Oncologists' perspective on advance directives, a French national prospective cross-sectional survey - the ADORE study.

BACKGROUND: The often poor prognosis associated with cancer necessitates empowering patients to express their care preferences. Yet, the prevalence of Advance Directives (AD) among oncology patients remains low. This study investigated oncologists' perspectives on the interests and challenges associated with implementing AD. METHODS: A French national online survey targeting hospital-based oncologists explored five areas: AD information, writing support, AD usage, personal perceptions of AD's importance, and respondent's profile. The primary outcome was to assess how frequently oncologists provide patients with information about AD in daily clinical practice. Additionally, we examined factors related to delivering information on AD. RESULTS: Of the 410 oncologists (50%) who responded to the survey, 75% (n = 308) deemed AD relevant. While 36% (n = 149) regularly inform patients about AD, 25% (n = 102) remain skeptical about AD. Among the respondents who do not consistently discuss AD, the most common reason given is the belief that AD may induce anxiety (n = 211/353; 60%). Of all respondents, 90% (n = 367) believe patients require specific information to draft relevant AD. Physicians with experience in palliative care were more likely to discuss AD (43% vs 32.3%, p = 0.027). Previous experience in critical care was associated with higher levels of distrust towards AD (31.5% vs 18.8%, p = 0.003), and 68.5% (n = 281) of the respondents expressed that designating a "person of trust" would be more appropriate than utilizing AD. CONCLUSION: Despite the perceived relevance of AD, only a third of oncologists regularly apprise their patients about them. Significant uncertainty persists about the safety and relevance of AD.

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.

[A 2023 inventory in oncology news]. / Qu'est-ce que 2023 aura permis de changer dans nos pratiques en cancérologie ?

In 2023, the improvement of our therapeutic management has largely taken shape. The aim of our article is to highlight the major advances that will change our practices. These are not only in the field of treatment, but also in the improvement of supportive care. Here, we present these new developments organ by organ, cancer by cancer. You can read everything or concentrate on the cancers that are your areas of expertise. But this exhaustiveness should be representative of our current state of progress.

MASCC guideline: cannabis for cancer-related pain and risk of harms and adverse events.

BACKGROUND: Approximately 18% of patients with cancer use cannabis at one time as palliation or treatment for their cancer. We performed a systematic review of randomized cannabis cancer trials to establish a guideline for its use in pain and to summarize the risk of harm and adverse events when used for any indication in cancer patients. METHODS: A systematic review of randomized trials with or without meta-analysis was carried out from MEDLINE, CCTR, Embase, and PsychINFO. The search involved randomized trials of cannabis in cancer patients. The search ended on November 12, 2021. The Jadad grading system was used for grading quality. Inclusion criteria for articles were randomized trials or systematic reviews of randomized trials of cannabinoids versus either placebo or active comparator explicitly in adult patients with cancer. RESULTS: Thirty-four systematic reviews and randomized trials met the eligibility criteria for cancer pain. Seven were randomized trials involving patients with cancer pain. Two trials had positive primary endpoints, which could not be reproduced in similarly designed trials. High-quality systematic reviews with meta-analyses found little evidence that cannabinoids are an effective adjuvant or analgesic to cancer pain. Seven systematic reviews and randomized trials related to harms and adverse events were included. There was inconsistent evidence about the types and levels of harm patients may experience when using cannabinoids. CONCLUSION: The MASCC panel recommends against the use of cannabinoids as an adjuvant analgesic for cancer pain and suggests that the potential risk of harm and adverse events be carefully considered for all cancer patients, particularly with treatment with a checkpoint inhibitor.

Multinational Association of Supportive Care in Cancer (MASCC) guidelines: cannabis for psychological symptoms including insomnia, anxiety, and depression.

PURPOSE: During the treatment of cancer, 18% of patients use cannabis for symptom management. Anxiety, depression, and sleep disturbances are common symptoms in cancer. A systematic review of the evidence for cannabis use for psychological symptoms in cancer patients was undertaken to develop a guideline. METHODS: A literature search of randomized trials and systematic reviews was undertaken up to November 12, 2021. Studies were independently assessed for evidence by two authors and then evaluated by all authors for approval. The literature search involved MEDLINE, CCTR, EMBASE, and PsychINFO databases. Inclusion criteria included randomized control trials and systematic reviews on cannabis versus placebo or active comparator in patients with cancer and psychological symptom management (anxiety, depression, and insomnia). RESULTS: The search yielded 829 articles; 145 from Medline, 419 from Embase, 62 from PsychINFO, and 203 from CCTR. Two systematic reviews and 15 randomized trials (4 on sleep, 5 on mood, 6 on both) met eligibility criteria. However, no studies specifically assessed the efficacy of cannabis on psychological symptoms as primary outcomes in cancer patients. The studies varied widely in terms of interventions, control, duration, and outcome measures. Six of 15 RCTs suggested benefits (five for sleep, one for mood). CONCLUSION: There is no high-quality evidence to recommend the use of cannabis as an intervention for psychological symptoms in patients with cancer until more high-quality research demonstrates benefit.

Implementation of palliative care day hospital for outpatients with advanced cancer.

OBJECTIVES: To describe the population of a palliative care day hospital (PCDH) in oncology and analyse the end-of-life trajectory. METHODS: Monocentric retrospective cohort study of all referred patients for the first time to PCDH over an 8-month period with the data collected in all PCDH in their pathway care. RESULTS: 116 patients were included for 319 stays in PCDH. At first referral PCDH, 62 (53.4%) patients had ongoing anticancer therapy. Twenty-four (20.7%) and 63 (54.3%) patients were in an unstable and deteriorating phase, respectively. Mean (SD) Eastern Cooperative Oncology Group performance status score was 2.8 (0.7). Mean (SD) stay per patient was 2.8 (2.2). For all stays, mean (SD) of joint intervention of palliative care team and oncologist was 1.2 (1.2) per patient. Mean (SD) of technical acts performed was 0.2 (0.6) per patient. Among the 109 deceased patients, 16 patients (14.7%) and 7 patients (6.4%) had received chemotherapy in the last month and 15 days before death, respectively. CONCLUSION: Our PCDH is a suitable place for a complex population still living at home. The reported patients' demographics and PCDH's organisation lead to a hybrid outpatient intervention between outpatient clinics and hospice care services. A randomised multicentric trial is ongoing to explore the impact of PCDH on patients' trajectory and the use of resources.

[A 2022 inventory in oncology news]. / Que retenir dans la prise en charge des cancers en 2022 ?

The Cancer Bulletin continues its tradition. At the beginning of 2023, the members of the editorial committee would like to share with you their analyses of the highlights of 2022. The objective remains to highlight what will change our practices and lead to different diagnostic or therapeutic options. Our synthesis will therefore focus on published data. They have been analyzed and placed in the more general context of the management of each type of cancer to deduce the practical consequences for our patients. This synthesis exercise will concern almost all tumor pathologies, most often on the therapeutic level, and will, however, exclude the evolution of techniques, whether they are diagnostic or used for the follow-up of our patients. The final objective is to allow you to have a thoughtful, didactic and practical reading. Our goal is to provide our readers with the rational bases that can lead to a different approach for treatments in 2023.

Impact of early palliative care on additional line of chemotherapy in metastatic breast cancer patients: results from the randomized study OSS.

PURPOSE: The most appropriate criteria and timing for palliative care referral remain a critical issue, especially in patients with metastatic breast cancer for whom long-term chemosensibility and survival are observed. We aimed to compare the impact of early palliative care including formal concertation with oncologists on decision for an additional line of chemotherapy compared with usual oncology care. METHODS: This randomized prospective study enrolled adult women with metastatic breast cancer and visceral metastases with a 3rd- or 4th-line chemotherapy (CT). Patients received usual oncology care with a palliative care consultation only upon patient or oncologist request (standard group, S) or were referred to systematic palliative care consultation including a regular concertation between palliative care team and oncologists (early palliative care group, EPC). The primary endpoint was the rate of an additional CT (4th or 5th line) decision. Quality of life, symptoms, social support and satisfaction were self-evaluated at 6 and 12 months, at treatment discontinuation or 3 months after discontinuation. RESULTS: From January 2009 to November 2012, two authorized cancer centers included 98 women (EPC: 50; S: 48). Thirty-seven (77.1%, 95%CI 62.7-88%) patients in the EPC group had a subsequent chemotherapy prescribed and 36 (72.0%, 95%CI 57.5-83.8%) in the S group (p = 0.646). No differences in symptom control and global quality of life were observed, but less deterioration in physical functioning was reported in EPC (EPC: 0 [- 53-40]; S: - 6; 7 [- 60 to - 20]; p = 0.027). Information exchange and communication were significant improved in EPC (exchange, EPC: - 8.3 [- 30 to + 7]; S: 0.0 [- 17 to + 23]; p = 0.024; communication, EPC: 12.5 [- 8 to - 37]; S: 0.0 [- 21 to + 17]; p = 0.004). CONCLUSION: EPC in metastatic breast cancer patients did not impact the prescription rate of additional chemotherapy in patients a 3rd- or 4th-line chemotherapy for metastatic breast cancer; however, EPC may contribute to alleviate deterioration in physical functioning, while facilitating communication. TRIAL REGISTRATION: ClinicalTrial.gov identifier: NCT00905281, May 20, 2009.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/consensus guidance on the use of cannabinoids for gastrointestinal symptoms in patients with cancer.

BACKGROUND: Gastrointestinal symptoms are common in patients with cancer, whether related to treatment or a direct effect of the disease itself. Patients may choose to access cannabinoids outside of their formal medical prescriptions to palliate such symptoms. However, clinical guidelines are lacking in relation to the use of such medicines for gastrointestinal symptoms in patients with cancer. METHODS: A systematic review of the evidence for the use of cannabinoids for symptom control in patients with cancer was undertaken. Search strategies were developed for Medline, Embase, PsychINFO, and the Cochrane Central Register of Controlled Trials, including all publications from 1975 up to 12 November 2021. Studies were included if they were randomized controlled trials of cannabinoids compared with placebo or active comparator in adult patients with cancer, regardless of type, stage, or treatment status. Articles for inclusion were agreed by all authors, and data extracted and summarized by two authors. Each study was scored according to the Jadad scale. This review was specifically for the purpose of developing guidelines for the use of cannabis for gastrointestinal symptoms, including chemotherapy-induced nausea and vomiting (CINV), chronic nausea, anorexia-cachexia syndrome, and taste disturbance. RESULTS: Thirty-six randomized controlled trials were identified that met the inclusion criteria for this review of gastrointestinal symptoms: 31 relating to CINV, one to radiotherapy-induced nausea and vomiting, and the remaining four to anorexia-cachexia and altered chemosensory disturbance. The populations for the randomized controlled trials were heterogeneous, and many studies were of poor quality, lacking clarity regarding method of randomization, blinding, and allocation concealment. For CINV, eleven RCTs showed improvement with cannabis compared to placebo, but out of 21 trials where cannabis was compared to other antiemetics for CINV, only 11 favoured cannabis. CONCLUSION: Tetrahydrocannabinol (THC) and nabilone were more effective in preventing CINV when compared to placebo but are not more effective than other antiemetics. For refractory CINV, one study of THC:CBD demonstrated reduced nausea as an add-on treatment to guideline-consistent antiemetic therapy without olanzapine. The MASCC Guideline Committee found insufficient evidence to recommend cannabinoids for the management of CINV, nausea from advanced cancer, cancer-associated anorexia-cachexia, and taste disturbance. High-quality studies are needed to inform practice.

[Emergency in oncologic patient's pathway]. / La consultation médicale en urgence dans le parcours du patient en oncologie.

BACKGROUND: Medical emergencies are defined at the medical level, whereas the use of emergency consultations is decided by the patient. Urgent oncology cares are specific due to clinical, therapeutic, technic and psychologic complexity. METHODS: This descriptive retrospective study about 142 consultations carried out at the unplanned medical unit, with an analyse of demographics, clinical characteristics, reason for medical appeal, deployed resources and oncological pathway for six months. RESULTS: Breast (48 %) and lung (21 %) cancer are the most common. 68 % of patients present with a disease at a non-curative stage and 83 % have received a cancer treatment within the previous two months. Pain is the main reason for consultation (19 ). 91 % of patients benefit from diagnostic and therapeutic procedures. At three month, half of patients use an emergency system again. At six months, the tumour progression rate is 54 %. The mortality rate is 33 % regardless of the risk of immediate aggravation. CONCLUSION: The use of emergency consultation mainly concerns patients in a palliative situation, sometimes announcing the change of the trajectory towards the advanced phase. The organization of the emergency care pathway should evolve to better consider the needs of this population, by formalizing longitudinal monitoring, collaboration with palliative care teams and coordination with care providers in the city.

Association between Nutritional Status and Treatment Response and Survival in Patients Treated with Immunotherapy for Lung Cancer: A Retrospective French Study.

Malnutrition is associated with a greater risk of morbidity and mortality and lower tolerance to chemotherapy. Our purpose was to study the association between nutritional status and the efficiency and tolerance of immunotherapy in non-small cell lung cancer (NSCLC). Nutritional and oncological data were reported at 2 months (M2) and 4 months (M4) after the initiation of immunotherapy (M0). The influence of nutritional status at M0 was estimated with the efficacy and toxicity of immunotherapy at M2 to M4. In total, 127 patients were included in the study, and nutritional status was estimated at M0 for 120 patients: 67% were not malnourished, 20% presented with moderate malnutrition, and 13% presented with severe malnutrition. There was no significant link between the nutritional status at M0 and the toxicity of immunotherapy at M2 and M4. However, severe malnutrition was significantly associated with treatment efficacy at M2 (p = 0.04) and with a lower survival rate with an HR (Hazard Ratio) = 2.32-95% C.I: 1.13-4.75 (p = 0.02). Furthermore, a monthly decrease of 1% of the weight had an HR = 1.17-95% C.I: 1.13-1.21 (p = 0.0001). Severe malnutrition and weight loss are independent factors associated with lower survival. Studies integrating the systemic detection of sarcopenia with a closer nutritional follow-up could highlight an improvement in survival.

A phase III randomized trial of weight loss to reduce cancer-related fatigue among overweight and obese breast cancer patients: MEDEA Study design.

BACKGROUND: Elevated body mass index (BMI) represents a risk factor for cancer-related fatigue (CRF). Weight loss interventions are feasible and safe in cancer survivors, leading to improved cardio-metabolic and quality of life (QOL) outcomes and modulating inflammatory biomarkers. Randomized data are lacking showing that a lifestyle intervention aimed at weight loss, combining improved diet, exercise, and motivational counseling, reduces CRF. Motivating to Exercise and Diet, and Educating to healthy behaviors After breast cancer (MEDEA) is a multi-center, randomized controlled trial evaluating the impact of weight loss on CRF in overweight or obese survivors of breast cancer. Herein, we described the MEDEA methodology. METHODS: Patients (N = 220) with stage I-III breast cancer and BMI ≥ 25 kg/m2, within 12 months of primary treatment, and able to walk ≥ 400 m are eligible to enroll. Participants are randomized 1:1 to health education alone vs. a personalized telephone-based weight loss intervention plus health education. Both arms receive a health education program focusing on healthy living. Patients in the intervention arm are paired with an individual lifestyle coach, who delivers the intervention through 24 semi-structured telephone calls over 1 year. Intervention goals include weight loss ≥ 10% of baseline, caloric restriction of 500-1000 Kcal/day, and increased physical activity (PA) to 150 (initial phase) and 225-300 min/week (maintenance phase). The intervention is based on the social cognitive theory and is adapted from the Breast Cancer Weight Loss trial (BWEL, A011401). The primary endpoint is the difference in self-reported CRF (EORTC QLQ-C30) between arms. Secondary endpoints include the following: QOL (EORTC QLQ-C30, -BR45, -FA12), anxiety, and depression (HADS); weight and BMI, dietary habits and quality, PA, and sleep; health care costs (hospital-admissions, all-drug consumption, sick leaves) and cost-effectiveness (cost per quality-adjusted life-year); and patient motivation and satisfaction. The primary analysis of MEDEA will compare self-reported CRF at 12 months post-randomization between arms, with 80.0% power (two-sided α = 0.05) to detect a standardized effect size of 0.40. DISCUSSION: MEDEA will test the impact of a weight loss intervention on CRF among overweight or obese BC survivors, potentially providing additional management strategies and contributing to establish weight loss support as a new standard of clinical care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04304924.

[A 2021 inventory in oncology news]. / L'année 2021 dans tous ses états : une synthèse digérée.

Once again this year, the Editorial Board presents here a summary of the most important advances in treatment and patient care in oncology over the past year. Some of the most important results in breast and gynecological cancers (endometrium and cervix), lung, brain, urologic and digestive cancers. Are also presented progresses in hematological malignancies, pediatric oncology, and of course supportive care essential for our patients.

Helping Patients Communicate With Oncologists When Cancer Treatment Resistance Occurs to Develop, Test, and Implement a Patient Communication Aid: Sequential Collaborative Mixed Methods Study.

BACKGROUND: Most cancer-related deaths result from disseminated diseases that develop resistance to anticancer treatments. Inappropriate communication in this challenging situation may result in unmet patient information and support needs. Patient communication aids such as question prompt lists (QPLs) may help. OBJECTIVE: This study aims to develop and pilot-test a specific QPL in the following two contrasting clinical contexts in France after cancer resistance has developed: triple-negative and luminal B metastatic breast cancer (MBC) and metastatic uveal melanoma (MUM). METHODS: A sequential study design with a mixed methods collaborative approach will be applied. The first step aims to build a specific QPL. Step 1a will explore oncologist-patient communication issues from oncology professionals' interviews (n=20 approximately). Step 1b will appraise information and support needs experienced by patients with MBC or MUM both quantitatively (n=80) and qualitatively (n=40 approximately). These data will be used to develop and pilot-test a QPL specific to patients with cancer experiencing initial or acquired resistance to treatment. We expect to obtain a core QPL that comprises questions and concerns commonly expressed by patients with resistant cancer and is complemented by specific issues for either MBC or MUM cancer sites. In step 1c, 2 focus groups of patients with any type of metastatic cancer (n=4) and health care professionals (n=4) will be conducted to revise the content of a preliminary QPL and elaborate an acceptable and feasible clinical implementation. In step 1d, the content of the QPL version 1 and implementation guidance will be validated using a Delphi process. Step 2 will pilot-test the QPL version 1 in real practice with patients with MBC or MUM (n=80). Clinical utility will be assessed by comparing responses to questionnaires administered in step 1b (QPL-naive historical control group) and step 2 (QPL intervention group). RESULTS: This study received grants in March and December 2019 and was approved by the French national ethics committee in July 2019. As of October 2021, interviews with oncology professionals have been conducted and analyzed (N=26 to reach saturation), and 39 and 27 patients with MBC and MUM, respectively, have been recruited. CONCLUSIONS: A clinically and culturally tailored QPL is expected to facilitate patients' participation in consultations, improve oncologists' responses to patients' information and support needs, and thus foster patients' psychological adjustment to the diagnosis and follow-up of cancer resistance to treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT04118062; http://clinicaltrials.gov/ct2/show/NCT04118062. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26414.

[How do we get around the barriers to integrating palliative care in oncology?] / Comment contourner les freins à l'intégration des soins palliatifs en oncologie ?

Supported by numerous scientific publications showing its clinical benefits, early palliative care has become a gold standard in oncology since 2017, recommended for patients with advanced cancer by the major societies of oncology. Nevertheless, palliative care team integration is still too late in France and the intervention of palliative care teams in oncology is still often limited to the management of patients and their relatives at the end of life. First, we will look at the main obstacles: the lack of staff in palliative care teams and the complex functioning of palliative care identified beds; also, the difficulties of communication with the patient and his relatives for the introduction of palliative care. We will then discuss the prospects for development, moving from the concept of early palliative care (systematic from the advanced phase) to integrated palliative care (targeted to patients' needs). Standardization of the integrated palliative care pathway requires the description of referral criteria, screening modalities, different clinical missions, and collaboration modalities with oncologists. Palliative care and oncology teams, working together, can enable holistic medicine that focuses on the needs of patients and their loved ones, giving voice to their preferences and aiming to improve their quality of life.

Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted nutrition in patients with advanced cancer.

PURPOSE: The pro vision of clinically assisted nutrition (CAN) in patients with advanced cancer is controversial, and there is a paucity of specific guidance, and so a diversity in clinical practice. Consequently, the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC) formed a Subgroup to develop evidence-based guidance on the use CAN in patients with advanced cancer. METHODS: This guidance was developed in accordance with the MASCC Guidelines Policy. A search strategy for Medline was developed, and the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were explored for relevant reviews/trials respectively. The outcomes of the review were categorised by the level of evidence, and a "category of guideline" based on the level of evidence (i.e. "recommendation", "suggestion", or "no guideline possible"). RESULTS: The Subgroup produced 11 suggestions, and 1 recommendation (due to the paucity of evidence). These outcomes relate to assessment of patients, indications for CAN, contraindications for CAN, procedures for initiating CAN, and re-assessment of patients. CONCLUSIONS: This guidance provides a framework for the use of CAN in advanced cancer, although every patient needs individualised management.

CT-Guided Percutaneous Vertebroplasty of the Cervico-Thoracic Junction for the Management of Pathologic Fracture or Symptomatic Lytic Lesion in Cancer Patients.

OBJECTIVES: The purpose of this retrospective observational study is to report author's experience in computed-tomography (CT)-guided percutaneous vertebroplasty (PV) of the cervicothoracic junction. METHODS: The records of all consecutive patients treated by PV at levels C7, T1, T2, and T3 in a tertiary cancer center during year 2020 were extracted from the Institutional electronic archive. Following data were collected: demographics, indication for PV, procedure features, outcomes, and complications. Technical success was defined as when the trocar was placed into the vertebral body, allowing the injection of polymethyl-metacrylate (PMMA). RESULTS: Eleven patients were identified who received PV on 14 levels. Mean procedure duration was 57 ± 22 min (range [31-142]). A "trans-pedicular approach at the targeted level" was used in 1 vertebra (7%), a "costotransverse approach, at the targeted level" was used in 1 vertebra (7%), a "transpedicular approach via the level below" was used in 3 vertebrae (22%), and a "costotransverse approach via the level below" was used in 9 vertebrae (64%). Meantime to deploy each trocar was 20 ± 5 min (range [12-32]). Technical success was achieved in 14/14 (100%) of vertebrae. Mean postoperative hospitalization duration was 1.9 ± 1.7 days (range [1-11]). According to CIRSE classification, no adverse event occurred. PMMA leakage occurred in two patients; both remained asymptomatic. CONCLUSION: This study provides arguments in favor of safety and efficiency of CT-guided vertebroplasty of levels C7, T1, T2, and T3, for both trocar deployment and monitoring of the vertebral body filling during the PMMA injection.