Delivery Models and Health Economics of Supportive Care Services in England: A Multicentre Analysis.

AIMS: Improvements in cancer treatment have led to more people living with and beyond cancer. These patients have symptom and support needs unmet by current services. The development of enhanced supportive care (ESC) services may meet the longitudinal care needs of these patients, including at the end of life. This study aimed to determine the impact and health economic benefits of ESC for patients living with treatable but not curable cancer. MATERIALS AND METHODS: A prospective observational evaluation was undertaken over 12 months across eight cancer centres in England. ESC service design and costs were recorded. Data relating to patients' symptom burden were collected using the Integrated Palliative Care Outcome Scale (IPOS). For patients in the last year of life, secondary care use was compared against an NHS England published benchmark. RESULTS: In total, 4594 patients were seen by ESC services, of whom 1061 died during follow-up. Mean IPOS scores improved across all tumour groups. In total, £1,676,044 was spent delivering ESC across the eight centres. Reductions in secondary care usage for the 1061 patients who died saved a total of £8,490,581. CONCLUSIONS: People living with cancer suffer with complex and unmet needs. ESC services appear to be effective at supporting these vulnerable people and significantly reduce the costs of their care.

A Short Report Examining the Introduction of Routine Use of Patient-Reported Outcome Measures in a Mixed Oncology Population.

AIMS: People living with treatable but not curable cancer often experience a range of symptoms related to their cancer and its treatment. During the COVID-19 pandemic, face-to-face consultations were reduced and so remote monitoring of these needs was necessary. University Hospitals Sussex implemented the routine use of electronic remote patient-reported outcome measures (PROMs) in a mixed oncology population, focusing on those with treatable but not curable cancers. MATERIALS AND METHODS: Over a 9-month period, patients were invited to register with My Clinical Outcomes (MCO) - a secure online platform for the collection of electronic PROMs. They were prompted by e-mail to complete assessments (EORTC QLQ-C30, EQ-5D-3L and EQ-5D VAS) routinely every 2 weeks. The team monitored patient scores and changes in these prompted clinical interventions. RESULTS: In total, 324 patients completed at least one assessment. The median number of assessments completed by each patient was eight. The most represented tumour groups were secondary breast (28%), prostate (25%) and other (32%). Median scores for the assessments did not deteriorate in a clinically or numerically significant way for patients living with non-curable conditions for the majority of patients monitored. CONCLUSION: Routine collection of electronic remote PROMs is an effective and useful strategy to provide real-time clinical feedback to teams. With integration into existing systems, online platforms (such as MCO) could provide efficient and patient-centred information for those providing care for people with cancer.

Digital Medicine in Men with Advanced Prostate Cancer - A Feasibility Study of Electronic Patient-reported Outcomes in Patients on Systemic Treatment.

AIMS: Electronic patient-reported outcome (ePRO) measures have the potential to improve patient care, both at an individual level by detecting symptoms and at an organisational level to rationalise follow-up. The introduction of ePROs has many challenges, including funding, institutional rigidity and acceptability for both patients and clinicians. There are multiple examples of successful ePRO programmes but no specific feasibility studies in those who are less digitally engaged. Prostate cancer is predominantly a disease of older men and digital exclusion is associated with increased age. We assessed the feasibility of ePRO completion in older men receiving treatment for advanced prostate cancer both within the clinic and from home. MATERIALS AND METHODS: Men receiving palliative systemic treatment were asked to complete ePROs on a tablet computer in the outpatient department at 0 and 3 months. Participants were also offered optional completion from home. Feasibility was assessed via a mixed methods approach. RESULTS: On-site ePRO completion was acceptable to most patients, with 90% finding it easy or straightforward and 80% preferring electronic over paper. Remote completion was more challenging, even for those who accessed e-mail daily and owned a tablet, with only 20% of participants successfully completing ePROs. Barriers to electronic completion can be categorised as technical, attitudinal and medical. Quality of life and symptom ePRO results were comparable with published data. CONCLUSIONS: On-site completion is achievable in this population with limited staff support. However, remote completion requires further work to improve systems and acceptability for patients. Remote completion is critical to add significantly to current clinical care by detecting symptoms or stratifying follow-up.

Multi-analyte profiling and pathway analysis of plasma for proteins associated with cancer-related fatigue syndrome in disease-free breast cancer patients after primary treatment.

CONTEXT: A significant number of women treated for breast cancer develop long-term fatigue afterwards. Previous research has suggested that fatigue may be due to a prolonged inflammatory response. However, there are conflicting results and the exact nature of the disturbance remains unclear. OBJECTIVES: To identify inflammatory markers associated with fatigue. METHODS: We recruited women from a breast cancer follow-up clinic and categorised them on the basis of a diagnostic interview as to whether they met the criteria for cancer-related fatigue syndrome (cases) or not (controls). We took plasma samples from each participant to analyse subsequently using a panel of 88 biological markers. RESULTS: 90 samples were analysed in total (45 cases and 45 controls). A factorial analysis of variance (using age as a fixed factor) demonstrated a number of differences in inflammatory cytokines. There were 28 significantly different analytes in total. Granulocyte colony stimulating factor was the most significantly different analyte (p<0.001). Many of the significant analytes were chemokine ligands found to be linked through an inflammatory pathway promoting T-cell and granulocyte production and activation. CONCLUSIONS: Our results add further weight to the hypothesis that cancer-related fatigue syndrome is associated with an increased pro-inflammatory immune response. Our findings indicate that these cytokine changes could underpin the subjective symptoms, such as perceived muscle weakness and concentration difficulties, experienced by women who feel fatigued after treatment.

A comparison of the characteristics of disease-free breast cancer survivors with or without cancer-related fatigue syndrome.

PURPOSE: To determine the prevalence of cancer-related fatigue syndrome (CRFS) in a population of disease-free breast cancer survivors and to investigate the relationship between CRFS and clinical variables. PATIENTS AND METHODS: Women (200) were recruited. All participants were between 3 months and 2 years after completion of primary therapy for breast cancer and were disease free. Subjects completed a diagnostic interview for CRFS and structured psychiatric interview. Participants also completed quality of life, mood and fatigue questionnaires, and provided a blood sample for haematological and biochemical analysis and a 24-h urine specimen for cortisol estimation. Subjects wore a wrist actigraph for 7 days to measure activity and sleep. RESULTS: Sixty women (30% of participants) were found to fulfil the criteria for CRFS. There were statistically significant differences between fatigued and non-fatigued women with respect to fatigue severity (p<0.01), mood (p<0.01) and quality of life scores (p<0.05). There were significant differences in blood variables including raised total white cell count and lower sodium (all p<0.02). There was no difference in the 24h urinary free cortisol levels. Actigraphic data demonstrated significant differences in sleep quality and disturbance, but not in overall levels of daytime activity or circadian rhythm. CONCLUSION: CRFS affects 30% of women after breast cancer treatment and has significant effects on quality of life and mood. There is some evidence that CRFS is related to sleep disturbance or to a persistent inflammatory or immune response.

A systematic review of the scales used for the measurement of cancer-related fatigue (CRF).

BACKGROUND: Fatigue in cancer is very common and can be experienced at all stages of disease and in survivors. There is no accepted definition of cancer-related fatigue (CRF) and no agreement on how it should be measured. A number of scales have been developed to quantify the phenomenon of CRF. These vary in the quality of psychometric properties, ease of administration, dimensions of CRF covered and extent of use in studies of cancer patients. This review seeks to identify the available tools for measuring CRF and to make recommendations for ongoing research into CRF. METHODS: A systematic review methodology was used to identify scales that have been validated to measure CRF. The inclusion criteria required the scale to have been validated for use in cancer patients and/or widely used in this population. Scales also had to meet a minimum quality score for inclusion. RESULTS: The reviewers identified 14 scales that met the inclusion criteria. The most commonly used scales and best validated were the Functional Assessment of Cancer Therapy Fatigue (FACT F), the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C30) (fatigue subscale) and the Fatigue Questionnaire (FQ). CONCLUSIONS: Unidimensional scales are the easiest to administer and have been most widely used. The authors recommend the use of the EORTC QLQ C30 fatigue subscale or the FACT F. The FQ gives a multidimensional assessment and has also been widely used. A substantial minority of the scales identified have not been used extensively or sufficiently validated in cancer patients and cannot be recommended for routine use without further validation.

Cancer-related fatigue.

Fatigue is a common symptom in patients with cancer and in disease-free survivors. It has a significant impact on the quality of life. Although subjective fatigue is often related to objective changes in physical functioning or impaired performance status, the two phenomena are not synonymous and need to be distinguished. A number of robust and reliable assessment instruments to measure fatigue severity are now available and criteria for cancer-related fatigue syndrome have been proposed. The underlying mechanisms and pathophysiology of cancer-related fatigue are unclear. Management strategies include the use of psycho-educational interventions, exercise programmes and pharmacological treatments. The best evidence for the effectiveness of drug treatments is for the haematopoietic agents in anaemic patients undergoing chemotherapy and for methylphenidate in an on-treatment population.

Drug therapy for the management of cancer related fatigue.

BACKGROUND: Cancer related fatigue (CRF) is common, under-recognised and difficult to treat. There have been trials looking at drug interventions to improve CRF but results have been conflicting depending on the population studied and outcome measures used. No previous reviews of this topic have been exhaustive or have synthesised all available data. OBJECTIVES: To assess the efficacy of drugs for the management of CRF. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (1st Quarter 2007), MEDLINE (1966 to March 2007) and a selection of cancer journals. We searched references of identified articles and contacted authors to obtain unreported data. SELECTION CRITERIA: Trials were included in the review if they 1) assessed drug therapy for the management of CRF compared to placebo, usual care or a non-pharmacological intervention in 2) randomised controlled trials (RCT) of 3) adult patients with a clinical diagnosis of cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. Meta-analyses were performed on different drug classes using continuous variable data. MAIN RESULTS: Forty-five trials met the inclusion criteria. Only 27 of these trials involving 6746 participants were judged to have used a sufficiently robust measure of fatigue and thus were deemed suitable for detailed analysis. The drugs were analysed by class (psychostimulants; haemopoetic growth factors; antidepressants and progestational steroids). Methylphenidate showed a small but significant improvement in fatigue over placebo (Z = 2.40; P = 0.02). Erythropoietin showed a small but significant improvement in fatigue (for anaemic patients receiving chemotherapy) compared to placebo (Z = 2.67; P = 0.008). Darbopoietin also demonstrated a smaller but significant improvement in fatigue over placebo (Z = 1.96; P = 0.05). Paroxetine and progestational steroids demonstrated no superiority over placebo in treating CRF. There was a very high degree of statistical and clinical heterogeneity in the trials and the reasons for this are discussed. It was not possible to determine optimum doses as a result of this review. AUTHORS' CONCLUSIONS: Erythropoietin and darbopoetin (for anaemic patients on chemotherapy) and psychostimulant trials provide evidence for improvement in CRF at a clinically meaningful level. There are no data to support the use of paroxetine or progestational steroids for the treatment of CRF. The obvious candidate drug for use in a large scale RCT is methylphenidate to confirm the preliminary results from this review.

How common is fatigue in disease-free breast cancer survivors? A systematic review of the literature.

BACKGROUND: There is some debate in the literature as to whether fatigue persists in the long term in women who have completed adjuvant breast cancer treatment. METHODS: A systematic review was conducted in order to characterise and quantify the phenomenon of post treatment fatigue (PTF). RESULTS: There was a wide variation in the measures of fatigue used, duration of follow-up and type of comparison made. Overall 18 studies were identified with a follow-up period of between 4 months and 10 years. Fourteen studies demonstrated the presence of continued PTF and/or differences in fatigue levels compared to a reference population up to 5 years after treatment. One short-term study reported no increase in fatigue at 4 months. Three studies (with an average follow up period of longer than 5 years) did not identify overall quality of life differences in breast cancer survivors when compared with a reference population. However there were significant differences in measures of physical functioning and mental fatigue. CONCLUSION: The authors conclude that there is good evidence of PTF occurring up to 5 years after completion of adjuvant therapy.

A retrospective review of the use of alfentanil in a hospital palliative care setting.

Alfentanil is becoming an alternative to diamorphine when parental opioids are required, especially in the presence of renal insufficiency. Its pharmacokinetic properties suggest that tolerance may be rapidly induced, whilst concomitant administration of drugs that interfere with the cytochrome P450 system may alter its metabolism. This retrospective audit looked at the use of subcutaneous alfentanil in a palliative care setting over a 21-month period. Forty-eight out of the 81 notes identified were available for analysis. Alfentanil was used for a median of 9 days (range 1-81) with median increase in dose of 80% (range 0-1125%). No significant correlation was found between duration of infusion and dose escalation. In addition no significant correlation was found between dose escalation and concomitant drugs that either inhibited or induced the P450 system. This is the first study to investigate the use of relatively long-term use of parenteral alfentanil. The results suggest that neither tolerance nor concomitant drug administration is of clinical significance in the dose escalation.