Objective
To delineate the trajectories of physical symptoms and psychological distress among patients with a solid metastatic cancer during the last year of life.
Methods
We used data of 345 ...decedents from a prospective cohort of 600 patients with a Stage IV solid cancer. Using group‐based trajectory modelling, we assessed (a) demographic (age, gender, education, cancer site) predictors of trajectory membership, (b) shift in trajectories associated with planned and unplanned hospitalizations, emergency room visits and chemotherapy, and (c) the association between trajectory membership and place of death.
Results
We identified three trajectories of physical symptoms—“persistent mild” (56%), “progressive moderate” (36%), and “progressive severe” (8%), and two for psychological distress—“persistent mild” (72%) and “progressive distress” (28%). Females (β = 1.40 SE = 0.55, p‐value = 0.01) and highly educated patients (β = 1.46 SE = 0.62, p‐value = 0.02) were more likely to experience progressive severe symptoms compared to persistent mild symptoms. Older patients were less likely (β = −1.01 SE = 0.33, p‐value = 0.003), while those with gynecological cancers (β = 1.51 SE = 0.65, p‐value = 0.02) were more likely to experience progressive distress compared to persistent mild distress. Planned and unplanned hospitalizations, emergency room visits, and chemotherapy were associated with a worsening in trajectories. Patients with higher distress were more likely to die in a hospice compared to a hospital.
Conclusions
Interventions to improve physical symptoms and distress can focus on patients at risk of being in worse trajectories and at critical time points in the last year of life—hospitalizations, emergency room visits, and chemotherapy.
Background
Assessing patient and caregiver experiences with care is central to improving care quality. The authors assessed variations in the experiences of advanced cancer patients and their ...caregivers with physician communication and care coordination by patient and caregiver factors.
Methods
The authors surveyed 600 patients with a stage IV solid malignancy and 346 caregivers every 3 months for more than 2 years. Patients entered the cohort any time during their stage IV trajectory. The analytic sample was restricted to patient‐caregiver dyads (n = 299). Each survey assessed patients' experiences with physician communication and care coordination; patients' symptom burden; caregivers' quality of life; and patients' and caregivers' anxiety, financial difficulties, and perceptions of treatment goals. An actor‐partner interdependence framework was used for analysis.
Results
Patients reported better physician communication (average marginal effect AME, 6.04; 95% confidence interval CI, 3.82 to 8.26) and care coordination (AME, 8.96; 95% CI, 6.94 to 10.97) than their caregivers. Patients reported worse care coordination when they (AME, –0.56; 95% CI, –1.07 to –0.05) or their caregivers (AME, –0.58; 95% CI, –0.97 to –0.19) were more anxious. Caregivers reported worse care coordination when they were anxious (AME, –1.62; 95% CI, –2.02 to –1.23) and experienced financial difficulties (AME, –2.31; 95% CI, –3.77 to –0.86). Correct understanding of the treatment goal (vs being uncertain) was associated with caregivers reporting physician communication as better (AME, 3.67; 95% CI, 0.49 to 6.86) but with patients reporting it as worse (AME, –3.29; 95% CI, –6.45 to –0.14).
Conclusions
Patients' and caregivers' reports of physician communication and care coordination vary with aspects of their own and each other's well‐being and with their perceptions of treatment goals. These findings may have implications for improving patients' and caregivers' reported experiences with health care practitioners.
Reports from patients with advanced cancer and their caregivers about physician communication and care coordination vary with aspects of their own and each other's well‐being and with their perceptions of treatment goals. Addressing the well‐being of both members of the dyad and reducing caregivers' uncertainty regarding treatment goals may improve reported experiences with health care providers.
In 2011, the International Society of Geriatric Oncology (SIOG) published the SIOG 10 Priorities Initiative, which defined top priorities for the improvement of the care of older adults with cancer ...worldwide.1 Substantial scientific, clinical, and educational progress has been made in line with these priorities and international health policy developments have occurred, such as the shift of emphasis by WHO from communicable to non-communicable diseases and the adoption by the UN of its Sustainable Development Goals 2030. Therefore, SIOG has updated its priority list. The present document addresses four priority domains: education, clinical practice, research, and strengthening collaborations and partnerships. In this Policy Review, we reflect on how these priorities would apply in different economic settings, namely in high-income countries versus low-income and middle-income countries. SIOG hopes that it will offer guidance for international and national endeavours to provide adequate universal health coverage for older adults with cancer, who represent a major and rapidly growing group in global epidemiology.
To determine the impact of each comprehensive geriatric assessment (CGA) domain on overall survival (OS) and develop a prognostic scoring system for elderly patients with cancer.
A retrospective ...analysis of CGA data collected from 249 consecutive patients with cancer who attended the outpatient geriatric oncology clinic at the National Cancer Center Singapore age 70 years or older was performed. Univariate and multivariate analyses were performed using Cox proportional hazards method to identify significant prognostic factors within the CGA. A simple nomogram to predict OS was developed using regression coefficients from the multivariate model. Concordance between predicted and observed response of the individual patient score was evaluated by means of Harrell's c-index. Calibration was performed using simulated data via bootstrap.
Median age of the patients was 77 years (range, 70 to 94 years). In our model, age (hazard ratio HR, 1.04; 95% CI, 1.01 to 1.07), abnormal albumin level (HR, 1.97; 95% CI, 1.23 to 3.15), poor Eastern Cooperative Oncology Group performance status (≥ 2 v < 2: HR, 1.77; 95% CI, 1.15 to 2.72), abnormal geriatric depression scale status (HR, 1.81; 95% CI, 1.29 to 2.56), high malnutrition risk (high v low risk: HR, 1.84; 95% CI, 1.17 to 2.87), and advanced disease stage (late v early: HR, 1.71; 95% CI, 0.98 to 2.95) were independent predictors of survival.
Results confirm the importance of the CGA in assessment of elderly patients with cancer. The development of this nomogram incorporating these prognostic factors helps predict OS of patients, for further intervention.
Summary Background Previous prognostic models for second-line systemic therapy in patients with metastatic renal cell carcinoma have not been studied in the setting of targeted therapy. We sought to ...validate the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model in patients with metastatic renal cell carcinoma receiving next-line targeted therapy after progression on first-line targeted therapy. Methods In this population-based study, we analysed patients who received second-line targeted therapy for metastatic renal cell carcinoma at 19 centres in Canada, USA, Greece, Japan, Singapore, South Korea, and Denmark. The primary endpoint was overall survival since the initiation of second-line therapy. We compared the prognostic performance of the IMDC model with the three-factor MSKCC model used for previously treated patients for overall survival since the start of second-line targeted therapy. Findings Between Jan 1, 2005, and Nov 30, 2012, we included 1021 patients treated with second-line targeted therapy. Median overall survival since the start of second-line targeted therapy was 12·5 months (95% CI 11·3–14·3). Five of six predefined factors in the IMDC model (anaemia, thrombocytosis, neutrophilia, Karnofsky performance status KPS <80, and <1 year from diagnosis to first-line targeted therapy) were independent predictors of poor overall survival on multivariable analysis. The concordance index using all six prognostic factors (ie, also including hypercalcaemia) was 0·70 (95% CI 0·67–0·72) with the IMDC model and was 0·66 (95% CI 0·64–0·68) with the three-factor MSKCC model. When patients were divided into three risk categories using IMDC criteria, median overall survival was 35·3 months (95% CI 28·3–47·8) in the favourable risk group (n=76), 16·6 months (14·9–17·9) in the intermediate risk group (n=529), and 5·4 months (4·7–6·8) in the poor risk group (n=261). Interpretation The IMDC prognostic model can be applied to patients previously treated with targeted therapy, in addition to previously validated populations in first-line targeted therapy. The IMDC prognostic model in the second-line targeted therapy setting has an improved prognostic performance and is applicable to a more contemporary patient cohort than that of the three-factor MSKCC model. Funding DF/HCC Kidney Cancer SPORE P50 CA101942-01, Kidney Cancer Research Network of Canada, Canadian Institute for Health Research, Trust Family, Loker Pinard, Michael Brigham, and Gerald DeWulf.
Therapy for metastatic renal cell carcinoma should be tailored to the circumstances and preferences of the individual patient. Age should not be a barrier to effective treatment. Systematic geriatric ...screening and assessment contributes to the goal of personalised management, in addition to the involvement of a multidisciplinary team. A task force from the International Society of Geriatric Oncology (SIOG) updated its 2009 consensus statement on the management of elderly patients with metastatic renal cell carcinoma by reviewing data from studies involving recently approved targeted drugs and immunotherapies for this disease. Overall, it seems that age alone does not appreciably affect efficacy. Among the pivotal studies that were included, there is a striking scarcity of analyses that relate toxic effects to patient age. Even if the adverse effects of therapy are no more frequent or severe in elderly patients than in their younger counterparts, the practical, psychological, and functional impact of treatment may be greater, especially if toxic effects are chronic and cumulative.
Mentoring nurtures a mentee's personal and professional development. Yet conflation of mentoring approaches and a failure to contend with mentoring's nature makes it difficult to study mentoring ...processes and relationships. This study aims to understand of mentee experiences in the Palliative Medicine Initiative (PMI). The PMI uses a consistent mentoring approach amongst a homogeneous mentee population offers a unique opportunity to circumnavigate conflation of practices and the limitations posed by mentoring's nature. The data will advance understanding of mentoring processes.
Sixteen mentees discussed their PMI experiences in individual face-to-face audio-recorded interviews. The two themes identified from thematic analysis of interview transcripts were the stages of mentoring and communication.
The 6 stages of mentoring are the 'pre-mentoring stage', 'initial research meetings', 'data gathering', 'review of initial findings, 'manuscript preparation" and 'reflections'. These subthemes sketch the progression of mentees from being dependent on the mentor for support and guidance, to an independent learner with capacity and willingness to mentor others. Each subtheme is described as stages in the mentoring process (mentoring stages) given their association with a specific phase of the research process. Mentoring processes also pivot on effective communication which are influenced by the mentor's characteristics and the nature of mentoring interactions.
Mentoring relationships evolve in stages to ensure particular competencies are met before mentees progress to the next part of their mentoring process. Progress is dependent upon effective communication and support from the mentor and appropriate and timely adaptations to the mentoring approach to meet the mentee's needs and goals. Adaptations to the mentoring structure are informed by effective and holistic evaluation of the mentoring process and the mentor's and mentee's abilities, goals and situations. These findings underline the need to review and redesign the way assessments of the mentoring process are constructed and how mentoring programs are structured.
Objectives:
Several therapies are available for the treatment of advanced/metastatic prostate cancer (PC). However, the systematic assessment of evidence pertaining to the use of these therapies in ...Asian patients is lacking.
Methods:
A systematic literature review (SLR) was conducted using PubMed/Medline search in May 2021 to identify the randomized/nonrandomized controlled trials (RCTs/non-RCTs) and real-world observational studies (prospective/retrospective). Only studies published as full manuscripts in English were included if reporting the efficacy, effectiveness, and/or safety of treatments in Asian patients with advanced/metastatic PC.
Results:
Of the 1,898 retrieved publications, 24 studies were included. These studies had patients with nonmetastatic castration-resistant PC (n = 2), metastatic castration-sensitive PC (n = 4), and metastatic castration-resistant PC (n = 18). Study designs included RCTs (n = 7), non-RCTs (n = 2), and real-world studies (n = 15). Treatments used in included studies were abiraterone acetate plus prednisone (AAP; n = 6), enzalutamide, lutetium-177 prostate-specific membrane antigen (177Lu-PSMA; n = 4 each), docetaxel (n = 3), apalutamide, radium-223 (n = 2 each), darolutamide, cabazitaxel, and pembrolizumab (n = 1 each). The evidence from RCTs (i.e., ARAMIS, SPARTAN, ARCHES, TITAN, LATITUDE, PREVAIL) demonstrated the clinical benefits of apalutamide, darolutamide, enzalutamide, and AAP in terms of overall, disease-free, and metastasis-free survival in Asian patients. These treatments were reported to be well tolerated, with no new safety signals identified in Asian population. The efficacy and safety profiles in Asian patients were consistent with the overall trial population. Data from real-world studies supported the effectiveness and tolerability of AAP, enzalutamide, radium-223, docetaxel, cabazitaxel, 177Lu-PSMA, and pembrolizumab in patients with advanced/metastatic PC.
Conclusions:
This SLR of the Asian data on therapies for advanced PC from the pivotal and real-world studies confirms similar efficacy and safety outcomes, consistent with the results from the pivotal clinical trials. These findings will help clinicians make better treatment decisions in clinical practice for patients with advanced/metastatic PC.
Prostate cancer is a disease of older adults that has undergone a significant therapeutic paradigm shift in the last decade with the emergence of novel androgen receptor pathway inhibitors (ARPis). ...One of the more commonly used ARPis is enzalutamide. This drug, along with darolutamide and apalutamide, initially received approvals in the metastatic castrate-resistant prostate cancer setting but is now utilized frequently in the metastatic castrate-sensitive and non-metastatic castration-resistant settings. Landmark phase III data illustrating ARPi efficacy in older adults are limited to those with excellent performance status. However, its role in unfit older prostate cancer patients remains to be explored in the context of a narrative review. This first-of-its-kind drug review aims to shed light on the most up-to-date evidence behind the unique toxicity profile of ARPis in the context of geriatric vulnerabilities such as cognitive and functional impairment, along with potential solutions and supporting evidence that exists to circumvent these issues in the vulnerable older adult.
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