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. .

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

No disponible.

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.

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.

Ketamine as augmentation for the treatment of major depression and suicidal risk in advanced cancer: Case report.

OBJECTIVE: Major depressive disorder (MDD) is common in patients diagnosed with advanced cancer (AC), with a prevalence of 16.5%. It is associated with great disability and worsened quality of life, increased number and intensity of physical symptoms, and lower survival. It is the main factor for the presence of suicidal ideation. Antidepressants show modest efficacy, and response requires several weeks. Ketamine has demonstrated a fast and robust antidepressant effect in subanesthetic doses. This effect may prove useful in patients with AC, MDD, and suicidal risk. METHOD: We report a case of a patient with advanced cervical cancer who presented with uncontrollable pain, MDD, and a suicide attempt. RESULT: A 39-year-old woman diagnosed with cervical cancer stage IVB presented to the Emergency Department after a suicide attempt by hanging. Upon evaluation by the palliative care psychiatrist, she reported intense pain, unresponsive to analgesics, and had a history of persistent suicidal ideation. Antidepressant treatment was started (sertraline 50mg/d) after a single dose of ketamine hydrochloride IV (0.5 mg/kg) was administered. Treatment response was measured using the Brief Edinburgh Depression Scale before and after the intervention. The depressive symptoms decreased by 17% on day 1, 39% on day 3, and 72% on day 17. SIGNIFICANCE OF RESULTS: This case report shows ketamine's efficacy as an augmentation agent alongside conventional antidepressant treatment in patients with AC. Moreover, it shows rapid response in suicidal ideation that has not been achieved with treatment as usual. More clinical trials are needed to support the potential benefit and safety of ketamine in patients with AC, MDD, and persisting suicidal ideation.

Validation of the Brief Edinburgh Depression Scale (BEDS) in a Mexican population with advanced cancer in a palliative care service.

OBJECTIVE: Depression in palliative advanced cancer patients is common, but often goes unrecognized. One of the first steps toward improving detection is the development of tools that are valid in the specific language and setting in which they are to be used. The Brief Edinburgh Depression Scale (BEDS) is a sensitive case-finding tool for depression in advanced cancer patients that was developed in the United Kingdom. There are no validated instruments to identify depression in Mexican palliative patients. Our aim was to validate the Spanish-language version of the BEDS in Mexican population with advanced cancer. METHOD: We conducted a cross-sectional study with outpatients from the palliative care unit at the Instituto Nacional de Cancerología in Mexico City. The Mexican BEDS was validated against a semistructured psychiatric clinical interview according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, classification criteria for major depressive disorder. The interviewer was blind to the BEDS score at the time of the assessment. RESULT: Seventy subjects completed the scale and interview. Women represented 71.4% of the sample and median age of subjects was 56.5 years (range, 20-85 years). The prevalence of major depressive disorder according to the psychiatric interview was 20%. The most valid cutoff for defining a case of depression was a score ≥5 of 18 on the Mexican BEDS, which gave a sensitivity of 85.7% and specificity of 62.5%. The scale's Cronbach's alpha was 0.71. SIGNIFICANCE OF RESULTS: Major depressive disorder is frequent in Mexican palliative patients. The Spanish-language Mexican version of the BEDS is the first valid case-finding tool in advanced cancer patients in this setting.

Assessment and Impact of Phase Angle and Sarcopenia in Palliative Cancer Patients.

Sarcopenia has been evaluated as a separate condition in cancer patients and as an important indicator of adverse outcomes. Muscle mass and phase angle are usually quantified by bioelectrical impedance analysis, due to its lower cost, and availability. The aim of this study was to assess the impact of sarcopenia, phase angle, and other characteristics on overall survival (OS) in palliative cancer patients at the National Cancer Institute of Mexico. We enrolled 628 patients (female, 59%). The most frequent disease was gastric cancer (39.5%). Kaplan-Meier analysis showed a significant survival disadvantage for patients with sarcopenia compared to patients without sarcopenia (p = 0.02). Sarcopenia univariably predicted OS [HR 1.4 (95% CI, 1.1-1.8), p = 0.001], but was not significant in multivariable Cox-regression analysis (p = 0.08). Significant predictors for sarcopenia in multivariable Cox-regression analysis were sex, age, body mass index, phase angle, clinical symptoms, and Karnofsky. Our results corroborate the reliability of sarcopenia and phase angle in Mexican population, showing that the measurement of these parameters might also be useful in early-stage cancer patients as prognostic markers.

Phase Angle of Bioelectrical Impedance Analysis as Prognostic Factor in Palliative Care Patients at the National Cancer Institute in Mexico.

Patients with advanced cancer often experience symptoms of disease and treatment that contribute to distress such as weight loss, which is present in up to 85% of cancer patients. Palliative care in these patients focuses on care aimed at improving quality of life. Phase angle (PA) is obtained by bioelectric impedance analysis (BIA) and is associated with cellular function. It is considered a reliable marker of malnutrition. A low PA may suggest deterioration of the cell membrane, which in palliative patients may result in a short-term survival. The aim of this study was to associate PA and survival in palliative patients of the National Cancer Institute of Mexico. We included 452 patients (women, 56.4%); the average PA was 4.0°. The most frequent disease was gastric cancer (39.2%). Mean body mass index (BMI) was 22.84. The average survival of patients with PA ≤ 4° was 86 days, while in the group with PA > 4°, it was 163 days (P > 0.0001). PA showed significant positive correlation with survival time and BMI. Our results corroborate the reliability of PA in Mexican population, as an indicator of survival in palliative care patients compared to the reported literature in other countries.

Bispectral Index monitoring in cancer patients undergoing palliative sedation: a preliminary report.

INTRODUCTION: Continuous palliative sedation (PS) is currently titrated based on clinical observation; however, it is often unclear if patients are still aware of their suffering. The aim of this prospective study is to characterize the level of consciousness in patients undergoing PS using Bispectral Index (BIS) monitoring. PATIENTS AND METHODS: We enrolled consecutive patients with refractory symptoms requiring PS. We documented the level of sedation using Ramsay Sedation Scale (RSS) and BIS at 0, 2, 4, 6, 12, and 24 h during the first day of PS and examined their degree of association. Intravenous midazolam or propofol was titrated according to the sedation level. RESULTS: Twenty patients on PS were recruited and had BIS continuous monitoring. Delirium was the most frequent reason for PS (n = 15, 75%). The median time of sedation was 24.5 h (interquartile range 6-46). The average time to achieve the desired sedation level was 6 h, and dose titration was required in 80% of the cases. At baseline, 14 (70%) patients were considered to be awake according to RSS (i.e., 1-3) and 19 (95%) were awake according to BIS (i.e., >60%). This proportion decreased to 31 and 56% at 4 h, 27% and 53 at 6 h, and 22 and 33% at 24 h. RS and BIS had moderate correlation (rho = -0.58 to -0.65); however, a small proportion of patients were found to be awake by BIS (i.e., ≥60%) despite clinical observation (i.e., RSS 4-6) indicating otherwise. CONCLUSIONS: The BIS is a noninvasive, bedside, real-time continuous monitoring method that may facilitate the objective assessment of level of consciousness and dose titration in patients undergoing PS.

Integrated oncology and palliative care: five years experience at the National Cancer Institute of Mexico.

Under the national plan for addressing cancer, prevention and detection play important roles. However, the cost of treatments and late diagnosis represent a significant burden on health services. At the National Cancer Institute, more than half of patients present with tumors in advanced stages, and approximately 10% of patients seen for the first time exhibit terminal-stage malignancies, where there are no feasible cancer treatment options, and the patients are instead admitted to the hospital exclusively for palliative symptomatic management. In 2010, the National Cancer Plan began implementing a model of integrative management of palliative care in oncology that has gradually come to include symptomatic palliative care, involving ambulatory, distant and hospitalized management of patients with cancer, in its final stages and, more recently, in earlier stages.

[National consensus of diagnosis and treatment of non-small cell lung cancer]. / Consenso nacional de diagnóstico y tratamiento del cáncer de pulmón de células no pequeñas.

Mexican specialists in oncology, oncologic surgery, thoracic surgery, pneumology, pathology, molecular biology, anesthesiology, algology, psychology, nutrition, and rehabilitation (all of them experts in lung cancer treatment) in order to develop the National Consensus on Lung Cancer. The consensus has been developed as an answer to the need of updated Mexican guidelines for the optimal treatment of the disease, as well as to the requirements that such guidelines be established by multidisciplinary panel, depicting the current attention given to cancer lung cases in Mexico. Thus, this paper analyses the epidemiological review, screening, diagnosis, staging, pathology, translational medicine, and the suitable therapies for early, locally advanced, and metastatic disease in the first, second, and third lines of management, as well as rehabilitation and palliative measures.

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.

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.

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.