Massimo Costantini

Actual and preferred place of death of cancer patients. Results from the Italian survey of the dying of cancer (ISDOC)

Objective: To describe actual and preferred place of death of Italian cancer patients and to analyse the preferences met regarding the place of death. Design: Mortality follow back survey of 2000 cancer deaths, identified with a two stage probability sample representative of the whole country. Information on patients’ experience was gathered from the non-professional caregiver with an interview. A section of the interview covered information on the actual and preferred place of death of the patients. Setting: 30 Italian local health districts randomly selected after stratification in four geographical areas. Participants: 1900 of 2000 (95.0%) caregivers of cancer deaths identified. Main outcome measures: Prevalence of actual and preferred places of death. Results: Valid interviews were obtained for 66.9% (n = 1271) of the caregivers. Place of death was home for 57.9% of Italian cancer patients, hospital for 34.6%, hospice for 0.7%, nursing home for 6.5%, and ambulance for 0.4%. Wide and significant differences within Italy were seen (home deaths ranged between 94.0% in the south and 28.2% in the north east). Home was the preferred place of death for 93.5% of patients that expressed a preference, with minimal differences within the country (between 89.5% and 99.0%). Overall 67.1% of the sample died in the place where they preferred to die. Conclusions: Policymakers should encourage health services to focus on ways of meeting individual preferences on place of death. As home was the preferred place of death for most cancer patients, effective programmes to enable the patients to remain at home should be implemented.

Dying with cancer, living well with advanced cancer

INTRODUCTION There are 1.7 million deaths from cancer in Europe each year and by 2020 the World Health Organisation (WHO) estimates that, globally, more than 15 million people will experience cancer and 10 million will die from it each year. Furthermore, as new therapies are developed, people are living longer with cancer than in the past, and the population with cancer will be older. MATERIALS AND METHODS We used epidemiologically based needs assessment approaches to estimate the number of people in Europe with symptoms and problems, published data and reviews to appraise treatment options, issues of communication, family care, bereavement and socio-demographic factors affecting care, and a European survey to consider the types of services. In addition, we used systematic literature review data to appraise the effectiveness of services and factors affecting place of death. RESULTS The quality of life of virtually all cancer patients with advanced disease is impaired by one or more symptoms, emotional, social, spiritual and communication concerns. Patients have a median of 11 symptoms. In Europe there are up to 1.6 million patients with pain each year, and in around one third of these it will be severe, requiring complex treatment. Almost an equal number are affected by fatigue, and more than 1 in 2 are affected by anxiety and/or depression, breathlessness, insomnia, nausea, constipation and/or anorexia. There is a complex interaction of factors affecting place of death--related to illness, the individual and environment--and although most people want to die at home, in most countries the majority of cancer patients die in hospital. In response to patient and family needs, systematic review shows the effectiveness of palliative care services. However, the distribution of services across Europe is inequitable. CONCLUSION Palliative care is becoming increasingly recognised as a vital component of cancer care, but requires investment in research, education and services, incorporating appropriate needs assessment and outcome measurements.

Palliative home care and place of death among cancer patients: a population-based study

This population-based study of all cancer deaths (n = 12 343) occurring in Genoa, Italy, from 1986 to 1990 investigated the relation between place of death and age, sex, marital status, education, cancer site and provision of palliative home care (PHC). The proportion of home deaths significantly increased from 27.9% (1986) to 33.0% (1990) and was twice as frequent among PHC users (60.8%) than among nonusers (29.3%). The number of patients dying of cancer who received PHC increased from 41 in 1986 (1.6% of cancer deaths) to 191 in 1990 (8.0% of cancer deaths). PHC users, when compared to nonusers were younger, more frequently married, had a higher level of education and were more frequently affected by cancers of the lung, breast or prostate. Multivariate analysis shows that the probability of home death increased with increasing age and education level and was higher in females and in married patients. The provi sion of PHC was the strongest predictor of home death (OR = 4.00; 95% Cl = 3.33-4.81), while the temporal trend almost disappeared. These results suggest that most of the increase in home deaths from 1986 to 1990 is attributable to the PHC and that expansion of the PHC services may enable about 60% of cancer patients to die at home. These results appear to be desirable from the individual patients viewpoint and in a public health perspective.

Randomized phase III trial evaluating the role of erythropoietin in the prevention of chemotherapy-induced anemia

PURPOSE Although erythropoietin (EPO) is known to be useful in treating chemotherapy-induced anemia, few data are available on its potential preventive role. The aim of this study was to evaluate the ability of EPO in preventing the development of clinically significant anemia in patients treated with chemotherapy. PATIENTS AND METHODS Sixty-two early-stage breast cancer patients undergoing accelerated adjuvant chemotherapy were randomized to receive EPO 150 U/kg three times a week or no additional treatment. Chemotherapy consisted of six cycles of cyclophosphamide 600 mg/m2, epirubicin 60 mg/m2, and fluorouracil 600 mg/m2 (CEF) intravenously on day 1, every 2 weeks with the support of granulocyte colony-stimulating factor (G-CSF), 5 microg/kg subcutaneously from day 4 to day 11. RESULTS Throughout the six cycles of chemotherapy, EPO-treated patients maintained stable values of hemoglobin, whereas control patients developed a progressive anemia. At the end of chemotherapy, the mean (+/- SD) hemoglobin decrease in the control group was 3.05 g/dL (+/- 1.0; 95% confidence interval [CI], 2.6 to 3.5), whereas in the EPO group it was 0.8 (+/- 1.4; 95% CI, 0.3 to 1.4). Clinically significant anemia (hemoglobin < or = 10 g/dL) occurred in 16 patients (52%; 95% CI, 33 to 69) in the control arm and in no patient (0%; 95% CI, 0 to 14) in the EPO arm (P = .00001). CONCLUSION EPO prevents anemia in patients undergoing chemotherapy. Further trials are required to identify subsets of patients in which the preventive use of this drug could be cost-effective.

Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions?: a systematic review

CONTEXT If access to effective palliative care is to extend beyond cancer patients, an understanding of the comparative prevalence of palliative care problems among cancer and non-cancer patients is necessary. OBJECTIVES This systematic review aimed to describe and compare the prevalence of seventeen palliative care-related problems across the four palliative care domains among adults with advanced cancer, acquired immune deficiency syndrome, chronic heart failure, end-stage renal disease (ESRD), chronic obstructive pulmonary disease, multiple sclerosis, motor neuron disease, Parkinsons disease, and dementia. METHODS Three databases were searched using three groups of keywords. The results of the extraction of the prevalence figures were summarized. RESULTS The electronic searches yielded 4697 hits after the removal of 1784 duplicates. Of these hits, 143 met the review criteria. The greatest number of studies were found for advanced cancer (n=57) and ESRD patients (n=47), and 75 of the 143 studies used validated scales. Few data were available for people living with multiple sclerosis (n=2) and motor neuron disease (n=3). The problems with a prevalence of 50% or more found across most of the nine studied diagnostic groups were: pain, fatigue, anorexia, dyspnea, and worry. CONCLUSION There are commonalities in the prevalence of problems across cancer and non-cancer patients, highlighting the need for palliative care to be provided irrespective of diagnosis. The methodological heterogeneity across the studies and the lack of non-cancer studies need to be addressed in future research.

Psychological and Symptom Distress In Terminal Cancer Patients with Met and Unmet Needs

This study identified the needs of terminal cancer patients, investigated the factors associated with unmet needs, and assessed psychological and symptom distress associated with unsolved needs. Ninety-four patients were randomly selected from 324 patients admitted for palliative care in 13 Italian centers. Two self-administered questionnaires (the Symptom Distress Scale and the Psychological Distress Inventory) were administered to all the patients. Patients needs were identified using a semi-structured interview, aimed at exploring five areas: physiological needs, safety needs, love and belonging needs, self-esteem needs, self-fulfillment needs. A content analysis of the answers defined 11 needs, and identified patients with unmet needs. The most frequent unmet needs were symptom control (62.8%), occupational functioning (62.1%), and emotional support (51.7%). The less frequently reported needs were those related to personal care (14.6%), financial support (14.1%), and emotional closeness (13.8%). Low functional state was significantly associated with a high proportion of patients with unmet needs of personal care, information, communication, occupational functioning, and emotional closeness. Patients with unmet needs showed significantly higher psychological and symptom distress for most needs. This study provides some suggestions about the concerns that should be carefully considered during the late stage of cancer.

Effect of a palliative home care team on hospital admissions among patients with advanced cancer.

This was a quasi-experimental study designed to determine whether, in patients with advanced cancer, a palliative home care team (PHCT) modified hospital utilization in the last six months before death. Of 2503 cancer deaths in the municipality of Genoa, Italy, in 1991, 189 (7.5%) received care from a PHCT. Three hundred and seventy-eight controls matched for primary tumour were selected. The groups were similar in terms of age, gender and most other demographic variables, except that educational level was lower, and times to death, from first diagnosis and from diagnosis of advanced or metastatic cancer, were longer among PHCT patients compared with the controls. Before referral to a PHCT, or a matched time in controls, both groups spent about 15% of days in hospital. After admission to a PHCT, the percentages of days in hospital increased in both groups as death approached, but it was much higher in the control group (30.3%; 95% confidence interval (CI): 26–34) than in the PHCT group (19.0%; 95% CI: 15–23). The difference between groups was most marked in the last month of life, and disappeared among those patients who were in care for more than 120 days (throughout the course of their illness). We conclude that a PHCT appears to reduce days in hospital and allows patients to spend more time at home. Differences in time in care between groups requires further investigations.

Assessing Psychological Distress in Cancer Patients: Validation of a Self-Administered Questionnaire

BACKGROUND Screening for psychological distress in cancer patients is important, considering the high prevalence of psychiatric disorders responsive to treatment. The aim of this study is to test the psychometric properties of the Psychological Distress Inventory (PDI), a 13-item self-administered questionnaire developed to measure psychological distress in cancer patients. PATIENTS AND METHODS The PDI was tested in three samples of 434 cancer patients. In the first sample (n = 102) it was administered with the State Trait Anxiety Inventory (STAI) and with the Eysenck Personality Questionnaire (EPQ). Its validity as a screening method for psychiatric disorders was evaluated through a clinical interview in the second sample (n = 107). The third sample (n = 225) provided information on the ability of the PDI to discriminate among patients in different clinical phases of disease and allowed an estimate of the prevalence of psychiatric disorders in these groups of patients. RESULTS A 0.88 alpha coefficient was obtained in the whole study sample. The correlations with the STAI scales were > 0.70. A positive correlation with neuroticism (r = 0.59) and a negative correlation with extroversion (r = -0.34) was observed. In the second sample, 67 patients (62.6%) received a psychiatric diagnosis according to the ICD-X criteria. The mean PDI scores were significantly lower for the 40 patients with no psychiatric diagnosis (mean 24.5) as compared with the 49 patients with adjustment disorders (mean 36.4) and with the 12 patients with depressive disorders (mean 40.8). The area under curve, estimated through a Receiver-Operating Characteristics analysis, was 0.88. A cut-off of 29 was associated with a 75% sensitivity and a 85% specificity. In the third sample, the lowest PDI scores were in patients with no evidence of disease (mean 24.7, 95% CL 23.0-26.4) as compared to patients undergoing antineoplastic treatment (mean 30.9, 95% CL 28.9-32.9) and to patients under palliative therapy (mean 36.0, 95% CL 34.0-37.9). The estimated prevalence of patients with psychiatric disorders in these three groups were respectively 5.0, 56.6 and 98.8%. CONCLUSIONS Our results suggest that the PDI is a reliable and valid tool for measuring psychological distress in cancer patients and to detect psychiatric disorders through a screening procedure.

Interobserver agreement in the histologic diagnosis of colorectal polyps: the experience of the multicenter adenoma colorectal study (SMAC)

Current clinical practice guidelines for patients with colorectal polyps are mainly based on the histologic characteristics of their lesions. However, interobserver variability in the assessment of specific polyp characteristics was evaluated in very few studies. The purpose of this study was to evaluate the interobserver agreement of four pathologists in the diagnosis of histologic type of colorectal polyps and in the degree of dysplasia and of infiltrating carcinoma in adenomas. A stratified random sample of 100 polyps was obtained from the 4,889 polyps resected within the Multicentre Adenoma Colorectal Study (SMAC), and the slides were blindly reviewed by the four pathologists. Agreement was analyzed using kappa statistics. A median kappa of 0.89 (range 0.79-1.0) was estimated for the interobserver agreement for the diagnosis of hyperplastic polyp vs. adenoma. The agreement in the diagnosis of tubular, tubulovillous, and villous type, was given by median kappa values of 0.50, 0.15, and 0.36, respectively. The median kappa for the diagnosis of infiltrating carcinoma was 0.78 (range 0.73-0.84). Agreement on diagnosis of adenoma histologic subtypes, degrees of dysplasia, or infiltrating carcinoma in adenoma was moderate. A simpler classifications might help to better identify patients at different risk of colorectal cancer.

Concomitant versus sequential administration of epirubicin and paclitaxel as first-line therapy in metastatic breast carcinoma: Results from the gruppo oncologico nord ovest randomized trial

The authors performed a randomized trial comprising patients with metastatic breast carcinoma (MBC). They used a noninferiority design to evaluate whether the results of sequential administration of epirubicin and paclitaxel were not markedly worse than the concomitant administration in terms of objective response rates (ORRs). Toxicity profile, quality of life (QOL), and pharmacoeconomic evaluations were evaluated as well.