ABSTRACT Introduction: Hematological toxicity (HT) remains a major side effect of anal cancer (AC) treatment that can lead to unplanned treatment breaks and may affect clinical outcome. Areas covered: This review paper analyses the predictive factors related to HT and methods to minimize HT. Expert commentary: The destruction of red bone marrow (BM) stem cells are responsible for acute HT. BM damage is correlated with radiation dose and volume of BM irradiated. Functional imaging has been used to precisely quantify specific regions of active Pelvic BM . Studies using LKB modelling confirmed that PBM and LSBM act like parallel organs with a consistent volume effect in the development of HT. BM dose-volume constraints are recommended to minimise HT. BM-sparing IMRT plans incorporating active BM sites as avoidance structures resulted in significant reduction of dose to PBM without compromising target coverage and decreased the dose delivered to the functional BM volume. The increased incidence of HT is attributed more to MMC rather than IMRT. A single dose of MMC could be considered to minimize the incidence of HT. Clinical research should focus on newer more potent and potentially less toxic systemic agents to be used in combination with radiation.
Introduction: The mental health of patients with advanced cancer at the end of life is a strong contributor to suffering on the part of both the patient and family. A closer look is needed to address the complexity of psychological adaptation to provide a comfortable transition between life and death.Areas covered: This review describes patient related factors, interventions, and outcomes targeting maintaining and improving mental health for individuals with advanced cancer at the end of life. The Preferred Reporting Items for Systematic reviews and Meta-analyses was used to review the state of the science and the evidence-based hierarchy provided a structure for ranking research quality.Expert commentary: Psychological adaptation for patients with advanced cancer is often comingled with physical symptoms to the extent that neither is distinct. Quality of life is essential in comfort care at end of life. All contributing factors must be considered including the often-missed spiritual needs, cultural factors, developmental issues, and communication relative to end of life. Discussed are both gaps in the science and interventions useful to enhancement of mental health comfort for patients with advanced cancer and their families at the end of life.
Introduction: With long-term cancer survivor rates increasing, quality of life, and a pivotal component of it, the ability to procreate are of growing importance. As treatment can compromise fertility, patients need to be informed about the currently available options to preserve it. However, decisional conflict may arise, as decisions have to be made within the short time frame after diagnosis and before treatment.Areas covered: Decisional conflict reflects the personal perception of uncertainty in choosing between different options. It is typical in decision-making in the context of fertility preservation (FP). It comprises factors such as feeling uninformed, lack of clarity regarding personal values, lack of support, and uncertainty and is associated with decisional regret. Research has shown that additional support tools such as decision aids have the potential to increase knowledge and reduce decisional conflict.Expert commentary: Improvement in the availability of and access to adequate and personalized support for all young cancer patients concerning FP is needed. Information provision should be comprehensive and tailored to individual needs and ideally complemented with a decision aid. Future research should focus on more individualized decision aids and on the male perspective, as existing decision aids are targeted at female cancer patients.
‘Cancer is a tremendous opportunity to have your face pressed right up against the glass of your mortality.’ (Jason Shinder, New York Times, 24 December 2008)While people in many parts of the world...
ABSTRACTIntroduction: Breathlessness is a common and distressing symptom in people with advanced cancer of all etiologies, often co-existing with cough and fatigue. Its incidence and severity incre...
Introduction: Cancer incidence is increasing; one in two people in the UK are expected to develop cancer during their lifetime. However, survival rates of people living with cancer have improved over the last few decades. More than 50% of all UK cancer patients survive for beyond 10 years, this rate has doubled in the last 40 years.Areas covered: This article provides a scientific review of the use of patient reported outcomes (PROs) to assess the short and longer term impact of cancer and treatment on patient quality of life and symptoms.Expert commentary: There is increasing recognition that, in addition to survival and other clinical metrics, we need to understand more about the impact that cancer and its treatment has on the everyday lives of people living with and beyond cancer. Patients must have access to information around quality of life and survival with which they can make more informed decisions about their care. We need to understand more about the natural history of recovery and wellbeing and the contributory factors to identify those who are not doing well and to understand how we can support them better, plan appropriate services and support patients in making choices about treatment.
Introduction: Pain afflicts quality of life and is common in cancer patients. Multiple myeloma is a hematological malignancy often associated with pain. In the last two decades overall survival improved thanks to introduction of novel chemotherapeutic agents such as the proteasome inhibitor bortezomib, and the immunomodulatory drug thalidomide. Unfortunately, these agents could be responsible for development of painful peripheral neuropathy.Areas covered: This review describes strategies for prevention and treatment of pain in multiple myeloma, focusing especially on bone lesions and neuropathy, considered as the main causes of pain in the disease.Expert commentary: Management of pain in multiple myeloma requires a multidisciplinary clinical assessment and a careful follow-up to offer the best treatment, best matched to each patient. Mild to moderate pain could be treated with paracetamol and/or weak opioids, while severe pain requires stronger analgesics. Bisphosphonates, kyphoplasty, vertebroplasty, and radiotherapy are specifically indicated for bone involvement. Neuropathy could be treated removing the cause and controlling symptoms. If it is drug-related, appropriate dose modification/suspension is mandatory. Further studies are needed to better understand pain etiopathogenesis, allowing elaboration of more efficacious analgesic strategies, especially for neuropathic and chronic pain management in order to improve quality of life in cancer patients.
Introduction: Once often perceived as a death sentence, colorectal cancer (CRC) is now a frequently treatable illness for most and a chronic disease for many. The number of people living with a diagnosis of CRC is expected to rise. Even after successful treatment, CRC survivors, mostly the elderly, frequently experience health problems and impaired quality of life (QoL).Areas covered: We present a review on the effects of physical activity and/or nutritional interventions in the QoL of CRC survivors as well as an explanatory introduction to the topic.Expert commentary: Targeting unhealthy lifestyle behavior of these vulnerable individuals during post-treatment care is a promising strategy for improving their health status and QoL, but more evidence is needed, especially for QoL. Thus, besides survival, efforts should also be directed toward improving the QoL of CRC survivors.
Introduction: Clinician predicted survival (CPS) is a crucial part of palliative care but is often found to be inaccurate with most clinicians providing overestimates of survival, potentially leading to suboptimal care. The present paper reviews the literature on CPS in patients receiving palliative radiotherapy and assesses the accuracy of clinician generated survival estimates.Method: A search of Cochrane Central Register of Controlled Trials, Embase, and Ovid MEDLINE was conducted on 2 February 2018 to identify English articles analyzing the accuracy of CPS in cancer patients receiving palliative radiotherapy.Results: Seven studies were included in this review. Survival was overestimated on average, with overestimates ranging from +22.8 to +167.3 days. One study reported average underestimates of survival. No significant differences in accuracy were seen between disciplines. There was no correlation between years of experience and accuracy of CPS.Expert commentary: The incorporation of accurate CPS into treatment and family-related decisions can improve quality of life of palliative radiotherapy patients. Research is needed on survival estimates informed by prognostic tools, validation of prognostic tools specific to palliative settings, and the effects of CPS on dose fractionation and other treatment decisions.
Introduction: Undertreatment of cancer pain is associated with inadequate assessment and inconsistent or non-standardized classification, resulting in failure to both appreciate its multidimensional nature and appropriately target therapeutic interventions. This review examines the classification of cancer pain with a focus on the progressive development of the Edmonton Classification System for Cancer Pain (ECS-CP); the appropriateness of its constituent features, associated outcomes and its potential future development in cancer pain classification.Areas covered: A Medline search from 1989 to November 2017, using combined terms ‘cancer’ or ‘oncology’, ‘Edmonton’, ‘pain’ or ‘analgesia’, and ‘staging’ or ‘classification’, identified 280 records. A total of 20 studies with empirical data relating to validation studies of the ECS-CP or evaluation of either its constituent or proposed domains were selected for inclusion in the core review.Expert commentary: The ECS-CP is a tool in evolution and a valid template for further cancer pain classification development. The assessment of ECS-CP domains requires a standardized approach. The domain ratings can inform the therapeutic strategy, and are associated with pain management outcomes, particularly stable pain control. The ECS-CP enables standardized reporting, based on patients’ pain and related characteristics, and thus may improve the validity of comparisons across research study samples.
KEYWORDS: Cancer rehabilitationoccupational therapysupportive careactivities of daily lifeperson centered care
INTRODUCTION:A critical challenge in oncology is interpreting clinical trial results to inform clinical decision making. Clinical trials typically focus on overall survival (OS) and progression-free survival (PFS) as primary endpoints, which do not reflect early signs of meaningful patient benefit or harm. Cancer symptom response (CSR) can provide information about early treatment response, and studies show that CSR predicts long-term health outcomes.AREAS COVERED:CSR requires careful consideration of its measurement and interpretation to facilitate integration into clinical practice. We describe considerations for the evaluation, analysis, and interpretation of CSR in clinical trials. To illustrate the potential clinical value of CSR, we performed a retrospective analysis of a three-arm randomized cooperative-group clinical trial.EXPERT COMMENTARY:Evaluation of CSR provides a meaningful assessment of early cancer treatment effects. It can act as an early signal of disease progression and death and thus can identify which patients with stable disease will have a more favorable prognosis. Future research will include development of methods for more accurate assessment of CSR, reduction of the number of symptoms used as signals for disease progression or survival by tumor type, and statistical methods that effectively correct for missing data and informative censoring.
KEYWORDS: Mindfulnessmeditationquality of lifehealth-related quality of lifepsycho-oncologycancer survivorscomprehensive careintegrative health
INTRODUCTION:chemotherapy-related cognitive dysfunction (CRCD) is a growing problem due to rising cancer rates and increasing numbers of cancer survivors. upwards of 70% of ovarian cancer patients report cognitive-changes following treatment for their cancer.AREAS COVERED:the underlying mechanisms of CRCD are a subject of active research and debate. the initial insult may start with the diagnosis of cancer itself, both in the number of peripheral cytokines it produces but also in the psychological changes caused by stress and anxiety associated with the diagnosis. chemotherapy, in its ability to alter dna in the replication cycle, has been shown to damage neurons and their stem cell precursors.EXPERT COMMENTARY:based on proposed mechanisms and advancements in other neuropsychological diseases, various pharmacologic and behavioral interventions have been demonstrated to show improvements in patient's quality of life and in their perceived cognitive abilities and memory. further research is necessary to be able to determine when and how these cognitive changes occur, and if their multiple potential biological underpinnings can synergize toward deleterious cognitive effects. future therapies will include prevention strategies to avert CRCD's effects on patients.
ABSTRACT Introduction: The challenges of achieving timely cancer diagnosis in adolescents and young adults are recognised. However, contributing factors and associated clinical and psychosocial outcomes are poorly understood. Areas covered: We present a scoping review of existing evidence into time intervals to diagnosis and potential mechanisms influencing the identification of cancer symptoms and impact on a timely diagnosis. Charting data using Walters ‘pathways to treatment’ we summarise the diagnostic pathway into four interval categories: appraisal, help-seeking, diagnostic, and pre-treatment, and illustrate where evidence exists and where unanswered questions remain. Expert commentary: Whilst the research base has expanded over the last decade in cancer care there continues to be limited research that reveals the complexity of the timeliness of diagnosis in this population. There are unique issues facing this age group in terms of rarity of cancer, complexity of symptoms and problems with healthcare system access that create a constellation of challenges. We offer explanations for diagnostic difficulties in this age group, and explain how, with the limited available evidence, we are still seeking solutions to what is a uniquely complex problem.
Shared decision-making (SDM) is a best practice in personalized medicine. SDM is defined as ‘an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences’ [1]. It reflects the ideals of person-centered care, by virtue of its inherent respect and valuation of the patient perspective as a vital component in the treatment decisionmaking process [2]. Amid a shift from the unbridled medical paternalism of the mid-twentieth century, to the other extreme of unqualified patient self-determination and medical consumerism, SDM reflects a reasonable midpoint in the pendulum swing between these more polarized approaches. Accordingly, the National Academy of Medicine has called for us all to do SDM, and has been doing so for more than a decade [3]. Unfortunately, it is not clear that this long-standing recommendation has had much impact on clinicians’ practices, despite growing evidence as to the many benefits of an SDM approach in cancer care and beyond [4–6]. Data continue to show that most patients with advanced cancer fundamentally misunderstand their prognosis [7,8], and that many Americans die each year in ways that they would not want, such as in hospital or intensive care unit settings, or receiving ineffective chemotherapies in the last 2 weeks of their life [9–11]. These gaps seem to be even worse in cases of prognostic uncertainty, such as hematologic malignancies, where cure may still be possible in those with relapsed or refractory disease (albeit less likely) [12–18]. As we grapple with this ongoing problem of poor-quality end-of-life care in oncology, SDM must be seen as an essential tool to improve these outcomes. More broadly though, SDM and the elicitation of patient preferences that must accompany it are essential to improving patients’ experiences of illness when facing a cancer diagnosis. After all, patients are the experts on their own experiences. SDM is particularly necessary in cases where reasonable people might disagree about the ‘right’ path, wherein there is truly a ‘preference-sensitive decision’ at play. A classic example is the choice of whether to pursue adjuvant chemotherapy for an early stage, colorectal, breast, or lung cancer. There is no clear ‘right answer’ in these settings, but rather a series of trade-offs to consider, the value of which might be perceived differently by people with differing value systems and priorities. While these therapies are known to reduce the risk of cancer recurrence, in many cases these reductions are relatively modest, in the order of a few percentage points. Along with such modest reductions in recurrence risk, these therapies also come with some long-term risks and short-term toxicities. For example, cardiotoxicity may result from anthracycline-containing regimens often used for breast cancer treatment. Similarly, neuropathy may result from oxaliplatincontaining regimens often used as adjuvant therapy for colorectal cancer, or from taxanes as used to treat breast or lung cancer. Hopefully, we all agree that it is important for our patients to understand the risks and benefits of any therapy they consider, and that an honest, open conversation must take place about the right path for eachperson. Such is the spirit of SDM, and thosewho care for people with cancer generally seem to agree in principle about its importance. The irony, however, is that most of us have not actually been trained in how to operationalize SDM in our practices. Rather, under the traditional apprenticeship model of medical training, we espouse more of a ‘see one, do one, teach one’ approach. Sadly, this often means that someone who has never been trained in SDM ends up themselves somehowmodeling it for the next generation of clinicians, who then muddle through it on their own after seeing it just once or twice, perhaps never having seen a vanguard example of SDM in the flesh. The result is what I tend to hear most often when I observe these interactions in practice: relatively superficial, one-time discussions about treatment paths, emphasizing risks and toxicities, but missing any meaningful exploration and sharing of preferences, priorities, goals, and values. As such, we fail to recognize the importance of ‘diagnosing preferences,’ an essential component of true SDM [19,20]. The importance of ‘diagnosing preferences’ became abundantly clear to me recently, as I struggled to understand some surprising results from a research study our team conducted [21]. In short, we found that a sizeable minority of laypersons would choose a palliative-intent chemotherapy instead of one that could cure them, even when the chance of cure approaches 50%. We expected that the chance of cure would largely drive decisionmaking, and it certainly did in part, however amajor predictor of a
ABSTRACT Introduction: It is well known that, with advances in the treatment of cancer patients achieving a 5-year overall survival of over 75% nowadays, pediatric neuro-oncologists are worried about long-term sequelae that frequently demand lifelong care and multiple specialist skills. Areas covered: This review aims to discuss the main issues concerning cancer survivors’ disabilities and rehabilitation, including cognitive and neuropsychological aspects, language and social skills, the return to school, starting or returning to work, endocrinological impairments, and supportive measures. The review also covers some experimental rehabilitation pathways based on advanced tools or techniques to provide an overview of the currently-available options for improving patients’ quality of life. We have included our findings deriving from a lengthy experience (2000–2015) of assessing brain tumor patients and managing their intensive tailored rehabilitation. A case report on a patient’s coping with childhood cancer into adult life has been added to give a pragmatic example of the psychological needs and difficulties of young cancer survivors during the necessary transition from pediatric age into adulthood adaptation. Expert commentary: It is important to stress that the tremendous progress made to date in our knowledge of pediatric neuro-oncology and in our management of patients has to be accompanied by a day-to-day effort to provide for their tailored rehabilitation, striving to bridge the gap that separates them from the normal life and experiences of their healthy peers.
INTRODUCTION:Approximately 70,000 adolescent and young adults (AYA) are diagnosed with cancer each year. While advancements in treatment have led to improved prognosis and survival for patients, these same treatments can adversely affect AYA reproductive capacity. Localized treatments such as surgery and radiation therapy may affect fertility by removing or damaging reproductive organs, and systemic therapies such as chemotherapy can be toxic to gonads, (ovaries and testicles), thus affecting fertility and/or endocrine function. This can be traumatic for AYA with cancer as survivors often express desire to have genetic children and report feelings of regret or depression as a result of infertility caused by cancer treatments.AREAS COVERED:Emerging technologies in the field of assisted reproductive technology offer new promise for preserving the reproductive capacity of AYA cancer patients prior to treatment as well as providing alternatives for survivors. The following review revisits contemporary approaches to fertility preservation as well newly developing technologies.EXPERT COMMENTARY:There are several advances in ART that hold promise for patients and survivors. However there are challenges that inhibit uptake including poor communication between providers and patients about risks and fertility preservation options; high costs; and lack of insurance coverage for fertility preservation services.
One of the main objectives of palliative care programmes is to maintain the best “possible” quality of life for patients and their relatives. The adjective ‘possible’ indicates that we must not sacrifice everything in an idealistic attempt to eliminate the finitude that characterizes life itself. On the contrary, so-called end of life can represent an opportunity for human growth. Quality of life does not simply refer to the control of the psychophysical symptoms of patients, nor it can fully represent the dignity of man as a human being, independently of its different levels of expression in individuals. Attention to quality of life really means a taking on of responsibility and continuity of care, which denotes “quality” in palliative care programmes.
The HER2+ breast cancer subtype accounts for 20–30% of cases and represents a particularly aggressive form of breast cancer. As this type of breast cancer is dependent on the HER2 receptor for prol...
