Best supportive care: a euphemism for no care or a standard of good care?

This article seeks to address the question: Is best supportive care (BSC) in research a euphemism for no care or a standard of good care? The data regarding the ethical and methodological validity of BSC studies are reviewed. Most of the BSC studies published over the past 25 years are really treatment versus no treatment studies represented as BSC studies. By ignoring the best contemporaneous standards of BSC, standardizing practices in multicenter studies, validating participating centers, or documenting treatment delivery, researchers belie the stated intention of studying BSC. Most studies sought to evaluate if there was any benefit of a new anti-tumor treatment versus discontinuation of anti-tumor therapies. Overwhelmingly, and with few exceptions, the impact of BSC practices was not really part of the key research question. To be ethical and methodologically valid, BSC studies must incorporate standards consistent with contemporaneous, proven BSC practice standards. Work is underway to develop widely validated standards of practice for the control arm of best supportive care studies. These can be readily incorporated in to study development and evaluation.     

Hospice care发展现状

在尚无公认的译名之前,Hospice(H)可考虑译为养护之家,Hospice care(HC)则为养护之家护理。为可资借鉴的一些有关 HC 的经验和信息,下面将 HC 现状予以扼要综述。早在1967年英国 Saunders 首先创立为晚期癌症患者服务的 H,     

Follow-up care after childhood cancer: Survivors’ expectations and preferences for care

AimsTo describe (1) self-rated quality of life, late effects and perceived future vulnerability, (2) expectations before a follow-up appointment, subsequent satisfaction and preferences for different models of care and (3) differences between survivors in quality of life, perceived late effects, vulnerability, expectations regarding follow-up, information needs (topics they want to and did discuss) and preferences for different models of care depending on risk stratification among childhood cancer survivors.MethodOne hundred and twelve of 141 survivors (18–45 years), diagnosed before 16 years and >5 years since diagnosis completed questionnaires before and after a follow-up appointment (or an abridged questionnaire if they did not attend an appointment within the study period). We collected data on physical (physical component score [PCS]) and mental (mental component score [MCS]) quality of life, late effects, future vulnerability and expectations about care (clinical: identification of late effects; supportive: employment, relationships). Medical information was extracted from case notes.ResultsMCS and PCS were comparable to population norms, but 55.5% of survivors reported ?1 late effect (range 1–9). Clinical care was rated more highly than supportive care (p < 0.001) especially in those with worse PCS (p = 0.042). Supportive care was rated highly by survivors who reported more late effects (p = 0.040), higher future vulnerability (p < 0.001) and lower MCS (p = 0.005), and by women (p = 0.014). Regardless of risk stratification, consultant-led follow-up was valued higher than other models (nurse-led care, GP-led care or postal/telephone follow-up, p < 0.001).ConclusionChildhood cancer survivors are in favour of sustaining long-term follow-up care within the existing consultant-led model but this is not feasible given the increasing number of survivors. In the future we therefore need to develop alternative services which will provide the best medical care for each survivor’s needs.     

Too old to care?

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH (http://www.theschwarzcenter.org/rounds.asp). The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient and support to caregivers, and encourages the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Ageism is a pervasive problem throughout society. It is rooted in language, attitudes, beliefs, behaviors, and policies. Aging profoundly influences physiology, challenging the medical community to accommodate but not discriminate. The elderly are at an increased risk of disease and disability. Sixty percent of cancer occurs in people aged 65 and older, and the population is aging. The treatment of cancer in the elderly is complicated by comorbidities and other physiological factors, particularly renal, bone marrow, and metabolic reserve. Caregivers have to treat patients in a manner that optimizes treatment and avoids anticipated harm. However, the caregiver is often faced with situations where they must balance their personal beliefs, professional values, and knowledge of medicine with their patients' preferences and needs. Discussion in the Rounds focused on age bias, drug toxicity, life prolongation, and symptom relief, with the role of the caregiver, and the relationship to the patient, being pivotal.     

Young adult cancer survivors’ follow-up care expectations of oncologists and primary care physicians

Purpose

Young adult cancer survivors face unique challenges associated with their illness. While both oncologists and primary care physicians (PCPs) may be involved in the follow-up care of these cancer survivors, we hypothesized that there is a lack of clarity regarding each physician’s roles and responsibilities.

Methods

A self-administered survey was mailed to young adult cancer survivors in British Columbia, Canada, who were aged 20 to 39 years at the time of diagnosis and alive at 2 to 5 years following the diagnosis to capture their expectations of oncologists and PCPs in various important domains of cancer survivorship care. Multivariate logistic regression models that adjusted for confounders were constructed to examine for predictors of the different expectations.

Results

Of 722 young cancer survivors surveyed, 426 (59%) responded. Among them, the majority were White women with breast cancer. Oncologists were expected to follow the patient’s most recent cancer and treatment-related side effects while PCPs were expected to manage ongoing and future cancer surveillance as well as general preventative care. Neither physician was perceived to be responsible for addressing the return to daily activities, reintegration to interpersonal relationships, or sexual function. Older survivors were significantly less likely to expect oncologists (p = 0.03) and PCPs (p = 0.01) to discuss family planning when compared to their younger counterparts. Those who were White were significantly more likely to expect PCPs to discuss comorbidities (p = 0.009) and preventative care (p = 0.001).

Conclusions

Young adult cancer survivors have different expectations of oncologists and PCPs with respect to their follow-up care. Physicians need to better clarify their roles in order to further improve the survivorship phase of cancer care for young adults.

Implications for Cancer Survivors

Young adult cancer survivors have different expectations of their oncologists and PCPs. Clarification of the roles of each physician group during follow-up can enhance the quality of survivorship care for young adults.

     

Initial care and outcome of glioblastoma multiforme patients in 2 diverse health care scenarios in Brazil: does public versus private health care matter?

Background

The aim of this study was to describe the epidemiological and survival features of patients with glioblastoma multiforme treated in 2 health care scenarios—public and private—in Brazil.

Methods

We retrospectively analyzed clinical, treatment, and outcome characteristics of glioblastoma multiforme patients from 2003 to 2011 at 2 institutions.

Results

The median age of the 171 patients (117 public and 54 private) was 59.3 years (range, 18–84). The median survival for patients treated in private institutions was 17.4 months (95% confidence interval, 11.1–23.7) compared with 7.1 months (95% confidence interval, 3.8–10.4) for patients treated in public institutions (P < .001). The time from the first symptom to surgery was longer in the public setting (median of 64 days for the public hospital and 31 days for the private institution; P = .003). The patients at the private hospital received radiotherapy concurrent with chemotherapy in 59.3% of cases; at the public hospital, only 21.4% (P < .001). Despite these differences, the institution of treatment was not found to be an independent predictor of outcome (hazard ratio, 1.675; 95% confidence interval, 0.951–2.949; P = .074). The Karnofsky performance status and any additional treatment after surgery were predictors of survival. A hazard ratio of 0.010 (95% confidence interval, 0.003–0.033; P < .001) was observed for gross total tumor resection followed by radiotherapy concurrent with chemotherapy.

Conclusions

Despite obvious disparities between the hospitals, the medical assistance scenario was not an independent predictor of survival. However, survival was directly influenced by additional treatment after surgery. Therefore, increasing access to resources in developing countries like Brazil is critical.     

Having trouble with pressure ulcers care?

Since 1997, we, the community pharmacists, have established this society, Aichi Prefecture Society for the Study of Pressure Ulcers Care, in order to furnish drug information about pressure ulcers care. Moist atmosphere is required for the healing of pressure ulcers. The moist environment that could be regulated depends on the physicochemical property of ointment bases. Therefore, ointment should reasonably be chosen to adjust the moisture. Since 2000, we have been committed to providing pharmacists, who work on home care, with a booklet to instruct how to choose ointments for pressure ulcers treatment. In 2002, when the Aichi pharmaceutical association held a training conference held at various hospitals using the booklet as a teaching material, hospital pharmacists cooperated by making a field study trip to observe pressure ulcers treatments. Nowadays researchers at pharmaceutical colleges have also cooperated in studying the efficacy and economical effect of the method of blending different ointments to improve the healing process of pressure ulcers.     

Elderly diabetics and care insurance system--does the home care service contribute to the home medical treatment?

To investigate whether home medical care service based on the public care insurance system contributes to the home medical treatment of elderly diabetics, the following aspects were evaluated. 1. Did glycemic control improve? 2. Were the patients pleased with the results obtained? 3. Was a load to the home care of the family reducing? 4. Did dependence on medical treatment decrease? The investigation was carried out targeting 17 patients among elderly diabetic patients of 65 years of age for whom home care service was provided. 1. HbA1c level did not change after the start of the care service. 2. Some degree of patient's satisfaction was obtained. 3. The burden of the family concerning home care decreased. 4. Dependence on medical treatment (repeated visits or hospitalization) decreased. Therefore, it was suggested that the care service contributed to the home medical treatment of elderly diabetic patients. It was raised as a problem what correspondence to the cases those who dislike the home care service, or an authorization application. From now on, it is considered important to introduce a care service in which a dietitian, a nurse, a pharmacist, etc, are involved.     

Breast and prostate cancer survivors’ experiences of patient-centered cancer follow-up care from primary care physicians and oncologists

Purpose

Patient-physician relationships impact health care seeking and preventive screening behaviors among patients. At the end of active treatment some cancer survivors report feeling disconnected from their care team. This study explores cancer survivors’ experiences of patient-centered cancer follow-up care provided by primary care physicians (PCP) and oncologists (ONC).

Methods

Three hundred five early stage, breast and prostate cancer survivors at least 2 years post treatment were surveyed from four community hospital oncology programs in New Jersey. Participants reported receipt of patient-centered care measured by care coordination, comprehensiveness of care, and personal relationship with PCPs and ONCs.

Results

PCPs received higher ratings for coordination of care and comprehensive care than ONCs from all survivors (P?<?0.01). However, prostate and breast cancer survivors rated strengths of their personal bonds with the physicians differently. While prostate cancer survivors rated PCPs significantly higher for all items (P?<?0.028), breast cancer survivors rated ONCs significantly higher on four out of seven items including having been through a lot together, understanding what is important regarding health, knowing their medical history and taking their beliefs and wishes into account (P?<?0.036).

Conclusions

Prostate and breast cancer survivors report different experiences with their PCPs and oncologists around the comprehensiveness and coordination of their cancer follow-up care in addition to the strength of their relationships with their physicians.

Implications for Cancer Survivors

There are important differences in the experience of patient-centered care among cancer survivors that should be considered when planning care models and interventions for these different populations.

     

Is it time to consider palliative care?

O'CONNOR S.J. (2012) European Journal of Cancer Care 21 , 281–282 Is it time to consider palliative care?     

Is cancer care best at high-volume providers?

For a variety of medical conditions and procedures, a higher volume-better outcome relationship has been hypothesized for over 25 years. An extensive, consistent body of literature supports a relationship between hospital volume and short-term outcomes for cancers treated with technologically complex surgical procedures. For cancer primarily treated by low-risk surgery, there are few studies. Recent studies found a modest (about 2%) difference in survival benefit between high-volume and low-volume providers associated with colon cancer surgery. Few evaluations in the last 15 years have addressed nonsurgical cancers, eg, lymphomas and testicular cancer. No reports have addressed recurrent or metastatic cancer. Care is better at high-volume providers for a select minority of cancers. Whether provider volume matters in the majority of cancers at the time of presentation has not been evaluated.