Abstract
Mann E, Goff SL, Colon-Cartagena W, et al.: Do-not-hospitalize orders for individuals with advanced dementia: Healthcare proxies' perspectives. J Am Geriatr Soc 2013;61:1568–1573.
The objective of this semistructured, qualitative interview study was to determine how well health care proxies (HCPs) understand do-not-hospitalize (DNH) orders and why they may or may not initiate them. Residents with advanced dementia in two nursing homes in western Massachusetts were studied. In-depth interviews were audiotaped and transcribed verbatim. Data were qualitatively analyzed in an iterative process, and emergent concepts were conceptually ordered into explanatory categories. Pertinent demographic and clinical information was collected from the Minimum Data Set (MDS) and patient charts. Results demonstrated that 16 of 31 eligible health care proxies (HCPs) were interviewed. Major findings included barriers to and facilitators of initiating DNH orders. Barriers included a perceived lack of physician involvement in decision making and limited understanding of DNH orders and the resident's prognosis. Facilitators included an HCP's personal experience in health care, understanding the prognosis of advanced dementia, and a desire to limit resident distress. The authors conclude that the potential barriers to and facilitators of HCPs initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with health care providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect individuals' values and wishes.
Garrido MM, Idler EL, Leventhal H, Carr D: Pathways from religion to advance care planning: Beliefs about control over length of life and end-of-life values. Gerontologist 2013;53:801–816.
The purpose of this study was to evaluate the extent to which religious affiliation and self-identified religious importance affect advance care planning (ACP) via beliefs about control over life length and end-of-life values. Adults aged 55 and older (n=305) from diverse racial and socioeconomic groups seeking outpatient care in New Jersey were surveyed. Measures included discussion of end-of-life preferences; living will (LW) completion; durable power of attorney for health care (DPAHC) appointment; religious affiliation; importance of religion; beliefs about who/what controls life length; end-of-life values; health status; and sociodemographics. Results demonstrated that of the sample, 68.9% had an informal discussion and 46.2% both discussed their preferences and did formal ACP (LW and/or DPAHC). Conservative Protestants and those placing great importance on religion/spirituality had a lower likelihood of ACP. This was largely accounted for by beliefs about God's controlling life length and values concerning the use of all available treatments. The authors conclude that beliefs and values about control account for relationships between religiosity and ACP. Beliefs and some values differ by religious affiliation. As such, congregations may be one nonclinical setting in which ACP discussions could be held, as individuals with similar attitudes toward the end of life could discuss their treatment preferences with those who share their views.
Holdhoff M, Chamberlain MC: Controversies in the treatment of elderly patients with newly diagnosed glioblastoma. J Natl Compr Canc Netw 2013;11:1165–1173.
Approximately half of all patients with glioblastoma are older than 65 years and nearly one-quarter are older than 70 years, with a rising incidence of this disease in the elderly population. The life expectancy of elderly patients with glioblastoma is significantly shorter than in younger patients. Potential explanations for this abbreviated survival include differences in tumor biology, reduced use of therapies, enhanced toxicity of treatment, or diminished efficacy of available therapies with increasing age. The current standard treatment of newly diagnosed, protocol eligible, nonelderly patients with glioblastoma is based on the randomized, prospective European Organization for Research and Treatment of Cancer and National Cancer Institute of Canada Clinical Trials Group (EORTC/NCIC) study that included patients aged 18 to 70 years with a performance status of Eastern Cooperative Oncology Group (ECOG) 0 to 2. Limited single-institution retrospective series suggest that clinically fit elderly patients may benefit from a similar treatment regimen. However, no randomized trial has been performed in the elderly population using this regimen. Available prospective, randomized clinical trials in the elderly population with glioblastoma have shown that radiotherapy is superior to supportive care only, that single-modality hypofractionated radiotherapy (reduced dose and shorter treatment schedule) is an alternative to single-modality standard fractionated radiotherapy, and that single-agent temozolomide is equivalent to radiotherapy alone. This article summarizes published data of current patterns of care in elderly patients and reviews published evidence as it pertains to the benefit of different treatment modalities in elderly patients with glioblastoma. The authors conclude that notwithstanding the previously mentioned randomized trials, the optimal treatment of elderly patients with glioblastoma remains controversial.
Grand B, Cazes A, Mordant P, et al.: High grade neuroendocrine lung tumors: Pathological characteristics, surgical management and prognostic implications. Lung Cancer 2013;81:404–409.
Among nonsmall cell lung cancers (NSCLC), large cell carcinoma (LCC) has a significant poor prognosis. Its neuroendocrine subtype has even a poorer diagnosis, with long-term survival similar to that with small cell lung cancer (SCLC). The purpose of this review was to examine the surgical characteristics of those tumors. The clinical records of patients who underwent surgery for lung cancer in two French centers from 1980 to 2009 were retrospectively reviewed. The authors particularly focused on patients with LCC or with high-grade neuroendocrine lung tumors. High-grade neuroendocrine tumors were classified as pure large cell neuroendocrine carcinoma (pure LCNEC); NSCLC combined with LCNEC (combined LCNEC); and SCLC combined with LCNEC (combined SCLC). There were 470 LCC and 155 high-grade neuroendocrine lung tumors, with no difference concerning gender, mean age, or smoking habits. There were significantly more exploratory thoracotomies in LCC and more frequent postoperative complications in high-grade neuroendocrine lung tumors. Pathologic TNM and five-year survival rates were similar, with five-year survival ranging from 34.3% to 37.6% for high-grade neuroendocrine lung tumors and LCC, respectively. Induction and adjuvant therapy were not associated with an improved prognosis. The subgroups of large cell neuroendocrine carcinoma—pure neuroendocrine; combined neuroendocrine—behaved similarly to combined SCLC, except that visceral pleura invasion proved more frequent in combined NE and less frequent in combined SCLC. Survival analysis showed a trend toward a lower five-year survival rate with combined SCLC. The authors conclude that LCC, LCNEC, and combined SCLC share the same poor prognosis, but surgical resection is associated with long-term survival in about one-third of patients.
Gomez JG, Lopez MEP, Bermejo MA, et al.: SEOM guide to antiemetic prophylaxis in cancer patients treated with chemotherapy 2013. Clin Translational Oncol 2013. E-pub ahead of print. doi: 10.1007/s12094-013-1093-2.
Chemotherapy induced emesis (CIE) in the form of nausea and vomiting is one of the adverse effects most feared by patients who receive treatment and one of the factors that most affect their quality of life and limit their functional capacity for everyday activities. Chemotherapy induced emesis can result from many factors, depending on the treatment and the patients themselves. The best treatment for CIE is prevention, based on the use of drugs aimed at inhibiting the signal of certain neurotransmitters involved in the process. Antiemetic prophylaxis for chemotherapy of high emetogenous potential lasting one day includes a combination of anti-5-HT3, neurokinin-1 inhibitors and dexamethasone. Antiemetic prophylaxis for chemotherapy of moderate emetogenous potential lasting one day includes a combination of palonosetron and dexamethasone. Prophylaxis is not recommended for chemotherapy with minimal emetogenous potential. In the case of unforeseen or refractory emesis, the use of olanzapine, metoclopramide, or phenothiazine should be considered.