BACKGROUND:Pain is common in advanced cancer, and many people require opioid switching to achieve adequate analgesia. However, longitudinal patterns of switching across the complete illness trajectory remain poorly characterised. This study describes the incidence, indications, dose Sthresholds, and prescribing patterns of opioid switching from advanced cancer diagnosis to death. METHODS:This retrospective cohort study analysed opioid prescribing data for 200 adults with advanced cancer from diagnosis to death. Prescribing data were converted to standardised oral morphine equivalent daily dose (oMEDD). Switching frequency, dose thresholds, duration of opioid use, documented indications, and prescriber patterns were analysed using descriptive statistics. RESULTS:Opioid switching occurred in 58% of patients (n=116), with some requiring up to four switches. Each successive switch occurred after substantial dose escalation during treatment on a given opioid, where starting doses of each successive switch approximately doubled: 20mg oMEDD for the first opioid, 30mg at first switch, 60mg at second, and 180mg at third switch. Median duration on each opioid progressively shortened with each switch: 39 days (IQR 9-98), 25 days (IQR 6-103), and 18 days (IQR 5-53) for the first, second, and third switchess respectively. Inadequate analgesia was the predominant indication (58% of switches). Palliative care clinicians initiated an increasing proportion of switches (31% of first opioids; 89% of third). CONCLUSION:Opioid switching is common across the advanced cancer trajectory, characterised by progressive dose escalation and shortening duration of use with each successive switch. These findings highlight the importance of access to multiple opioid options and timely specialist palliative care involvement.

BACKGROUND:Unpaid caregivers play a crucial role in providing care for people with life-limiting illnesses such as cancer, yet their economic contributions are rarely recognised in economic evaluations, leaving caregivers to shoulder significant direct and indirect costs. AIM:To explore the direct and indirect costs experienced by unpaid caregivers of people with cancer receiving palliative care. DESIGN:A qualitative study underpinned by a social constructivist framework, reported in line with COREQ and RTARG guidelines. Semi-structured interviews were conducted with unpaid caregivers to capture their lived experiences of caregiving costs. Thematic analysis was employed. SETTING AND PARTICIPANTS:The study was conducted at a single tertiary hospital in Melbourne, Australia. Eleven caregivers (43-87 years; mean 64 years) participated, including spouses, children, and parents of cancer patients who had accessed palliative care. RESULTS:Caregivers reported a wide range of direct costs, including food, equipment, medications, transportation, insurance, and home modifications. Indirect costs emerged as equally burdensome, including time spent on personal care, care-coordination, employment disruption, and loss of leisure. These burdens frequently extended beyond the caregiving period, undermining economic security and long-term wellbeing. CONCLUSIONS:Caregiving imposes substantial and enduring direct and indirect costs that are rarely measured or recognised in decisions made around health systems. Findings highlight the need for a validated tool to capture the full cost of caregiving, to guide equitable comprehensive economic evaluation.

Aboriginal and Torres Strait Islander people (hereafter respectfully referred to as First Nations) experience poorer cancer outcomes and higher mortality rates compared to non-Indigenous Australians. Barriers in accessing and engaging with cancer care services contribute significantly to these disparities. The First Nations Cancer Coordinator (FNCC) role offers a model that combines cultural and coordination support to improve the navigation of cancer services for First Nations people. This project sought to understand perceptions and impact of a pilot FNCC intervention on the care of First Nations patients, from the perspective of cancer care teams. An exploratory, qualitative study was undertaken. The study was co-designed with a First Nations Community Advisory Group. Semi-structured interviews were undertaken with ten non-Indigenous cancer staff who had worked alongside the FNCC to support First Nations patients with cancer and their families. Analysis revealed three overarching themes relating to the scope and impact of the FNCC role: 1) Integrating cultural wisdom in cancer care delivery; 2) Relationship building through dedicated time and presence; 3) Bridging cultures by facilitating two-way communication and trust between patients and healthcare providers. The findings highlight the critical importance of FNCC roles in advocating for and enhancing cultural safety in cancer care, essential for addressing disparities and improving cancer outcomes for First Nations Australians.

BACKGROUND:Informal caregivers are essential to the provision of cancer care at the end of life, yet the economic costs they bear remain poorly understood and are neither routinely captured nor used in economic evaluation. The absence of consistent data collection and agreed methods for valuation risks underestimating these costs in both policy and practice. AIM:To synthesise the current evidence on the costs borne by informal caregivers for individuals with cancer who have accessed palliative care or are at the end of life and to highlight methodological considerations in measuring these costs. DESIGN:A systematic search and narrative synthesis. DATA SOURCES:MEDLINE, CINAHL, PsycINFO and Cochrane databases were searched for relevant studies published in English between 2013 and 2023. RESULTS:The analysis included 18 studies. Costs to caregivers were categorised into direct costs (eg, out-of-pocket expenses), indirect costs (eg, employment impact) and time costs associated with caregiving tasks. Carer costs varied by cancer stream, functional status and phase of illness. Significant inequities were evident, with carers who were female, rurally located or from socioeconomically disadvantaged groups experiencing higher burdens. There was no standard methodology for measurement of caregiving costs. Heterogeneity in study design, populations and valuation methodologies limited direct comparison of cost estimates across settings. CONCLUSIONS:Informal caregiving imposes significant and unevenly distributed costs. There is a need for an economic tool to standardise how these costs are measured. This would promote integration of carer cost into economic evaluations and would inform policies that support equity and sustainability in cancer care.

BACKGROUND:Despite evidence supporting the benefits of Patient-Reported Outcome Measures (PROMs) in palliative care, their widespread implementation remains unrealized. This article aims to provide key insights and recommendations to aid the implementation of PROMs in health care services by addressing the question: What are the attitudes of health care professionals toward PROMs in palliative care, as reported in the qualitative literature? METHODS:We conducted a systematic search with a narrative synthesis of the findings. Systematic searches of Medline, EMBASE, CINAHL, and PsycInfo were undertaken for studies with qualitative evidence, published between June 2013 and January 2025. Included studies were primary studies using qualitative methods to explore health care professionals' attitudes and experiences with PROMs in adult palliative care settings. Study quality was appraised using the Critical Appraisal Skills Program checklist, and findings were synthesized using thematic analysis informed by a hermeneutic framework. RESULTS:Nineteen studies met the inclusion criteria and were included for analysis. We identified three central themes regarding the attitudes of health care professionals toward PROMs: (1) the effect of PROMs on the provision of health care, (2) the contribution of PROMs in delivering patient-centered care, and (3) the integration of PROMs into clinical practice. CONCLUSIONS:Given the ongoing challenges in integrating PROMs into routine palliative care, a systematic implementation approach is imperative. Our findings highlight important areas that require detailed consideration to enhance routine PROM implementation in clinical care, by reducing barriers and attending to clinician concerns.

Purpose Medicinal cannabis is increasingly used in cancer care despite limited high-quality evidence to inform practice. It is increasingly legalized around the world; however, this has outpaced high-quality research on cancer symptom outcomes, leading to patient and prescriber uncertainty. This trial evaluates the safety profile, tolerability, and impact of medicinal cannabis on quality of life in advanced cancer. Methods This is a Phase I/II multicenter clinical trial. The Phase I component is open-label and aims to determine the safety profile and tolerability of medicinal cannabis use by evaluating clinical outcomes and pharmacokinetic profile. The Phase II component is a double-blind, randomized clinical trial that aims to determine the impact of medicinal cannabis on quality of life and symptom control (pain, anorexia, anxiety, sleep, nausea, treatment satisfaction, toxicity, and caregiver burden) using validated instruments in people with advanced cancer. Findings & Implications This trial is expected to generate important knowledge about the tolerability, efficacy, and adverse effects of medicinal cannabis in people with advanced cancer, with a particular focus on quality of life and symptom burden. Protocol adaptations aimed at enhancing inclusivity may be worth noting in future studies. Collectively, the findings have the potential to inform clinical practice, reduce decisional uncertainty among prescribers and patients, and affect care for the estimated 10 million people who die of advanced cancer annually worldwide.Australian New Zealand Clinical Trials Registry identifier: ACTRN12619001534178

BACKGROUND:While evidence demonstrates benefits of early palliative care, translation into practice remains inconsistent. Effective implementation strategies are required to advance the field. AIM:To understand implementation strategies perceived as effective in delivering early palliative care for people with cancer. DESIGN:Multi-site stepped-wedge implementation trial of an early palliative care model for people with cancer, 'Care Plus', with qualitative outcome data focused upon perceptions of implementation strategies. Designed to target barriers to palliative care, Care Plus intervention involved: introduction of palliative care at designated cancer specific illness points; outpatient delivery of minimum three palliative care consultations alongside usual cancer care; and primary care case conferences. Interviews to understand perceptions of implementation strategies were audio-recorded, transcribed and analysed using a combined thematic inductive and theoretical deductive approach. This enabled identification of emerging ideas as well as categorisation based upon the RE-AIM implementation framework domains (Reach, Effectiveness, Adoption, Implementation and Maintenance). SETTING/PARTICIPANTS:Four Australian hospitals, involving patients, carers and healthcare providers purposively sampled across representative tumour streams. RESULTS:Fifty-one interviews: patients (n = 11), caregivers (n = 2) and healthcare providers (physicians n = 19, nurse consultants/practitioners n = 16, other n = 3), with, in total, 232 patients receiving Care Plus. Participants highlighted effective implementation strategies as: clinician-endorsed 'transition' points to prompt referral; systematic identification of patients; patient referral embedded into workflows; branding 'Care Plus', key phrases and mentored training to support referring clinicians; regular feedback to clinicians; and co-locating palliative care and cancer clinics. CONCLUSION:These effective strategies are available for the field to replicate supporting broader palliative care implementation. TRIAL REGISTRATION:ACTRN12619001703190, [https://www.anzctr.org.au/].

The quality of palliative and end-of-life care (EOLC) in residential aged care (RACFs) is variable, and often suboptimal. The aim of IMPART is to improve palliative care in RACFs. IMPART provides online training and telehealth palliative-geriatric support to aged care staff and family physicians/general practitioners (GPs) to enable timely EOLC discussions, clinical support, and improve documentation of care preferences. This may lead to preference-based care, reduction of unplanned hospitalization, and improved quality of life and EOLC. This protocol describes a study to evaluate the effectiveness, cost, and implementation process of the IMPART intervention. This study is a pragmatic, stepped-wedge, cluster randomized controlled trial across 10 RACFs to evaluate the IMPART intervention. Clusters are randomly assigned to intervention or control groups. The IMPART intervention group 1) receives timely end-of-life support from specialist In-Reach teams using telehealth; 2) engages RACF staff and GPs in a Planning Ahead Team to reflect on current practices and co-design an Action Plan to improve EOLC planning and processes; 3) receives an online interactive, needs-based EOLC education program for staff and GPs working in RACFs. The control groups receive the IMPART intervention in subsequent waves. The primary outcome measure is reduction of unplanned hospital admissions and avoidable hospital transfers for residents at end-of-life when appropriate care in their RACF is possible and consistent with residents’ wishes. Secondary outcomes include reduction of emergency department presentations and length of stay of unplanned hospital admissions, and improvement in residents’ quality of life, comfort, satisfaction, and quality of EOLC. RACFs are high-mortality settings, yet the quality of palliative and EOLC varies across facilities. There is an urgent need for timely and integrated high-quality palliative care delivered in this context. Implementing IMPART, as a novel telehealth intervention, aims to address this need. This large multisite trial will provide robust evidence about the impact of the intervention (efficacy, cost-effectiveness, and process evaluation), to inform future roll-out and scale-up into the residential aged care sector. anzctr.org.au; ACTRN12622000760774. Prospectively registered on 27/05/2022.

Previous reports indicated many patients with advanced cancer and limited life expectancy have ongoing preventive medication prescription (PMP) of uncertain benefit and increased risk. Our review of palliative care oncology admissions found high rates of PMP (69%) at time of first palliative care admission, despite high rates of inpatient deprescription (88%) and death at a median of 16 days (interquartile range 10-45) following admission. Rates of PMPs did not vary by time from last systemic treatment (P = 0.29) or by prior palliative care involvement (P = 0.82). Physicians and the wider multidisciplinary care team may be missing deprescription opportunities for terminally ill patients.

BACKGROUND:Opioid-induced constipation is a common side effect of Oxycodone. Oxycodone/Naloxone Prolonged Release (OXN PR) mitigates opioid-induced constipation in non-cancer pain, however its evidence is limited in people with pain from advanced cancer. AIMS:To demonstrate analgesic non-inferiority, and superiority in reducing constipation for Oxycodone/Naloxone Prolonged Release (OXN PR) compared to Oxycodone Prolonged Release (Oxy PR). DESIGN:Multi-centre open-label randomised controlled trial comparing OXN PR to Oxy PR over 5 weeks. The primary aim was to demonstrate analgesic non-inferiority of OXN PR compared to Oxy PR. The secondary aim was to demonstrate superiority of constipation reduction in the OXN PR arm. SETTING/PARTICIPANTS:Participants with moderate-severe pain (⩾4/10) from advanced cancer were eligible. RESULTS:Thirty seven of planned 96 patients were recruited with the study stopping early due to enrolment challenges during the COVID-19 pandemic. Average pain was -1.5 points (95% CI -3.3; 0.4) favouring the OXN PR arm compared to Oxy PR at 5 weeks, meeting analgesic non-inferiority, defined as falling within a one point non-inferiority margin. The OXN PR arm demonstrated less constipation with a significantly lower Bowel Function Index score (-24.87 (95% CI 47.54; 2.21), p = 0.03) compared to Oxy PR. Adverse effect safety profile favoured OXN PR. CONCLUSIONS:OXN PR is non-inferior to Oxy PR in analgesic effectiveness and superior in reducing constipation. These results indicate OXN PR as the choice of opioid preparation in advanced cancer. Future studies may explore adding naloxone to other slow and immediate release opioid preparations. TRIAL REGISTRY:Australian New Zealand Clinical Trials RegistryTrial registration number:ACTRN12619001282178URL of trial registry record:https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377673&isReview=true.

Background: High-flow nasal oxygen (HFNO) therapy delivers humidified, heated air with flow rates of up to 60 L/min with oxygen entrained. HFNO has advantages over conventional oxygen therapy, including precise and reliable fraction of inspired oxygen delivery, therefore is recommended as first-line treatment for people with acute hypoxaemic respiratory failure. Objectives: This pilot study aimed to determine the feasibility and acceptability of domiciliary nasal high flow (NHF) without entrained oxygen for people with chronic obstructive pulmonary disease (COPD) and severe breathlessness. Design: Single-arm, mixed-methods, pilot study of an 8-day, air-only NHF intervention in adults with COPD and severe breathlessness not requiring domiciliary oxygen therapy. Methods: Participants were educated and advised to use NHF for ⩾7 h per night for 7 nights with day use as desired. Patient-reported outcome measures were assessed on Days 3, 5 and 8. Primary outcome: feasibility. Secondary outcomes: breathlessness (dyspnoea), fatigue, quality of life, physical function, sleep, tolerability and safety. Acceptability was also assessed through semi-structured interviews. Results: Fifteen participants were enrolled (mean age 73.6; 40% women; mean FEV 1 41% predicted, mean DLCO 43.0% predicted; mean modified Medical Research Council score 3.7). Thirteen (87%) completed the trial, with 8 (54%) keeping the device at the end of the trial and 3 (20%) continuing use long-term. Adherence varied, with average daily usage higher amongst participants who kept the device compared to those who returned it (6.8 h ± 2.3 h vs 3.4 h ± 3.7 h). No changes in worst breathlessness (mean = 0.7, SD = 1.2, p = 0.109), dyspnoea mastery (mean = 0.3, SD = 0.6, p = 0.176) or fatigue (mean = 0.0, SD = 2.4, p = 1.00) were observed at Day 8 compared to baseline. No significant adverse events were reported. Qualitative interviews demonstrated subjective improvements in breathlessness, dry mouth and sputum production for some participants, whilst others found NHF uncomfortable. Fear of NHF dependence and concerns regarding long-term running costs were reported. Conclusion: Domiciliary NHF was a feasible intervention, albeit with varied adoption and acceptability. These trial implementation outcomes may have affected preliminary effectiveness outcomes. Further research is required to determine what role domiciliary NHF may have for people with COPD and severe breathlessness. Trial registration: ACTRN12621000044820.