cancer Center for inpatients whose complex care requires a multi-professional approach involving many participants: oncologists but also health-caregivers, a member of the palliative care team, an intensivist, and a psychologist. This study is aimed at describing the role of this newly multidisciplinary meeting implemented in a French Comprehensive Cancer Center. METHODS: Each week, the health-caregivers decide which situations should be examined, depending on the difficulty of a case. The discussion goes on to include the goal of treatment, the intensity of care, ethical and psychosocial issues, and the patient's life plan. Finally, to obtain feedback from the teams, a survey has been distributed to assess the interest in the CSM. RESULTS: In 2020, 114 inpatients were involved, and 91% were in an advanced palliative situation. During the CSMs, 55% of the discussions focused on whether to continue specific cancer treatment-29% about whether to continue invasive medical care-50% about optimizing supportive care. We estimate that between 65 and 75% of CSMs influenced further decisions. Death occurred during the hospitalization for 35% of the patients that were discussed. The lapse of time between last chemotherapy and death was 24 days (IQR, 28.5). CSMs were well received, since 80% of the teams find these meetings useful. CONCLUSIONS: CSMs reach conclusions for medical and nursing staff involved, in order to improve the management of inpatients with cancer in advanced palliative situation and to define the better goals of care.

[Implementation of a multimodal strategy for information and collection of advance directives in a comprehensive cancer center]. / Mise en place d'une stratégie multimodale d'information et de recueil des directives anticipées dans un Centre de lutte contre le cancer (CLCC).

INTRODUCTION: In France, advance directives (AD) remain unknown and underused by healthcare users and professionals. This is particularly true in oncology. This work was carried out with patients and caregivers of a Comprehensive Cancer Center to improve their appropriation and information. METHODS: The project, built by the Ethics Committee, the Patients Committee and the Palliative Care Team, made it possible to develop over 6 months a training program, an information procedure and several original documents. RESULTS: A total of 34 one-hour training courses for all professionals were organized. A procedure for making information available, including the right to draft ADs, has been implemented. This procedure is personalized, gradual and multi-professional. When a patient wishes to write his AD, he is accompanied by a dedicated team and benefits from a specific form, which enlighten values and preferences before addressing the desired level of therapeutic commitment. Communication elements were diffused, and a specific training on "anticipated discussions" was created. A dedicated space in the computerized chart makes it possible to locate the existence of ADs and to display them instantaneously. DISCUSSION - CONCLUSION: Based on the observation of the obstacles to the use of ADs, the strategy we implemented aims to provide information that is both efficient and ethically respectful for both patients and caregivers. ADs are only one element facilitating autonomy and anticipation, and must be associated with a shared continuous definition of the project and of the goals of care.

Development of a Decision-Aid Form (DAF) for the stratification of care in a French comprehensive cancer center, a tool to support identification of care goals.

BACKGROUND: For cancer patients, life-threatening complications may be difficult to anticipate, which can lead to complex medical decision-making processes. Since 2015, the Gustave Roussy Cancer Center has used a Decision-Aid Form (DAF), which contains an estimated gradation of care in cases where patients' conditions worsen. In this study, we assessed the acceptability of the DAF and the predictive value of the proposed stratification of care with regard to care delivered and patient's outcomes. METHODS: During a 5-month period, all patients who had been transferred from Site 1 to Site 2 of the hospital were prospectively included. RESULTS: A DAF was completed for 89.3% of the 206 patients included. Planned stratification of care was indicated in nearly all cases. The involvement of the palliative care team was indicated in only 29% of the DAF. The value of the WHO/ECOG Performance Status (PS) was limited. Finally, the field "information for patients and relatives" was infrequently completed. Although the possibility of transfer to the Intensive Care Unit was proposed for two-thirds of the patients, 76% of the 35 patients experiencing an acute event received only medical or palliative care. Overall, the level of therapeutic commitment suggested by the DAF was most often revised towards less aggressive care. CONCLUSIONS: The results of our study suggest that implementing an advanced stratification record is possible in a French cultural setting. To achieve complete cultural acceptance, our large integrated institutional program continues to play a key role in anticipating intent, tracing and sharing information with patients and their relatives.

[An updated synthesis of the international recommendations about the use of non-pharmacological interventions in the treatment of fatigue]. / Synthèse actualisée des recommandations internationales sur le traitement de la fatigue par des interventions non pharmacologiques.

INTRODUCTION: Fatigue is a frequent and disturbing symptom in oncology but remains undertreated. Given the absence of effective drug treatment, non-pharmacological interventions have a prominent place in the treatment of fatigue. However, they are relatively unknown by professionals who lack of clear points of reference to refer patients with confidence. This article aims to improve the knowledge about this therapeutic field through an updated synthesis of the levels of recommendations and available evidence. METHODS: A three-step approach was conducted, including (1) a synthesis of international guidelines on non-pharmacological interventions in the treatment of fatigue among adults in oncology, (2) a systematic review of recent data in the literature, (3) a comparison between the synthesis of guidelines and the systematic review with the aim of updating the levels of evidence. RESULTS: Five guidelines were synthesized; 111 systematic reviews were analyzed. Their comparison mainly showed: (1) a convergence in favor of the use of physical activity, educational interventions and cognitive-behavioral therapies, with levels of evidence ranging from moderate to high; (2) a consolidation of short-term efficacy evidence to support the use of mindfulness-based approaches and yoga; 3) the persistence of a lack of sufficiently reliable data to establish the efficacy of other types of intervention. DISCUSSION: Supported by international guidelines and recent data, the use of non-pharmacological interventions in the treatment of fatigue is critical and has to become better known.

Regulation of CD4(+)NKG2D(+) Th1 cells in patients with metastatic melanoma treated with sorafenib: role of IL-15Rα and NKG2D triggering.

Beyond cancer-cell intrinsic factors, the immune status of the host has a prognostic impact on patients with cancer and influences the effects of conventional chemotherapies. Metastatic melanoma is intrinsically immunogenic, thereby facilitating the search for immune biomarkers of clinical responses to cytotoxic agents. Here, we show that a multi-tyrosine kinase inhibitor, sorafenib, upregulates interleukin (IL)-15Rα in vitro and in vivo in patients with melanoma, and in conjunction with natural killer (NK) group 2D (NKG2D) ligands, contributes to the Th1 polarization and accumulation of peripheral CD4(+)NKG2D(+) T cells. Hence, the increase of blood CD4(+)NKG2D(+) T cells after two cycles of sorafenib (combined with temozolomide) was associated with prolonged survival in a prospective phase I/II trial enrolling 63 patients with metastatic melanoma who did not receive vemurafenib nor immune checkpoint-blocking antibodies. In contrast, in metastatic melanoma patients treated with classical treatment modalities, this CD4(+)NKG2D(+) subset failed to correlate with prognosis. These findings indicate that sorafenib may be used as an "adjuvant" molecule capable of inducing or restoring IL-15Rα/IL-15 in tumors expressing MHC class I-related chain A/B (MICA/B) and on circulating monocytes of responding patients, hereby contributing to the bioactivity of NKG2D(+) Th1 cells.

Scurvy in liver transplant patients.

We report on scurvy in 3 liver transplant recipients. Clinical presentation was limited to ecchymotic purpura and mild follicular keratosis with no mucosal involvement. Skin biopsies suggest vitamin C deficiency, which was confirmed by a low level of vitamin C in both sera and leukocyte specimens. Skin lesions dramatically improved within a few weeks after supplementation with ascorbic acid.