Neuropalliative care in a tertiary-level hospital.

OBJECTIVES: Palliative care in neurology is a recent specialty to improve the quality of life of patients with severe neurological diseases. This study aims to determine the frequency of neurological inpatients who had indication of palliative care, and evaluate the symptomatology, demographic profile, the need for supportive measures, advance directives for life and medical history of patients in a tertiary hospital in Brazil. METHODS: This cross-sectional analytical study evaluated all patients admitted to the neurological semi-intensive care unit (ICU) at Hospital Israelita Albert Einstein with neurological conditions from February through August 2022. The Palliative Performance Scale (weight loss greater than 5% associated with body changes and a negative response to the question: 'Would you be surprised if the patient died within 1 year?') was used to indicate palliative care. Patients were divided into three groups: patients with palliative care needs (groupindication), patients without palliative care needs (groupwithout indication) and patients who received at least one assessment of a palliative care team (grouppalliative). Demographic data were analysed using the Χ2 test for qualitative and Kruskal-Wallis test for quantitative variables. RESULTS: Of the 198 patients included in the study, 115 (58%) had palliative care needs. Only 6.9% received assessment by the palliative care team, and 9.56% had advance directives in their medical records. Patients in groupindication had a higher prevalence of symptoms, such as fatigue, depression, shortness of breath and lack of appetite, and required more supportive measures, such as oxygen therapy, enteral/parenteral nutrition, admissions at ICU and days in hospital. CONCLUSION: Despite the high demand for palliative care in neurology, few patients receive this treatment, resulting in decreased quality of care. Therefore, greater integration and discussion of palliative care in neurology are needed.

A Comparison of Caregiver Burden of Patients with Advanced Cancer in Different Palliative Cancer Care Settings.

Background: Informal caregivers may experience a significant burden while caring for cancer patients. Little is known about how caregiver burden varies across different palliative cancer care settings and the factors influencing it. Objectives: We compared the severity of caregiver subjective stress burden (emotional impact) among caregivers of patients seen in the outpatient supportive care center (SCC) with those being cared for in the acute palliative care unit (PCU). Secondary aims were to compare other caregiver burden dimensions, quality of life, and any association of caregiver subjective stress burden to various patient and caregiver factors. Setting and Design: Eligible patients and their informal caregivers in the SCC or PCU at a comprehensive cancer center in the USA were approached and enrolled. The Montgomery-Borgatta Caregiver Burden Scale and the Short-form 36 were used to measure burden and quality of life. Multivariate general linear regression was employed to evaluate the effect of covariates on subjective stress burden. Results: Ninety-eight dyads in the SCC and 74 dyads in the PCU were enrolled. PCU caregivers reported worse subjective stress burden (p = 0.0029) and mental health (p = 0.0299). Multivariate analysis showed correlations between subjective stress burden and caregivers' objective burden (p = 0.0136), subjective demand burden (p ≤ 0.0001), mental health (p = 0.0074), duration of caregiving (p = 0.0680), education (p = 0.0192) and with patients' anxiety (p = 0.0003) and current/recent cancer treatment (p = 0.0579). Conclusion: PCU caregivers demonstrated worse emotional burden and mental health than those in the SCC. More research is needed to tailor interventions for various caregiver burden dimensions. NCI Clinical Trial Registration Number ID: NCI-2019-01197.

Patients' Perspective of Timeliness and Usefulness of an Outpatient Supportive Care Referral at a Comprehensive Cancer Center.

CONTEXT: Current guidelines recommend early referral to palliative care for patients with advanced cancer; however, no studies have examined the optimal timing of referral from the patients' perspective. OBJECTIVES: To examine patients' perceptions of timeliness of referral and its association with survival among patients with advanced cancer referred to an outpatient supportive care (SC) clinic. METHODS: This cross-sectional prospective study in an SC clinic at a comprehensive cancer center included patients aged 18 years or older with locally advanced, recurrent, or metastatic cancer. Patients were asked to complete an anonymous survey regarding the timeliness and perceived usefulness of SC referral within four weeks of their first SC consultation. RESULTS: Of 253 eligible patients, 209 (83%) enrolled in the study and 200 completed the survey. Median survival was 10.3 months. Most patients (72%) perceived that referral occurred "just in time," whereas 21% felt it was "late," and 7% felt "early." A majority (83%) found the referral useful, and 88% would recommend it to other patients with cancer. The perception of being referred early was associated with lower reported levels of pain (P = 0.043), fatigue (P = 0.004), drowsiness (P = 0.005), appetite loss (P = 0.041), poor well-being (P = 0.041), and lower physical (P = 0.001) and overall symptom distress (P = 0.001). No other associations were found between perceived timeliness and usefulness and patients' baseline characteristics. CONCLUSION: Most patients with a median survival of 10 months perceived that SC referral was timely and useful. Patient care needs rather than the timing of advanced cancer diagnosis drove this perception of referral timing. Lower symptom burden was associated with the perception of being referred to early.

Timing of palliative care access and outcomes of advanced cancer patients referred to an inpatient palliative care consultation team in Brazil.

OBJECTIVE: Little is known about the outcomes of cancer patients referred to palliative care (PC) teams in developing countries. Our aim was to examine the timing of PC access and outcomes of patients with advanced cancer referred to an inpatient PC consultation team in Brazil. METHOD: Retrospective study of consecutive patients with advanced cancer admitted to a tertiary care general hospital (April 2015-December 2016) and referred for the first time to an inpatient PC consultation team. Patients' demographics, clinical features, time from first consult to death or discharge, and outcomes on medication use, clinical interventions, and end-of-life preferences were retrieved. An analysis was performed before and after PC. RESULT: One hundred eleven patients were included. Median age was 68; 72% had an Eastern Cooperative Oncology Group performance status ≥3. The median timing of PC access was 9 days (first interquartile = 3, third interquartile = 19). The use of analgesics (from 75% to 85%, p = 0.001) and opioids (from 50% to 73%, p < .001) increased. A lower proportion was receiving antibiotics (68% vs 48%, p < 0.001), thromboprophylaxis (44% vs 26%, p < 0.001), antihypertensives (28% vs 15%, p = 0.001), and antiemetic agents (64% vs 54%, p = 0.027). Chemotherapy use was lower (39-25%, p < 0.001). More patients had an end-of-life preference (39% to 25%, p < 0.001) and were not willing to receive intubation (32% vs 60%, p < 0.001), intensive care treatment (30% vs 55%, p < 0.001), cardiopulmonary resuscitation (35% vs 62%, p < 0.001), and artificial nutrition (22% vs 34%, p < 0.001). SIGNIFICANCE OF RESULTS: Although PC referrals occurred exceedingly late during the cancer disease trajectory, positive changes were observed in medication profiles, clinical interventions use, and end-of-life preferences of patients with advanced cancer referred to a specialized inpatient PC consultation team in Brazil. Further efforts are needed to improve early palliative cancer care in developing countries.

Anti-cytokines in the treatment of cancer cachexia.

Cancer-related cachexia (CRC) is a multidimensional, frequent and devastating syndrome. It is mainly characterized by a loss of skeletal muscle tissue, accompanied or not by a loss of adipose tissue that leads to impaired functionality, poor quality of life, less tolerability to cancer-directed therapies, high levels of psychosocial distress, and shorter survival. Despite its clinical importance, there is a lack of effective pharmacological therapies to manage CRC. Pro-cachectic cytokines have been shown to play a critical role in its pathogenesis, providing the conceptual basis for testing anti-cytokine drugs to treat this paraneoplastic syndrome. The aim of this review was to examine the current evidence on anti-cytokines in the treatment of CRC. Several anti-cytokine agents targeting one or more molecules (i.e., TNF-alpha, IL-1 alpha, IL-6, and others) have been investigated in clinical trials for the treatment of CRC, mainly in phase I and II studies. Results have been mixed, and few drugs have demonstrated positive effects in larger phase III trials. Thalidomide, a derivative of glutamic acid with anti-inflammatory, immunomodulatory, and anti-angiogenic properties, and MABp1, a natural IgG1k human monoclonal antibody against IL-1 alpha, have shown the most prominent clinical benefits. Studies have recruited heterogeneous cancer patient populations in late disease stages, and many had issues with accrual and attrition. Anti-cytokines remain a promising treatment strategy in the treatment of CRC. Agents targeting multiple CRC cytokines and pathways, while also possessing anti-tumor effects, such as thalidomide and MABp1, have attained the most interesting outcomes, and warrant further investigation. Future studies including more homogenous populations, using valid and clinically meaningful outcome measures and testing low toxicity drugs in earlier stages of the cancer cachexia continuum might achieve better results.

Changes in the Care Setting of First Consults to Palliative and Supportive Care Over a Seven-Year Period.

CONTEXT: Optimal benefits from palliative care (PC) are achieved when first consults (PC1) occur early, in the outpatient setting. Late PC1, like those in the intensive care unit (ICU), limit these benefits. OBJECTIVES: The objective of this study was to determine the proportion of PC1 over time in the outpatient, ICU, and inpatient non-ICU settings. We also examined patients' baseline characteristics and the timing of PC access (from PC1 to death) by the setting of PC1. METHODS: We retrospectively evaluated consecutive cancer patients' records at our cancer center to ascertain the annual number of PC1 and its distribution across settings (2011-2017). ICU PC1 (n = 309) and a random sample of an equal number of outpatient and inpatient non-ICU PC1 were reviewed to retrieve patients' characteristics and death date. RESULTS: PC1 total annual number increased by 58% from 2011 (n = 2286) to 2017 (n = 3615). We found a significant decrease in the proportion of ICU PC1 (from 2.3% in 2011 to 1% in 2017, P < 0.001). There were no significant changes in the proportion of PC1 at outpatient versus inpatient settings (P = 0.2). Hematologic cancer patients were more likely to have an ICU PC1 (P < 0.001). Median survival (months) was 7.7 (6.3-9.7), 3.4 (2.4-4.5), and 0.1 (0.1-0.1) for outpatient, inpatient, and ICU, respectively (P < 0.01). CONCLUSION: PC1 total annual number has increased, and the proportion of PC1 at ICU, a very late clinical setting, is decreasing. Further efforts are needed to integrate PC in hematologic cancer care.

Outcomes of Embedded Palliative Care Outpatients Initial Consults on Timing of Palliative Care Access, Symptoms, and End-of-Life Quality Care Indicators among Advanced Nonsmall Cell Lung Cancer Patients.

OBJECTIVE: To determine the timing of palliative care (PC) access, symptoms, and end-of-life (EOL) quality care outcomes of patients with advanced nonsmall cell lung cancer (NSCLC) referred to outpatients embedded palliative care consults (EPC) compared with those of outpatients palliative care consults (OPC). BACKGROUND: There are no studies comparing the outcomes of outpatients EPC consults with those of stand-alone OPC consults among patients with NSCLC. DESIGN: The design consists of a random sample of OPC consults (January 2009 to July 2012) and EPC consults (August 2012 to June 2013) at MD Anderson Cancer Center. After the initial consult, all EPC follow-ups occurred at the OPC clinic. MEASUREMENTS: Patients' characteristics, symptoms (assessed by Edmonton Symptom Assessment Scale), time from referral to first consult, overall survival from consult to death, and EOL quality care outcomes (ICU admissions, emergency center visits, hospitalizations within last 30 days, cancer treatments within last 14 days, hospice referrals, advanced care planning [ACP] discussions, and completion of advanced directives) were reviewed. RESULTS: A total of 340 consults were included (EPC consults = 147). Baseline Eastern Cooperative Oncology Group status (2.2 vs. 1.9, p < 0.001) and median pain (6 vs. 5, p = 0.038) were higher among EPC consults. In EPC consults, time from referral to first consult was shorter (median: 0 day vs. 7 days, p < 0.001), and ACP discussions occurred more frequently (90% vs. 77%, p = 0.026), and earlier (median: 2 month vs. 1 month before death, p = 0.018). No other significant differences in symptoms, EOL outcomes, or survival were observed. CONCLUSIONS: EPC consults plus OPC follow-ups accessed PC earlier, and had more frequent and earlier ACP discussions as compared with OPC consults. Embedded palliative cancer care might not be the ideal model for an initial PC consultation. Further research is necessary.

Association between Advanced Cancer Patients' Perception of Curability and Patients' Characteristics, Decisional Control Preferences, Symptoms, and End-of-Life Quality Care Outcomes.

BACKGROUND: There are limited studies on factors associated with cancer patients' perception of curability. OBJECTIVE: To examine advanced cancer patient's perception of curability and its association with patient's sociodemographic and clinical characteristics, decisional control preference (DCP), symptoms, and end-of-life quality care outcomes. DESIGN: Secondary analysis of a study to determine the DCP and illness understanding of advanced cancer patients receiving palliative care (PC). MEASUREMENTS: Data of the Illness Understanding survey, the Control Preference Scale, and demographics, symptoms, and end-of-life quality care outcomes were reviewed. RESULTS: Of 121 patients, 104 (86%) were evaluable. Median age was 56 years, 60% were women, and 64% had a Karnofsky performance status ≤60. Thirty-seven percent inaccurately reported that their cancer was curable. Patients with accurate perception were more likely to choose a passive DCP (20% vs. 2.6%, p = 0.04). An accurate perception of curability was associated with a longer time from advanced cancer diagnosis to PC referral (odds ratio [OR] = 1.04, p = 0.04). There was a trend toward an association between inaccurate perception of curability, male gender (OR = 0.29, p = 0.09), and intensive care unit admission within 30 days of death (OR = 0.26, p = 0.09). No other significant associations between perception of curability and patients' demographics, clinical characteristics, symptoms, or end-of-life quality care outcomes were found. CONCLUSIONS: Thirty-seven percent of advanced cancer patients receiving PC inaccurately perceived their disease curable. These patients were more likely to have earlier PC referrals. An accurate perception of curability was associated with passive DCP. Further studies are needed to test effective communication strategies to mitigate this misperception.

Continuous palliative sedation for patients with advanced cancer at a tertiary care cancer center.

BACKGROUND: Palliative sedation (PS) is an intervention to treat refractory symptoms and to relieve suffering at the end of life. Its prevalence and practice patterns vary widely worldwide. The aim of our study was to evaluate the frequency, clinical indications and outcomes of PS in advanced cancer patients admitted to our tertiary comprehensive cancer center. METHODS: We retrospectively studied the use of PS in advanced cancer patients who died between March 1st, 2012 and December 31st, 2014. PS was defined as the use of continuous infusion of midazolam or neuroleptics for refractory symptoms in the end of life. This study was approved by the Research Ethics Committee of our institution (project number 2481-15). RESULTS: During the study period, 552 cancer patients died at the institution and 374 met the inclusion criteria for this study. Main reason for exclusion was death in the Intensive Care Unit. Among all included patients, 54.2% (n = 203) received PS. Patients who received PS as compared to those not sedated were younger (67.8 vs. 76.4 years-old, p < 0.001) and more likely to have a diagnosis of lung cancer (23% vs. 14%, p = 0.028). The most common indications for sedation were dyspnea (55%) and delirium (19.7%) and the most common drugs used were midazolam (52.7%) or midazolam and a neuroleptic (39.4%). Median initial midazolam infusion rate was 0.75 mg/h (interquartile range - IQR - 0.6-1.5) and final rate was 1.5 mg/h (IQR 0.9-3.0). Patient survival (length of hospital stay from admission to death) of those who had PS was more than the double of those who did not (33.6 days vs 16 days, p < 0.001). The palliative care team was involved in the care of 12% (n = 25) of sedated patients. CONCLUSIONS: PS is a relatively common practice in the end-of-life of cancer patients at our hospital and it is not associated with shortening of hospital stay. Involvement of a dedicated palliative care team is strongly recommended if this procedure is being considered. Further research is needed to identify factors that may affect the frequency and outcomes associated with PS.

Assessment of adherence to the guidelines for the management of nausea and vomiting induced by chemotherapy.

OBJECTIVE: To assess adherence of the prescribing physicians in a private cancer care center to the American Society of Clinical Oncology guideline for antiemetic prophylaxis, in the first cycle of antineoplastic chemotherapy. METHODS: A total of 139 chemotherapy regimens, of 105 patients, were evaluated retrospectively from 2011 to 2013. RESULTS: We observed 78% of non-adherence to the guideline rate. The main disagreements with the directive were the prescription of higher doses of dexamethasone and excessive use of 5-HT3 antagonist for low risk emetogenic chemotherapy regimens. On univariate analysis, hematological malignancies (p=0.005), the use of two or more chemotherapy (p=0.05) and high emetogenic risk regimes (p=0.012) were factors statistically associated with greater adherence to guidelines. Treatment based on paclitaxel was the only significant risk factor for non-adherence (p=0.02). By multivariate analysis, the chemotherapy of high emetogenic risk most correlated with adherence to guideline (p=0.05). CONCLUSION: We concluded that the adherence to guidelines is greater if the chemotherapy regime has high emetogenic risk. Educational efforts should focus more intensely on the management of chemotherapy regimens with low and moderate emetogenic potential. Perhaps the development of a computer generated reminder may improve the adherence to guidelines.

Assessment of adherence to the guidelines for the management of nausea and vomiting induced by chemotherapy / Avaliação da aderência à diretriz de cuidados para náuseas e vômitos induzidos por quimioterapia

ABSTRACT Objective: To assess adherence of the prescribing physicians in a private cancer care center to the American Society of Clinical Oncology guideline for antiemetic prophylaxis, in the first cycle of antineoplastic chemotherapy. Methods: A total of 139 chemotherapy regimens, of 105 patients, were evaluated retrospectively from 2011 to 2013. Results: We observed 78% of non-adherence to the guideline rate. The main disagreements with the directive were the prescription of higher doses of dexamethasone and excessive use of 5-HT3 antagonist for low risk emetogenic chemotherapy regimens. On univariate analysis, hematological malignancies (p=0.005), the use of two or more chemotherapy (p=0.05) and high emetogenic risk regimes (p=0.012) were factors statistically associated with greater adherence to guidelines. Treatment based on paclitaxel was the only significant risk factor for non-adherence (p=0.02). By multivariate analysis, the chemotherapy of high emetogenic risk most correlated with adherence to guideline (p=0.05). Conclusion: We concluded that the adherence to guidelines is greater if the chemotherapy regime has high emetogenic risk. Educational efforts should focus more intensely on the management of chemotherapy regimens with low and moderate emetogenic potential. Perhaps the development of a computer generated reminder may improve the adherence to guidelines. .

RESUMO Objetivo: Avaliar a adesão dos médicos prescritores, de um centro privado especializado em oncologia, à diretriz de antiêmese profilática da American Society of Clinical Oncology, no primeiro ciclo de quimioterapia antineoplásica. Métodos: Foram avaliados retrospectivamente 139 esquemas de quimioterapia, de 105 pacientes, tratados no período de 2011 a 2013. Resultados: Foram observados 78% de taxa de não adesão à diretriz. As principais discordâncias com a diretriz foram prescrição de doses mais elevadas de dexametasona e uso excessivo de antagonista 5-HT3 para regimes de quimioterapia de risco emetogênico baixo. Pela análise univariada, malignidades hematológicas (p=0,005), uso de dois ou mais quimioterápicos (p=0,05) e regimes de alto risco emetogênico (p=0,012) foram fatores estatisticamente associados a maior adesão à diretriz. O tratamento baseado em paclitaxel foi o único fator estatisticamente significativo para a não adesão (p=0,02). Pela análise multivariada, a quimioterapia de alto risco emetogênico apresentou maior correlação com a adesão à diretriz (p=0,05). Conclusão: Houve maior aderência para a quimioterapia de alto risco emetogênico. Esforços educacionais devem se concentrar mais intensamente na gestão de regimes de quimioterapia com potencial emetogênico baixo e moderado. Talvez o desenvolvimento de lembretes gerados por sistemas informatizados possa melhorar a aderência à diretriz. .

Is there publication bias towards Brazilian articles on cancer?

OBJECTIVE: To investigate whether Brazilian articles on cancer are published in journals with an impact factor and/or repercussion (measured by the number of citations) inferior to those that come from foreign organizations. METHODS: A search was carried out in PubMed for the MeSH term "neoplasm" with the limits clinical trial, affiliation of the Brazilian author(s), and interval from July 1st, 2009 to June 30, 2010. Selected for matching were non-Brazilian related articles published from three months prior to three months after the date of publication of the Brazilian study. The numbers of citations were obtained from two databases, as well as the impact factor for the journals in which the articles were published. RESULTS: Forty-three national and 876 related international articles were identified. The Brazilian publications had a mean impact factor of 3.000 versus 3.430 of the international ones (p=0.041). There was no statistically significant difference as to the number of citations between the two groups. The affiliation of the first author with a Brazilian or foreign organization did not significantly influence the number of citations or the impact factor. CONCLUSION: Brazilian articles are significantly less accepted in journals with higher impact factors, although it does not compromise its repercussion on the scientific community.

Existe viés de publicação para artigos brasileiros sobre câncer? / Is there publication bias towards Brazilian articles on cancer?

OBJETIVO: Investigar se artigos brasileiros sobre câncer são publicados em periódicos de fator impacto e/ou repercussão (medida pelo número de citações) inferiores aos oriundos de instituições estrangeiras MÉTODOS: Pesquisou-se, no PubMed, o MeSH Term "neoplasm" com os limitadores: clinical trial, afiliação de autor(es) brasileira e intervalo de 1º de julho de 2009 a 30 de junho de 2010. Foram selecionados para pareamento artigos relacionados, não brasileiros, publicados entre três meses antes e três meses depois da data de publicação do estudo brasileiro. Foram obtidos os números de citações, em duas bases de dados, assim como o fator de impacto para as revistas nas quais os artigos foram publicados. RESULTADOS: Identificaram-se 43 artigos nacionais e 876 internacionais relacionados. Os brasileiros apresentaram fator de impacto médio de 3.000 contra 3.430 dos internacionais (p=0,041). Não houve diferença estatisticamente significativa quanto ao número de citações entre os grupos. A afiliação do primeiro autor à instituição brasileira ou estrangeira também não influenciou significativamente no número de citações nem no fator de impacto. CONCLUSÃO: Artigos brasileiros são significativamente menos aceitos em revistas de maior impacto sem aparente comprometimento de sua repercussão na comunidade científica.

OBJECTIVE: To investigate whether Brazilian articles on cancer are published in journals with an impact factor and/or repercussion (measured by the number of citations) inferior to those that come from foreign organizations. METHODS: A search was carried out in PubMed for the MeSH term "neoplasm" with the limits clinical trial, affiliation of the Brazilian author(s), and interval from July 1st, 2009 to June 30, 2010. Selected for matching were non-Brazilian related articles published from three months prior to three months after the date of publication of the Brazilian study. The numbers of citations were obtained from two databases, as well as the impact factor for the journals in which the articles were published. RESULTS: Forty-three national and 876 related international articles were identified. The Brazilian publications had a mean impact factor of 3.000 versus 3.430 of the international ones (p=0.041). There was no statistically significant difference as to the number of citations between the two groups. The affiliation of the first author with a Brazilian or foreign organization did not significantly influence the number of citations or the impact factor. CONCLUSION: Brazilian articles are significantly less accepted in journals with higher impact factors, although it does not compromise its repercussion on the scientific community.