Mediating role of self-efficacy between unmet needs and quality of life in palliative cancer caregivers.

OBJECTIVE: Although unmet support needs are associated with health-related quality of life (HRQOL) in cancer caregivers, little is known about the mechanism underlying the relationship between two variables. The self-efficacy (SE) theory and literature suggest that caregiving SE is important in the perception of and reaction to caregiving demands, which in turn affects HRQOL. The aim of this study was to examine whether caregiving SE mediates the relationship between unmet support needs and HRQOL in family caregivers of palliative cancer patients. METHODS: This secondary analysis used the data from 125 family caregivers of palliative cancer patients who were recruited from two public hospitals in Hong Kong. The caregivers completed a survey questionnaire that covered socio-demographic characteristics, unmet support needs, caregiving SE, and HRQOL. Parallel mediation analyses were conducted via SPSS PROCESS macro (Model 4) to test the hypothesized models. RESULTS: The direct effect of unmet support needs on mental HRQOL was significant (effect = -0.49, 95% CI = -0.06 to -0.92). For the indirect effect, only caregiving SE in the domain of 'care for the care recipient' mediated the relationship between unmet support needs and mental HRQOL (effect = -0.32, 95% CI = -0.08 to -0.59). CONCLUSION: The findings suggest that caregiving SE may function as a mechanism through which unmet support needs influence mental HRQOL in family caregivers of palliative cancer patients. Healthcare providers should consider developing supportive care interventions to improve caregivers' HRQOL by incorporating effective strategies to enhance SE and reduce unmet needs for this population.

Reliability, validity and acceptability of the traditional Chinese version of the carer support needs assessment tool in Hong Kong palliative care settings.

BACKGROUND: Among the few existing needs assessment tools for family carers, the 14-item Carer Support Needs Assessment Tool (CSNAT) is the only brief and holistic needs screening tool designed for everyday use in palliative care practices. The aim of this study was to evaluate the reliability, validity, and acceptability of the traditional Chinese version of the CSNAT in palliative care settings in Hong Kong. METHODS: This adopted a cross-sectional and correlation design with repeated measures. The participants were 125 family carers of palliative cancer patients and 10 healthcare providers (HCPs) that were recruited from two local hospitals. The evaluation of psychometric properties included the following: (1) content validity through HCPs including frontline physicians, nurses, social workers, and clinical psychologists; (2) construct validity between the CSNAT items and those of the validated tools that measured caregiver burden, social support, and caregiving self-efficacy; and (3) one-week test-retest reliability in a sub-sample of 81 caregivers. The acceptability of the tool was assessed by the carers using several closed-ended questions. RESULTS: The content validity index of the CSNAT at the scale level was 0.98. Each item of the CSNAT was significantly and moderately correlated with caregiver burden (Spearman's r = 0.24 to 0.50) and caregiving self-efficacy (r = - 0.21 to - 0.52), but not for social support. All CSNAT items had fair to moderate test-retest reliability (weighted kappa = 0.21 to 0.48), with the exception of two items "managing your relatives' symptoms, including giving medicines" and "having time for yourself in the day". Regarding the acceptability of the CSNAT, almost all HCPs were willing to use the CSNAT for carer assessment and support. 89.6% of the carers demonstrated a comprehensibility of the CSNAT tool and 92.9% felt comfortable answering the questions. Around 90% of the carers agreed to use the tool for screening, discussing needs, and making referrals. CONCLUSION: The traditional Chinese version of the CSNAT is a tool with high validity and acceptability and adequate reliability that measures family carers' support needs, which should be considered for wide application in local palliative care practices.

Integrated palliative medicine in public oncology: a 10-year review.

OBJECTIVES: The rapid ageing population of Hong Kong has a high demand on oncology and palliative care (PC) service. This study was the first territory-wide assessment in Hong Kong to assess the palliative service coverage in patients with advanced cancer in the past decade. METHODS: Cancer deaths of all 43 public hospitals of Hong Kong were screened. Randomly selected 2800 cancer deaths formed a representative cohort in all seven service clusters of Hospital Authority at 4 time points (2006, 2009, 2012, 2015). Individual patient records were thoroughly reviewed. Predictors of PC coverage was evaluated in univariable and multivariable analyses. RESULTS: From 2006 to 2015, PC coverage improved steadily from 55.4% to 68.9% (p<0.001). Median time of referral to PC service to death was 25 days (IQR: 53). For duration of inpatient PC, the median time was 22 days (IQR: 44) and it was stable over the past 10 years. Median time of referral to outpatient service to death was 74 days (IQR: 144) and there was an improvement observed (p<0.05). The current system was highly heterogeneous that PC varied between 9.8% and 84.8% in different hospitals depending on the PC service infrastructure. Multivariable Cox model identified patients associated with lower PC coverage: male, <50, rapid disease deterioration and staying in hospitals without multidisciplinary team clinic and designated palliative bed support (all p<0.01). CONCLUSION: There was concrete achievement in palliative service development in the past decade. Heterogeneity and late service provision should be addressed in future.

Integrative Palliative Care Service Model Improved End-of-Life Care and Overall Survival of Advanced Cancer Patients in Hong Kong: A Review of Ten-Year Territory-Wide Cohort.

Background: Integrated palliative care in oncology service has been widely implemented in Hong Kong since 2006. Aim: The study aimed to review its impact on end-of-life outcomes and overall survival (OS) of cancer patients, as well as its utilization of health care resources in the past 10 years. Design: Cancer deaths of all 43 public hospitals of Hong Kong were screened. Setting/Participants: Randomly selected 2800 cancer deaths formed a representative cohort in all seven service clusters of Hospital Authority at four time points (2006, 2009, 2012, and 2015). Individual patient records were thoroughly reviewed. Propensity score-matched (PSM) analysis was employed to compare the survival of patients. Results: Palliative care provision was associated with improved palliative care outcome, including more prescription of strong opioid, fewer cardiopulmonary resuscitations and intensive care unit admissions, and less futile chemotherapy usage in the end-of-life period (all p < 0.001). In the PSM analysis, the median OS in patients with palliative service (5.10 months, 95% confidence interval [CI] 4.52-5.68 months) was significantly better than those without palliative service (1.96 months, 95% CI 1.66-2.27 months). Patients in the palliative care group had more specialist clinic visits (p < 0.001) and longer hospital stay (p < 0.001) in the last six months of life, although the duration of last admission stay at acute general ward was shortened (p < 0.001). Conclusion: Our results suggested palliative care has played a role in the remarkable improvement in end-of-life outcomes and OS. However, current palliative care model relied heavily on hospital resources. Future work is needed to strengthen community care and to build up quality monitoring systems.

The effect of horticultural therapy on the quality of life of palliative care patients.

Palliative care patients experience a variety of needs and perceive their quality of life as being only fair. This study adopted a single-group repeated-measure design to investigate the effect of horticultural therapy on the quality of life of palliative care patients using the Quality of Life Concern in End of Life Questionnaire. Significant differences in the domains of "existential distress" and "health care concern" were observed immediately postintervention and at 4 weeks postintervention, respectively. No other significant differences were seen in the other domains or in the total mean score of the outcome measure.

Impact of Competing Values and Choices on Democratic Support in Hong Kong.

This paper examines the reasons for the relatively low democratic support (DS) in Hong Kong in the context of competing values and choices based on the previous Asian Barometer Surveys. In so doing, it establishes a three-factor theoretical model that includes survey attitudinal statements related to authoritarianism (AU), nationalism (NA) and economic evaluations (EC) on DS. Using confirmatory factor analysis (CFA), the analysis shows that the hypothesized model is a very good fit. The Hong Kong people's relatively low DS, in terms of their unconditional support for democracy and the degree of democracy they want for Hong Kong, can be well explained by the three factors in combination. The factors have various extent of impact on DS, with AU being the strongest, followed by EC, and then NA. The paper contributes by illustrating the usefulness of CFA in political values research, unraveling the comparative importance of the values and choices in affecting DS, and establishing a model for further testing.

The meaning of hope from the perspective of Chinese advanced cancer patients in Hong Kong.

AIM: This article reports a study to examine the meaning of hope from the perspective of Chinese advanced cancer patients in Hong Kong. METHODS: Semi-structured interviews were conducted with a convenience sample of advanced cancer patients recruited from the palliative care unit of a local hospital. Data were saturated after 17 participants were interviewed. Qualitative content analysis was adopted to analyse the data. FINDINGS: Hope as experienced by the participants was found to consist of five components: living a normal life, social support, actively letting go of control, reconciliation between life and death, and wellbeing of significant others. CONCLUSIONS: While hope is related to the wellbeing of patients with advanced cancer, successful palliative care partly depends on an awareness of the importance of hope in the end-of-life context and cultural sensitivity to the meanings behind it from the patients' own perspective.

Comparing noncancer and cancer deaths in Hong Kong: a retrospective review.

This retrospective study aimed to compare noncancer deaths with cancer deaths in the following: 1) utilization of the public health care system in the last six months of life; 2) end-of-life care received; and 3) documentation of the advance care planning (ACP) process. The following sample was recruited from the deaths in 2006 in four public hospitals for analysis: 656 noncancer deaths consisting of 239 deaths from chronic renal failure (CRF), 242 deaths from chronic obstructive pulmonary disease (COPD) and 175 deaths from congestive heart failure (CHF), and 183 cancer deaths. Only 1.4% of noncancer patients received palliative care, compared with 79.2% of cancer patients. As compared with cancer, the noncancer patients were older (79.1±9.5 vs. 71.1±12.4 years, P<0.001) and had more comorbid conditions (2.3±1.4 vs. 1.6±1.4, P<0.001). Utilization of public health care was more intensive in noncancer patients, with more intensive care unit admissions, more ward admissions, more bed days occupied, and more clinic attendances. Within the last two weeks of life, the noncancer patients had more invasive interventions initiated, fewer symptoms documented, less analgesics and sedatives prescribed, less do-not-resuscitate orders in place, and more cardiopulomonary resuscitation performed. Dyspnea, edema, pain, and fatigue were among the most documented symptoms in both cancer and noncancer patients. A higher proportion of ACP discussions were first documented within three days before death in COPD and CHF patients as compared with CRF and cancer patients. There is a need to develop palliative care for noncancer patients in Hong Kong.

Health-care professionals' perspective on hope in the palliative care setting.

Hope is considered a coping strategy as well as a factor that enhances quality of life for patients with advanced cancer. Most studies on the meaning of hope are from the patients' perspective. However, the health-care professionals' view is also important since it may affect their practice. This study explored the meaning of hope to patients with advanced cancer from health-care professionals' perspective. This was a qualitative study that used a hermeneutic phenomenological approach. Five focus group interviews were conducted with 23 participants including physicians, nurses, social workers, occupational therapists, chaplains, and a physiotherapist working in the palliative care unit of a hospital in Hong Kong. Data analysis revealed four themes: expected hopelessness, a dynamic process of hope, hope-fostering strategies, and peace as the ultimate hope. It appears that health-care professionals' hopefulness contributes to the hopefulness of patients. Opportunities to reflect on their values, beliefs, and experience may help health-care professionals enhance their ability to foster hope in patients.

Healthcare professionals' perceptions of existential distress in patients with advanced cancer.

AIM: This paper is a report of an exploration of the phenomenon of existential distress in patients with advanced cancer from the perspectives of healthcare professionals. BACKGROUND: Existential distress is an important concern in patients with advanced cancer; it affects their well-being and needs to be addressed in the provision of holistic care. METHOD: Focus groups were conducted from November 2008 to February 2009 with physicians, nurses, social workers, occupational therapists, physiotherapists, and chaplains working in a palliative care unit that served patients with advanced cancer in Hong Kong. Data collection and analysis were guided by the grounded theory approach. All categories were saturated when five focus groups had been held with a total number of 23 participants. FINDINGS: We found three causal conditions of existential distress: anticipation of a negative future, failure to engage in meaningful activities and relationships, and having regrets. Three basic (caring, relating and knowing) and six specific (positive feedback, religious support, new experiences, task setting, exploring alternatives and relationship reconciliation) intervening strategies were identified. Whether the intervening strategies would be effective would depend on patients' openness and readiness; healthcare professionals' self-awareness, hopefulness, and interest in knowing the patients; and a trusting relationship between patients and healthcare professionals. A sense of peace in patients was considered a consequence of successful interventions. CONCLUSION: This paper acknowledges the lack of an accepted conceptual framework of existential distress in patients with advanced cancer. It is based on healthcare professionals' views, and further studies from the perspectives of patients and their families are needed.

Pegylated derivatives of recombinant human arginase (rhArg1) for sustained in vivo activity in cancer therapy: preparation, characterization and analysis of their pharmacodynamics in vivo and in vitro and action upon hepatocellular carcinoma cell (HCC).

BACKGROUND: Protein used in medicine, e.g. interferon, are immunogenic and quickly broken down by the body. Pegylation is a recognized way of preserving their integrity and reducing immune reactions, and works well with enzymes used to degrade amino acids, a recent focus of attention in controlling cancer growth. Of the two arginine-degrading enzymes being explored clinically, arginine deiminase is a decidedly foreign mycoplasm-derived enzyme, whereas human arginase 1 is a native liver enzyme. Both have been pegylated, the former with adjuncts of 20 kD, the latter with 5 kD PEG. Pegylation is done by several different methods, not all of which are satisfactory or desirable. METHODS: The preparation of novel polyethylene glycol (PEG) derivatives for modifying proteins is described, but directed specifically at pegylation of recombinant human arginase 1 (rhArg1). rhArg1 expressed in Escherichia coli was purified and coupled in various ways with 5 different PEG molecules to compare their protective properties and the residual enzyme activity, using hepatocellular cell lines both in vitro and in vivo. RESULTS: Methoxypolyethylene glycol-succinimidyl propionate (mPEG-SPA 5,000) coupled with very high affinity under mild conditions. The resulting pegylated enzyme (rhArg1-peg5,000 mw) had up to 6 PEG chains of 5K length which not only protected it from degradation and any residual immunogenicity, but most importantly let it retain >90% of its native catalytic activity. It remained efficacious in depleting arginine in rats after a single ip injection of 1,500 U of the conjugate as the native enzyme, plasma arginine falling to >0.05 microM from approximately 170 microM within 20 min and lasting 6 days. The conjugate had almost the same efficacy as unpegylated rhArg1 on 2 cultured human liver cancer (HCC) cell lines. It was considerably more effective than 4 other pegylated conjugates prepared. CONCLUSION: Valuable data on the optimization of the pegylation procedure and choice of ligand that best stabilizes the enzyme arginase 1 are presented, a protocol that should equally fit many other enzymes and proteins. It is a long lasting arginine-depleting enzyme in vivo which will greatly improve its use in anti-cancer therapy.

Pegylated recombinant human arginase (rhArg-peg5,000mw) inhibits the in vitro and in vivo proliferation of human hepatocellular carcinoma through arginine depletion.

Hepatocellular carcinoma (HCC) is believed to be auxotrophic for arginine through the lack of expression of argininosuccinate synthetase (ASS). The successful use of the arginine-depleting enzyme arginine deiminase (ADI) to treat ASS-deficient tumors has opened up new possibilities for effective cancer therapy. Nevertheless, many ASS-positive HCC cell lines are found to be resistant to ADI treatment, although most require arginine for proliferation. Thus far, an arginine-depleting enzyme for killing ASS-positive tumors has not been reported. Here, we provide direct evidence that recombinant human arginase (rhArg) inhibits ASS-positive HCCs. All the five human HCC cell lines we used were sensitive to rhArg but ADI had virtually no effect on these cells. They all expressed ASS, but not ornithine transcarbamylase (OTC), the enzyme that converts ornithine, the product of degradation of arginine with rhArg, to citrulline, which is converted back to arginine via ASS. Transfection of HCC cells with OTC resulted in resistance to rhArg. Thus, OTC expression alone may be sufficient to induce rhArg resistance in ASS-positive HCC cells. This surprising correlation between the lack of OTC expression and sensitivity of ASS-positive HCC cells shows that OTC-deficient HCCs are sensitive to rhArg-mediated arginine depletion. Therefore, pretreatment tumor gene expression profiling of ASS and OTC could aid in predicting tumor response to arginine depletion with arginine-depleting enzymes. We have also shown that the rhArg native enzyme and the pegylated rhArg (rhArg-peg(5,000mw)) gave similar anticancer efficacy in vitro. Furthermore, the growth of the OTC-deficient Hep3B tumor cells (ASS-positive and ADI-resistant) in mice was inhibited by treatment with rhArg-peg(5,000mw), which is active alone and is synergistic in combination with 5-fluorouracil. Thus, our data suggest that rhArg-peg(5,000mw) is a novel agent for effective cancer therapy.