IntroductionThere is growing concern about the aggressiveness of cancer care at the end of life (ACCEoL), defined as overly aggressive treatments that compromise the quality of life at its end. Recognising the most affected patients is a cornerstone to improve oncology care. Our aim is to identify factors associated with ACCEoL for patients with cancer dying in hospitals.MethodsAll adult patients with cancer who died in public hospitals in mainland Portugal (January 2010 to December 2015), identified from the hospital morbidity database. This database provided individual clinical and demographic data. We obtained hospital and region-level variables from a survey and National Statistics. The primary outcome is a composite ACCEoL measure of 16 indicators. We used multilevel random effects logistic regression modelling (p<0·05).ResultsWe included 92 155 patients: median age 73 years; 62% male; 53% with metastatic disease. ACCEoL prevalence was 71% (95% CI 70% to 71%). The most prevalent indicators were >14 days in the hospital (43%, 42–43) and surgery (28%, 28–28) in the last 30 days. Older age (p<0·001), breast cancer (OR 0·83; 95% CI 0·76 to 0·91), and metastatic disease (0·54; 95% CI 0·50 to 0·58) were negatively associated with ACCEoL. In contrast, higher Deyo-Charlson Comorbidity Index (p<0·001), gastrointestinal and haematological malignancies (p<0·001), and death at cancer centre (1·31; 95% CI 1·01 to 1·72) or hospital with medical oncology department (1·29; 95% CI 1·02 to 1·63) were positively associated with ACCEoL. There was no association between hospital palliative care services at the hospital of death and ACCEoL.ConclusionClinical factors related to a better understanding of disease course are associated with ACCEoL reduction. Patients with more comorbidities and gastrointestinal malignancies might represent groups with complex needs, and haematological patients may be at increased risk because of unpredictable prognosis. Improvement of hospital palliative care services could help reduce ACCEoL, particularly in cancer centres and hospitals with medical oncology department, as those services are usually under-resourced, thus reaching few.
(1) Background: Current scientific evidence suggests that most cancers, including breast cancer, can be treated during pregnancy without compromising maternal and fetal outcomes. This, however, raises questions regarding the ethical implications of clinical care. (2) Methods: Using a systematic literature search, 32 clinical practice guidelines for cancer treatment during pregnancy published between 2002 and 2021 were selected for analysis and 25 of them mentioned or made references to medical ethics when offering clinical management guidance for clinicians. (3) Results: Four bioethical themes were identified: respect for patient’s autonomy, balanced approach to maternal and fetal beneficence, protection of the vulnerable and justice in resource allocation. Most guidelines recommended informing the pregnant patient about available evidence-based treatment options, offering counselling and support in the process of decision making. The relational aspect of a pregnant patient’s autonomy was also recognized and endorsed in a significant number of available guidelines. (4) Conclusions: Recognition and support of a patient’s autonomy and its relational aspects should remain an integral part of future clinical practice guidelines. Nevertheless, a more structured approach is needed when addressing existing and potential ethical issues in clinical practice guidelines for cancer treatment during pregnancy.
Deleterious variants in the BRCA1/BRCA2 genes and homologous recombination deficiency (HRD) status are considered strong predictors of response to poly (ADP-ribose) polymerase (PARP) inhibitors (PARPi). The introduction of PARPi in clinical practice for the treatment of patients with advanced ovarian cancer imposed changes in the molecular diagnosis of BRCA1/BRCA2 variants. BRCA1/BRCA2 tumor testing by next-generation sequencing (NGS) can detect simultaneously both somatic and germline variants, allowing the identification of more patients with higher likelihood of benefiting from PARPi. Our main goal was to determine the frequency of somatic and germline BRCA1/BRCA2 variants in a series of non-mucinous OC, and to define the best strategy to be implemented in a routine diagnostic setting for the screening of germline/somatic variants in these genes, including the BRCA2 c.156_157insAlu Portuguese founder variant. We observed a frequency of 19.3% of deleterious variants, 13.3% germline, and 5.9% somatic. A higher prevalence of pathogenic variants was observed in patients diagnosed with high-grade serous ovarian cancer (23.2%). Considering the frequencies of the c.3331_3334del and the c.2037delinsCC BRCA1 variants observed in this study (73% of all BRCA1 pathogenic germline variants identified) and the limitations of NGS to detect the BRCA2 c.156_157insAlu variant, it might be cost-effective to test for these founder variants with a specific test prior to tumor screening of the entire coding regions of BRCA1 and BRCA2 by NGS in patients of Portuguese ancestry.
68 Background: There is growing concern about the aggressiveness of cancer care at the end of life (ACCEoL). Recognizing the most affected patients is a cornerstone to improve this public health unmet need. Our aim is to identify factors associated with ACCEoL for cancer patients dying in hospitals. Methods: Cohort study of adults with ICD9CM diagnosis of cancer, who died in public hospitals in mainland Portugal (Jan'10 - Dec'15), identified from the hospital morbidity database (HMD). HMD provided individual clinical and demographic data. The primary outcome is a composite ACCEoL measure of 16 indicators, expanding an earlier framework, validated by an expert panel. We obtained hospital and area-level variables from a hospital survey and National Statistics. We used multilevel random effects logistic regression modelling (p < 0.05). Results: We included 92,155 patients: median age 73 yo; 61.9% male; 53.0% metastatic. ACCEoL prevalence was 71.1%. The most prevalent indicators were > 14 days in hospital (42.7%) and surgery in last 30 days (27.8%). Older age (p < 0.001), breast cancer (OR 0.83; 95%CI 0.76-0.91) and metastatic disease (0.54; 0.50-0.58) were associated with less ACCEoL. In contrast, higher Deyo-Charlson comorbidity index (p < 0.001), gastrointestinal (GI) and hematological malignancies (p < 0.001), and death at a cancer center (1.31; 1.01-1.72) or hospital with medical oncology (MO) dept. (1.29; 1.02-1.63) were associated with higher ACCEoL. There was no association between existence of hospital palliative care services (HPCS) at the hospital of death and ACCEoL. Conclusions: Our study confirmed that clinical factors related with better understanding of disease course are associated with ACCEoL reduction. Patients with more comorbidities and GI malignancies might represent groups with complex needs, and hematological patients may be at increased risk because of unpredictable prognosis. It is important to better understand how to reduce ACCEoL in cancer centers and hospitals with MO dept.; improvement of HPCS could be an answer as these services are usually under-resourced, thus reaching few.
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