Palliative Care Interventions and End-of-Life Care for Patients with Metastatic Breast Cancer: A Multicentre Analysis.

BACKGROUND: The aim of this study was to describe the implementation of integrated palliative care (PC) and the intensity of care in the last 3 months before death for patients with metastatic breast cancer. MATERIALS AND METHODS: We conducted a multicentric study of all adult patients with metastatic breast cancer who died over a 4-month period. Complete data were collected and checked from clinical records, including PC interventions and criteria regarding EOL care aggressiveness. RESULTS: A total of 340 decedent patients from 12 comprehensive cancer centres in France were included in the study. Sixty-five percent met the PC team with a median time of 39 days between the first intervention and death. In the last month before death, 11.5% received chemotherapy, the frequency of admission to intensive care unit was 2.4%, and 83% experienced acute hospitalization. The place of death was home for 16.7%, hospitalization for 63.3%, PC unit for 20%. Univariate and multivariate analyses showed factors independently associated with a higher frequency of chemotherapy in the last month before death: having a dependent person at home, meeting for the first time with a PC team < 30 days before death, and time between the first metastasis and death below the median. CONCLUSION: PC team integration was frequent and late for patients with metastatic breast cancer. However, PC intervention > 30 days is associated with less chemotherapy in the last month before death. Further studies are needed to better understand how to implement a more effective mode of PC integration for patients with metastatic breast cancer.

[Integrative oncology: Report and place for a dedicated consultation in a comprehensive cancer center]. / L'oncologie intégrative : état des lieux et place d'une consultation dédiée dans un centre de lutte contre le cancer.

Progress in the care of cancer patients has brought out new needs that go beyond the scope of conventional medicine regularly. Integrative oncology allows patients, besides specific care, to access complementary therapies (CT); with the aim of improving in this case the quality of life and the future of the patients and to help them become actors, before, during and after the treatment of their cancer. As for breast cancer management, international recommendations have been given for several years in favor of the use of CT, especially mind-body therapies, and regarded as effective care. Being able to refer patients suffering from any tumors to CT, through a structured procedure, integrated into the care pathway, would improve overall cancer management and the quality of life of the patients during chemotherapy. Improved communication from the oncologist about CT could better the relationships between the oncologist and the patient, and would be a better way to reduce the choice of practices that might be at risk, while improving compliance with conventional treatment. In this context, we report the opening of an integrative oncology consultation within a comprehensive cancer center, detailing the procedure of the consultation, describing the patients and their expectations, as well as the proposals made to them. This type of consultation is still underdeveloped in France and will be the subject of studies in the field of Humanities and social sciences.

Reasons for acceptance and refusal of early palliative care in patients included in early-phase clinical trials in a regional comprehensive cancer centre in France: protocol for a qualitative study.

INTRODUCTION: A few studies have highlighted the potential synergy between early palliative care and inclusion in an early-phase clinical trial that may improve quality of life, reduce symptoms of exhaustion related to the side effects of treatment and allow patients to complete their treatment protocol. The primary objective of this qualitative study is to evaluate the reasons for acceptance or refusal of early palliative care in patients included in early-phase clinical trials. METHOD AND ANALYSIS: All patients from the Centre Léon Bérard (Comprehensive Cancer Centre in Lyon, France) who consent to one of the early-phase clinical trials proposed at the centre will be invited to participate in this study. The cohort will consist of a subgroup (n=20) of patients who accept palliative care together with their clinical trial, and a second subgroup (n=20) of patients who decline it. Patients will be interviewed in exploratory interviews conducted by a psychology researcher before the start of their clinical trial. The interviews will be audio-recorded. Patients will also be asked to complete quality of life and anxiety/depression questionnaires both before the beginning of the treatment and at the end of their clinical trial. The content of the interviews will be analysed thematically. Descriptive and comparative statistical analysis of both cohorts will also be conducted. ETHICS AND DISSEMINATION: Personal data will be collected and processed in accordance with the laws and regulations in force. All patients will give informed consent to participate. This study complies with reference methodology MR004 of the Commission Nationale de l'Informatique et des Libertés. The protocol has received the validation of an ethics committee (Groupe de Réflexion Ethique du CLB, number: 2020-006). The results will be disseminated through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04717440.

Issues of mindfulness implementation for oncology caregivers.

OBJECTIVES: Burn out is high in oncology. We aim to evaluate the feasibility and identify the barriers for mindfulness implementation in oncology professionals. METHODS: We conducted a pilot study in which voluntary oncology caregivers entered mindfulness workshops, and complete online questionnaires. We also conducted a qualitative study to better identify the practical reasons which hamper the implementation of mindfulness in oncology caregivers having refused to participate. RESULTS: 83.3% of volunteers for the workshops were women, 60.00% (16/30) of caregivers completed the program. Caregivers' resistances to mindfulness practice were: a lack of availability and information, complex organisation with limited free time, and accept spending time to take care of themselves. CONCLUSIONS: This work highlights the interest of mindfulness for caregivers in oncology, we have identified specific issues hindering the implementation of such technique which can be further investigated.

[Scientific medicine and care relationship: From the therapeutic alliance to the therapeutic effect of the alliance]. / Médecine scientifique et relation de soin : de l'alliance thérapeutique à l'effet thérapeutique de l'alliance.

The new paradigm of precision medicine in oncology questions today the respective place of evidence-based medicine and doctor-patient relationship. Based on the results of a randomized study comparing the efficacy of a homeopathic molecule in the prevention of nausea and vomiting induced by chemotherapy in non-metastatic breast cancer, this article extends and develops the discussion of maintaining an unresolved tension between medical art and medical science, between care and cure. This tension sets a base for the authors of the therapeutic alliance in medicine, defined as a dialectic constantly adjourned between the alliance of the doctor with the patient and his therapy, and the therapeutic effect of this alliance. Because if a policy or a public opinion were to promote an exclusively rational medicine deprived of the field of relation to care, or on the contrary a medicine based only on clinical sense and intuition, then respectively the ethics of care and the progress of therapy would be threatened. It is advisable to be aware of erring from the truth, amplified today by social networks, as much due to a tide of scientific positivism, as an excess of the "good caring soul". Taking into account the therapeutic alliance makes it possible to no longer oppose scientific medicine and care relationship.

Second primary cancers: a retrospective analysis of real world data using the enhanced medical research engine ConSoRe in a French comprehensive cancer center.

BACKGROUND: Second primary cancers (SPC) account for 18% of all cancers. We used the enhanced medical/health data mining tool ConSoRe to search aggregated data, analyze electronic patient records (EPR), and better characterize patients with SPC. METHODS: This retrospective cohort study used ConSoRe to identify EPRs from patients with SPC referred to the regional cancer center Leon Bérard from 1993 to 2017, and examined characteristics of patients with SPC, frequencies of first primary cancer (FPC) localization in the global population of patients with SPC, and time to SPC. Data set was extracted on January 1, 2018. RESULTS: Among 296,530 EPRs, we identified 157,187 patients with FPC, including 13,002 (8%) patients with SPC. Between 2000 and 2010, the rate of SPC was 34%, and 52% of SPC were identified in the last years (2010-2017). In men, main cancers were head and neck cancer, lymphoma, and prostate carcinoma accounting for 15.6%, 12.8%, and 10.5% of FPC, while the three most common SPC were head and neck cancer (13.2%), lung cancer (11.8%) and lymphoma (9.2%). In women, breast cancers, lymphoma, and skin cancers accounted for 48.8%, 8%, and 5.1% of first cancers, and for 31.1%, 7% and 6% of SPC. CONCLUSION: The data mining tool ConSoRe contributes to access to real world data, and to better characterize patients with SPC. Expanding such approach to any comprehensive center will allow a global overview of the follow-up of patients with cancer, and help to improve long-term management and adapt surveillance.

PALLIA-10, a screening tool to identify patients needing palliative care referral in comprehensive cancer centers: A prospective multicentric study (PREPA-10).

PURPOSE: The identification and referral of patients in need of palliative care should be improved. The French society for palliative support and care recommended to use the PALLIA-10 questionnaire and its score greater than 3 to refer patients to palliative care. We explored the use of the PALLIA-10 questionnaire and its related score in a population of advanced cancer patients. METHODS: This prospective multicentric study is to be conducted in authorized French comprehensive cancer centers on hospitalized patients on a given day. We aimed to use the PALLIA-10 score to determine the proportion of palliative patients with a score >3. Main secondary endpoints were to determine the proportion of patients already managed by palliative care teams at the study date or referred to palliative care in six following months, the prevalence of patients with a score greater than 5, and the overall survival using the predefined thresholds of 3 and 5. RESULTS: In 2015, eighteen French cancer centers enrolled 840 patients, including 687 (82%) palliative patients. 479 (69.5%) patients had a score >3, 230 (33.5%) had a score >5, 216 (31.4%) patients were already followed-up by a palliative care team, 152 patients were finally referred to PC in the six subsequent months. The PALLIA-10 score appeared as a reliable predictive (adjusted ORRef≤3 : 1.9 [1.17-3.16] and 3.59 [2.18-5.91]) and prognostic (adjusted HRRef≤3  = 1.58 [95%CI 1.20-2.08] and 2.18 [95%CI 1.63-2.92]) factor for patients scored 4-5 and >5, respectively. CONCLUSION: The PALLIA-10 questionnaire is an easy-to-use tool to refer cancer inpatients to palliative care in current practice. However a score greater than 5 using the PALLIA-10 questionnaire would be more appropriate for advanced cancer patients hospitalized in comprehensive cancer center.

[Osteopathy for chronic pain after breast cancer surgery: A monocentric randomised study]. / Étude randomisée monocentrique évaluant l'efficacité de l'ostéopathie dans la prise en charge des douleurs chroniques après chirurgie mammaire en oncologie.

Twenty-five to 65% of patients suffer from chronic pain after breast cancer. The treatment combines analgesic drugs and psychophysical techniques. HYPOTHESIS: Osteopathy improves the control of pain and the quality of life of patients. METHODS: This randomized prospective single center study allocated patients to the initiation of a standard analgesic treatment exclusively (arm A) or associated to osteopathy (arm B) between from 1 to 12months after surgery. MAIN OBJECTIVE: Intensity of pain (VAS at three months [j90]). SECONDARY OBJECTIVES: Pain (VAS) at 6 and 12 months, analgesic consumption, anxiety/depression (HADS), and Quality of life (QLQ-C30). Eighty patients were planned to observe a 2-point difference in VAS (5% bilateral alpha, 90% power). RESULTS: Twenty-eight patients (A: 14; B: 14, median age 50 years) were included from April 2011 to February 2014; the study was stopped due to a too slow recruitment. No difference in the VAS pain score between arms was observed at j90 (P=0.258), nor at 6 and 12 months. At j90, the HADS depression score was reduced in arm B (P=0.049). Improvement in the overall score of quality of life (P=0.015), and reduced pain sub-score (P=0.021) were observed at j90 in arm B. DISCUSSION: Patients are strongly seeking complementary therapies. Few studies exist. Our study has encountered major recruitment difficulties therefore limiting the interpretation of the results. Despite the absence of difference in the main objective, some other scores (QOL, depression) are noteworthy in favor of osteopathy. Further multicentric studies are needed.

[Pain and cancer Information dedicated to cancer patients and relatives]. / Douleur et cancer Informations à l'usage des personnes malades et de leurs proches.

Patient information is a major challenge for public health. It has become part of the patients' rights, in response to their need for information and involvement in medical decision-making. Since 1998, the French National Federation of Comprehensive Cancer Centres (FNCLCC) has developed an information and education program dedicated to patients and relatives: the SOR SAVOIR PATIENT program. The methodology of the program adheres to the quality criteria established for the elaboration of documents containing patient information. The SOR SAVOIR PATIENT guide Pain and Cancer aims to answer patients' questions regarding cancer specific pain and to help them become actively involved in their care. It was elaborated by a multidisciplinary workgroup, which included methodologists, one linguist, pain specialists and twenty patients and relatives. Patients' information needs and personal experience of pain were assessed using focus groups, semi-structured interviews and questionnaires. Through eight chapters, which can be read in an independent way, Pain and cancer provides key information on the causes, the mechanisms, the evaluation, the prevention and the treatment of pain. The guide also presents advices and practical tools to facilitate the assessment of the pain and the communication between patients and professionals. Finally, this guide aims to overcome ideas such as that morphine is synonymous of end of life or drug addiction, that pain is a sign of aggravation of cancer and that nurses know how to detect the pain. Intended first for the patients and their close relations, Pain and Cancer is also a useful tool for health professionals. Indeed, it presents knowledge based on the most recent recommendations developed for clinical practice. Thanks to a wide distribution of the guide to patients, their families and the professionals, we trust that this guide will facilitate dialogue around pain, and ultimately its care. This article is an abstract of the guide. The complete SOR SAVOIR PATIENT guide can be downloaded from the SOR website at: www.sor-cancer.fr.

[Therapeutic education in oncology: involving patient in the management of cancer]. / L'éducation thérapeutique en cancérologie: vers une reconnaissance des compétences du patient.

The notion of therapeutic education was only recently introduced in cancer. Although the term is commonly used, no standard definition exists for the concept and principles of therapeutic education and its efficacy remains to be assessed. Therapeutic education is complementary to the healthcare approach and aims to get the patients more involved in their disease and the treatment decision-making process. This discipline, placed at the interface of human and social sciences, was first developed for the management of chronic diseases (diabetes, asthma). It derives from the principle that involving patients in their own care and management can help them better adjust to life with a chronic disease. The lengthening survival time of cancer patients, which contributes to making cancer a chronic disease, as well as changes in the patient-caregiver relationship contribute to the development of therapeutic education in cancer. Pilot studies, conducted principally in the United States, evaluating the side effects of chemotherapy and the management of pain, have demonstrated that such educational programs could improve patient quality of life and decrease the side effects of treatments. The success of these programs depends on several parameters: taking into account patient's opinion in the elaboration and preparation of the programs; involving skilled multidisciplinary teams engaged in iterative educational actions; having recourse to methodological tools to evaluate the impact of implemented programs. Consistent with the World Health Organization guidelines, research should be conducted in France in order to elaborate and implement cancer-specific education programs and evaluate their potential benefit. Patient education programs on pain, fatigue, nutrition and treatment compliance are currently being developed at Saint-Etienne Regional Resource Centre for cancer information, prevention and education, within the framework of the Canceropole Lyon Auvergne Rhône-Alpes.

[Organisational diagnosis of a home care-coordinating unit in oncology: which choices for the comprehensive cancer center of Lyon?]. / Diagnostic organisationnel d'un service hospitalier de coordination des soins à domicile en cancérologie. Quels choix stratégiques pour le Centre régional de lutte contre le cancer de Lyon?

Lyon comprehensive cancer center developed a home care-coordinating unit (HCCU) allowing a wide range of cancer care at home. We present the results of an organisational and strategical analysis of the unit, in relation with internal and external contexts. We describe the functioning of the unit, modelled from the daily follow-up of professionnels. Patient discharge is initiated by the oncologist at the inpatient clinic, at the day-hospital or at outpatient visit. After consent of the patient and relatives, the HCCU (nurses and medical oncologists) evaluates patient's needs, organises hospital discharge (contacts with community nurses and general practitioner, supply of medical appliances and drugs), and provides follow-up and counselling to patient and caregivers. The HCCU works in a challenging environment, with both partners and competitors. Within the hospital, it collaborates with all other units. Outside the hospital, partners are, besides patients themselves; general practitioners and community nurses home care agencies and network services, private medical appliance providers, and public health authorities. The unit might evolve towards formal home hospitalisation or community-hospital network. Collaboration of both structure closely associated with hospital could allow to provide continuous and graduated care by the same caregivers even if administrative structures change.

Factors predicting home death for terminally ill cancer patients receiving hospital-based home care: the Lyon comprehensive cancer center experience.

This study aimed to determine factors favoring home death for cancer patients in a context of coordinated home care. A retrospective study was conducted among patients followed up by the home care coordinating unit of the cancer center of Lyon. The main endpoint was place of death. Univariate analysis included general characteristics (age, gender, rural or urban residence, disease), Karnofsky Index (KI), type of care at referral (chemotherapy, palliative care, or other supportive care), and coordinating medical oncologist (MCO) home visits. Significant factors were used in a logistic regression analysis. Of 250 patients, 90 (36%) had home death. Low KI and MCO home visit were correlated with home death (odds ratio, respectively, 2.1 and 3.1). These results indicate that health care support favors home death. A hospital-based home care unit is effective for bridging the gap between community and hospital. MCO home visits offer concrete support to health care professionals, patients, and relatives.