Humanización en la comunicación de malas noticias en el paciente oncológico y paliativo / Humanization in the communication of bad news in cancer and palliative patients

La comunicación de malas noticias, si bien supone un momento de importante vulnerabilidad para el paciente y sus allegados, es un acto necesario para una atención de calidad. Se trata de una habilidad transversal que, sin embargo, suele carecer de una formación específica en las facultades de Medici-na. Existen numerosos protocolos que establecen las bases de una comunicación eficiente. No obs-tante, lo que marca la diferencia en términos de humanidad es el toque personal que cada médico ofrece. En este artículo ofrecemos una reflexión sobre la visión predominante en el Servicio de Onco-logía Médica de Fuenlabrada del proceso de comunicación de malas noticias. Exponemos conceptos metafísicos, psicológicos y sociales sobre los cuales impera la necesidad de reflexionar para, desde una compresión profunda de la dificultad que la comunicación de malas noticias entraña, ser capa-ces de mejorar. Así mismo, sugerimos elementos fácilmente incorporables a la práctica clínica diaria.

Although the communication of bad news is a moment of great vulnerability for the patient and his or her relatives, it is necessary for quality care. However, it is a cross-cutting skill that often needs more specific training in medical schools. Numerous protocols lay the groundwork for efficient communication. However, each physician's personal touch makes a difference in terms of humanity. In this article, we reflect on the predominant vision of communicating bad news in the Medical On-cology Service of Fuenlabrada. We expose metaphysical, psychological, and social concepts on which there is a need to reflect to be able to improve from a deep understanding of the difficulty that the communication of bad news entails. Finally, we suggest elements that can be easily incorporated into daily clinical practice.

Development of the Anxiety, Depression and Coping (ADAF) screening tool for emotional and coping problems in cancer patients.

OBJECTIVE: Clinical guidelines recommend psychological screening in cancer patients. However, most scales cover many items and hamper detection. In addition, patients are generally referred from routine consultations. The specific objective of the present study was to develop and validate a tool, Anxiety, Depression, Coping (ADAF), to screen for anxiety and depression and assess coping in cancer patients. METHODS: Cross-sectional, multicenter study performed in the medical and radiotherapy-oncology services of five hospitals in Madrid and coordinated by the Medical Oncology Service of Hospital Clínico San Carlos (CEIC nº19/265-E). To determine psychometric properties, the ADAF screening questionnaire ADAF was administered. ADAF includes five items (1 related to anxiety symptoms, 2 related to depressive symptoms, 1 for helplessness coping, and 1 for avoidance coping). Hospital Anxiety and Depression Scale and Mini-Mental Adjustment to Cancer scale were used as the gold standards. Intraclass correlation coefficients were calculated and receiver operating characteristic (ROC) curves constructed. A p value of <0.05 was considered significant. RESULTS: A total of 186 patients completed the evaluation. The correlation coefficients were significant for all dimensions (anxiety, depression, helplessness coping, and avoidance coping) (p < 0.001). The statistical analysis of the ROC curves suggested that the cut-off point for screening was >2 points (3 in the case of depression), with a sensitivity and specificity between 62% and 90%, and an area under the curve above 0.8 for the first 4 items. CONCLUSIONS: ADAF screening has adequate reliability and good sensitivity and specificity. This instrument is useful and can be easily applied to identify emotional and coping problems in cancer patients.

ADJUVANT CHEMOTHERAPY IN LOCALLY ADVANCED RECTAL CANCER: DECIDING ON THE OPTIMAL STRATEGY.

BACKGROUND: Neoadjuvant therapy, followed by surgery, reduces the risk of local relapse in rectal cancer, but approximately 30% will relapse with distant metastases, highlighting the importance of adjuvant chemotherapy (aCT). OBJECTIVE: The objective of the study was to study two regimens of adjuvant treatment in patients with locally advanced rectal cancer and analyze their efficacy and toxicity. METHODS: Between January 2009 and December 2016, 193 patients with Stage II-III rectal cancer who had received neoadjuvant therapy were included by consecutive non-probability sampling. The decision to administer aCT, as well as the specific regimen, was at the discretion of the medical oncologist. Disease-free survival (DFS) and overall survival (OS) were calculated. RESULTS: The mean DFS was 84.85 (95% confidence interval [CI]: 79-90) months in 164 patients receiving aCT, compared to 57.71 (95% CI: 40-74) months in 29 who did not receive aCT (p < 0.001). Then, mean OS was 92.7 (95% CI: 88-97) months and 66.18 (95% CI 51-81) months, respectively (p < 0.001). DFS was 83.6 (95% CI: 76-91) months in 74 patients receiving adjuvant 5-fluorouracil (5-FU), and 82.9 (95% CI: 75-90) months in 90 receiving 5-FU plus oxaliplatin (p = 0.49). OS was 87 (95% CI: 80-94) versus 93.65 (95% CI: 88-99) months, respectively (p = 0.76). The multivariate analysis identified aCT hazard ratio (HR) 0.30 (95% CI: 0.1-0.46), perineural invasion HR 3.36 (95% CI: 1.7-6.5), and pathological complete response HR 0.10 (95% CI; 0.01-0.75) as independent markers of DFS. CONCLUSIONS: In our study, aCT was associated with longer DFS and OS. 5-FU plus oxaliplatin showed greater toxicity with no added benefit in DFS or OS.

Adjuvant chemotherapy in locally advanced rectal cancer: deciding on the optimal strategy

ABSTRACT Background: Neoadjuvant therapy, followed by surgery, reduces the risk of local relapse in rectal cancer, but approximately 30% will relapse with distant metastases, highlighting the importance of adjuvant chemotherapy (aCT). Objective: The objective of the study was to study two regimens of adjuvant treatment in patients with locally advanced rectal cancer and analyze their efficacy and toxicity. Methods: Between January 2009 and December 2016, 193 patients with Stage II-III rectal cancer who had received neoadjuvant therapy were included by consecutive non-probability sampling. The decision to administer aCT, as well as the specific regimen, was at the discretion of the medical oncologist. Disease-free survival (DFS) and overall survival (OS) were calculated. Results: The mean DFS was 84.85 (95% confidence interval [CI]: 79-90) months in 164 patients receiving aCT, compared to 57.71 (95% CI: 40-74) months in 29 who did not receive aCT (p < 0.001). Then, mean OS was 92.7 (95% CI: 88-97) months and 66.18 (95% CI 51-81) months, respectively (p < 0.001). DFS was 83.6 (95% CI: 76-91) months in 74 patients receiving adjuvant 5-fluorouracil (5-FU), and 82.9 (95% CI: 75-90) months in 90 receiving 5-FU plus oxaliplatin (p = 0.49). OS was 87 (95% CI: 80-94) versus 93.65 (95% CI: 88-99) months, respectively (p = 0.76). The multivariate analysis identified aCT hazard ratio (HR) 0.30 (95% CI: 0.1-0.46), perineural invasion HR 3.36 (95% CI: 1.7-6.5), and pathological complete response HR 0.10 (95% CI; 0.01-0.75) as independent markers of DFS. Conclusions: In our study, aCT was associated with longer DFS and OS. 5-FU plus oxaliplatin showed greater toxicity with no added benefit in DFS or OS.

Prognostic Nomogram and Patterns of Use of FOLFIRI-Aflibercept in Advanced Colorectal Cancer: A Real-World Data Analysis.

INTRODUCTION: The VELOUR study evaluated the efficacy and safety of adding aflibercept to FOLFIRI (fluorouracil, leucovorin, irinotecan) in second-line therapy for metastatic colorectal cancer (mCRC). However, a nomogram that can stratify patients according to prognosis is unavailable, and the frequency and effect of the pragmatic use of modified schedules in actual practice remains unknown. METHOD: The sample consists of 250 patients with mCRC treated with aflibercept and irinotecan-based chemotherapy at nine Spanish academic centers between January 2013 and September 2015. The result of a Cox proportional hazards model regression for overall survival (OS), adjusted for covariates available in daily practice, was represented as a nomogram and web-based calculator. Harrell's c-index was used to assess discrimination. RESULTS: The prognostic nomogram for OS includes six variables: Eastern Cooperative Oncology Group performance status, tumor location, number of metastatic sites, mutational status, better response to previous treatment(s), and carcinoembryonic antigen. The model is well calibrated and has acceptable discriminatory capacity (optimism-corrected c-index, 0.723; 95% confidence interval [CI], 0.666-0.778). Median OS was 6.1 months (95% CI, 5.1-8.8), 12.4 months (95% CI, 9.36-14.8), and 22.9 months (95% CI, 16.6-not reached) for high-, intermediate-, and low-risk groups, respectively. Age, comorbidity, or use of modified FOLFIRI regimens did not affect prognosis in this series. Grade 3-4 adverse events were less common following modified schedules. The admission rate because of toxicity was higher in ≥65 years (9.7% vs. 19.6%; odds ratio, 2.26; p = .029). CONCLUSION: We have developed and internally validated a prognostic model for use in individuals with colorectal cancer initiating therapy with FOLFIRI-aflibercept to predict both OS and the effect of pragmatic modifications of the classic regime on efficacy and safety. This can aid in decision making and in designing future trials. IMPLICATIONS FOR PRACTICE: In this study, the authors developed and conducted the internal validation of a prognostic nomogram that makes it possible to stratify patients who are eligible for second-line FOLFIRI-aflibercept based on their probability of survival. This model was developed in a multicenter sample from nine Spanish hospitals. Furthermore, to increase the study's validity, the practical use of aflibercept in this setting was investigated, including doses or pragmatic modifications. The results suggest that the modified schedules often used in this daily clinical practice-based patient population are associated with less severe toxicity without apparent detriment to survival endpoints. It is believed that these data complement the information provided by the VELOUR trial and are relevant for the oncologist in treating colon cancer in the second-line setting.

Enfermedad pulmonar intersticial secundaria a oxaliplatino. Una complicación infrecuente pero posible / Interstitial lung disease caused by oxaliplatin. An uncommon but not unknown complication

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SEOM clinical guidelines for the treatment of advanced colorectal cancer.

Colorectal cancer is the first cause of cancer diagnosis in Spain. Over half of the patients are diagnosed with or will eventually develop distant metastasis. The current manuscript aims to provide synthetic practical guidelines for the therapeutic approaches in advanced disease. Available systemic therapeutic options, and integration and sequencing of chemotherapy with surgical procedures are discussed. Extent of disease, treatment objective, tumor kras mutation status, as well as patient's functional and comorbid conditions shall be considered to properly design the most adequate therapeutic strategy.