RESUMEN

Communication in oncology has always been challenging. The new era of precision oncology creates prognostic uncertainty. Still, person-centered care requires attention to people and their care needs. Living with cancer portends an experience that is life-altering, no matter what the outcome. Supporting patients and families through this unique experience requires careful attention, honed skills, an understanding of process and balance measures of innovation, and recognizing that supportive care is a foundational element of cancer medicine, rather than an either-or approach, an and-with approach that emphasizes the regular integration of palliative care (PC), geriatric oncology, and skilled communication.

Asunto(s)

Neoplasias , Atención Dirigida al Paciente , Medicina de Precisión , Humanos , Oncología Médica/métodos , Neoplasias/terapia , Cuidados Paliativos/métodos , Medicina de Precisión/métodos

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@ramsedhom and colleagues highlight the opportunity of palliative care to bend the cost (and value) curve in cancer. Enhanced, early, and expanded access to PC offers benefits to inpatients with cancer and cost savings to health systems and payors.

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BACKGROUND: Randomized controlled trials (RCTs) examining the outcomes with limus drug-coated balloons (DCBs) vs paclitaxel DCBs were small and underpowered for clinical endpoints. OBJECTIVES: This study sought to compare the angiographic and clinical outcomes with limus DCBs vs paclitaxel DCBs for percutaneous coronary intervention (PCI). METHODS: An electronic search of Medline, EMBASE, and Cochrane databases was performed through January 2024 for RCTs comparing limus DCBs vs paclitaxel DCBs for PCI. The primary endpoint was clinically driven target lesion revascularization (TLR). The secondary endpoints were late angiographic findings. Summary estimates were constructed using a random effects model. RESULTS: Six RCTs with 821 patients were included; 446 patients received a limus DCB, and 375 patients received a paclitaxel DCB. There was no difference between limus DCBs and paclitaxel DCBs in the incidence of TLR at a mean of 13.4 months (10.3% vs 7.8%; risk ratio [RR]: 1.32; 95% CI: 0.84-2.08). Subgroup analysis suggested no significant interaction among studies for de novo coronary lesions vs in-stent restenosis (Pinteraction = 0.58). There were no differences in the risk of major adverse cardiovascular events, cardiac mortality, or target vessel myocardial infarction between groups. However, limus DCBs were associated with a higher risk of binary restenosis (RR: 1.89; 95% CI: 1.14-3.12), late lumen loss (mean difference = 0.16; 95% CI: 0.03-0.28), and a smaller minimum lumen diameter (mean difference = -0.12; 95% CI: -0.22 to -0.02) at late follow-up. In addition, late lumen enlargement occurred more frequently (50% vs 27.5%; RR: 0.59; 95% CI: 0.45-0.77) with paclitaxel DCBs. CONCLUSIONS: Among patients undergoing DCB-only PCI, there were no differences in the risk of clinically driven TLR and other clinical outcomes between limus DCBs and paclitaxel DCBs. However, paclitaxel DCBs were associated with better late angiographic outcomes. These findings support the need for future trials to establish the role of new-generation limus DCBs for PCI.

Asunto(s)

Angioplastia Coronaria con Balón , Catéteres Cardíacos , Fármacos Cardiovasculares , Materiales Biocompatibles Revestidos , Enfermedad de la Arteria Coronaria , Paclitaxel , Intervención Coronaria Percutánea , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Angioplastia Coronaria con Balón/instrumentación , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/mortalidad , Fármacos Cardiovasculares/administración & dosificación , Fármacos Cardiovasculares/efectos adversos , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Reestenosis Coronaria/etiología , Paclitaxel/administración & dosificación , Paclitaxel/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento

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BACKGROUND: no-reflow can complicate up to 25% of pPCI and is associated with significant morbidity and mortality. We aimed to compare the outcomes of intracoronary epinephrine and verapamil with intracoronary adenosine in the treatment of no-reflow after primary percutaneous coronary intervention (pPCI). METHODS: 108 STEMI patients had no-reflow during pPCI were assigned into four groups. Group 1, in which epinephrine and verapamil were injected through a well-cannulated guiding catheter. Group 2, in which same drugs were injected in the distal coronary bed through a microcatheter or perfusion catheter. Group 3, in which adenosine was injected through a guiding catheter. Group 4, in which adenosine was injected in distal coronary bed. Primary end point was the achievement of TIMI III flow and MBG II or III. Secondary end point was major adverse cardiovascular and cerebrovascular events (MACCEs) during hospital stay. RESULTS: The study groups did not differ in their baseline characteristics. Primary end point was achieved in 15 (27.8%) patients in the guide-delivery arm compared with 34 (63%) patients in the local-delivery arm, p < 0.01. However, the primary end point did not differ between the epinephrine/verapamil group and the adenosine group (27 (50%) vs 22 (40.7%), p = 0.334). The secondary end points were similar between the study groups. CONCLUSION: Local delivery of epinephrine, verapamil and adenosine in the distal coronary bed is more effective in achieving TIMI III flow with MBG II or III compared with their guide-delivery in patients who suffered no-reflow during pPCI. There was no difference between epinephrine/verapamil Vs. adenosine.

Asunto(s)

Adenosina , Epinefrina , Fenómeno de no Reflujo , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Verapamilo , Humanos , Verapamilo/administración & dosificación , Masculino , Femenino , Adenosina/administración & dosificación , Epinefrina/administración & dosificación , Persona de Mediana Edad , Intervención Coronaria Percutánea/métodos , Fenómeno de no Reflujo/etiología , Fenómeno de no Reflujo/tratamiento farmacológico , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/cirugía , Anciano , Vasodilatadores/administración & dosificación , Resultado del Tratamiento , Estudios Prospectivos

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This cross-sectional study evaluates rural-urban disparities in age-adjusted mortality rates and place of death (eg, at home or medical facility) for patients with head and neck cancer.

Asunto(s)

Neoplasias de Cabeza y Cuello , Humanos , Neoplasias de Cabeza y Cuello/mortalidad , Estados Unidos/epidemiología , Masculino , Femenino , Persona de Mediana Edad

RESUMEN

The integration of palliative care into routine oncology practice is the standard of care by most leading cancer organizations. Palliative medicine helps to deliver higher quality of care at a lower cost. However, there are barriers to implementing palliative oncology at many institutions for myriad reasons. In this article, we discuss an innovative strategy that ASCO implemented called the Communities of Practice (CoP). We share our experiences as the Palliative Care CoP and how our group seeks to develop processes and structures to collectively promote systemic change and enhance palliative care delivery for people with cancer. Our Palliative Care CoP engages with senior leaders, administrators, and those in power to achieve a shared vision of delivering holistic health care for people with serious illness. We continue to evolve to meet our members' growing needs by addressing eight main domains: (1) increasing palliative care education and resources; (2) creating opportunities for global palliative care research; (3) providing peer mentorship and community building; (4) engaging with patient advocates; (5) supporting and developing interdisciplinary teams; (6) assisting with professional development and identity formation, especially for trainees and early career faculty; (7) extending our outreach through social media; and (8) enhancing the clinical practice of palliative oncology. The ASCO CoP has been a vital forum to realize ASCO's mission of conquering cancer and advancing the Art and Science of Cancer Care: From Comfort to Cure.

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Oncología Médica , Cuidados Paliativos , Humanos , Neoplasias/terapia , Sociedades Médicas , Grupo Paritario , Comunidad de Práctica

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AIMS: This study aims to investigate the trends in the global cardiovascular disease (CVD) burden attributable to smoking from 1990 to 2019. METHODS AND RESULTS: Global Burden of Disease Study 2019 was used to analyse the burden of CVD attributable to smoking (i.e. ischaemic heart disease, peripheral artery disease, stroke, atrial fibrillation and flutter, and aortic aneurysm). Age-standardized mortality rates (ASMRs) per 100 000 and age-standardized disability-adjusted life year rates (ASDRs) per 100 000, as well as an estimated annual percentage change (EAPC) in ASMR and ASDR, were determined by age, sex, year, socio-demographic index (SDI), regions, and countries or territories. The global ASMR of smoking-attributed CVD decreased from 57.16/100 000 [95% uncertainty interval (UI) 54.46-59.97] in 1990 to 33.03/100 000 (95% UI 30.43-35.51) in 2019 [EAPC -0.42 (95% UI -0.47 to -0.38)]. Similarly, the ASDR of smoking-attributed CVD decreased between 1990 and 2019. All CVD subcategories showed a decline in death burden between 1990 and 2019. The burden of smoking-attributed CVD was higher in men than in women. Significant geographic and regional variations existed such that Eastern Europe had the highest ASMR and Andean Latin America had the lowest ASMR in 2019. In 2019, the ASMR of smoking-attributed CVD was lowest in high SDI regions. CONCLUSION: Smoking-attributed CVD morbidity and mortality are declining globally, but significant variation persists, indicating a need for targeted interventions to reduce smoking-related CVD burden.

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The burden of cardiovascular disease (CVD) attributed to smoking declined worldwide between 1990 and 2019. The burden of smoking-attributed CVD was higher in men than in women in 2019. There were significant variations between different countries and regions such that Eastern Europe had the highest death rate and Andean Latin America had the lowest death rate in 2019. Also, countries with high socio-economic status had lower death rates from smoking-attributed CVD. This highlights the need for targeted interventions to reduce the burden of smoking-attributed CVD.The overall age-adjusted deaths from CVD attributed to smoking declined from 57.16/100 000 in 1990 to 33.03/100 000 in 2019.In 2019, ischaemic heart disease was the leading cause of smoking-attributed CVD deaths.

Asunto(s)

Enfermedades Cardiovasculares , Carga Global de Enfermedades , Fumar , Humanos , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/mortalidad , Carga Global de Enfermedades/tendencias , Masculino , Femenino , Persona de Mediana Edad , Anciano , Fumar/efectos adversos , Fumar/epidemiología , Fumar/mortalidad , Adulto , Salud Global , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Distribución por Sexo , Anciano de 80 o más Años , Prevalencia , Causas de Muerte/tendencias

RESUMEN

OBJECTIVE: To examine the characteristics and outcomes among patients with high-risk pulmonary embolism (PE) and malignancy. PATIENTS AND METHODS: The Nationwide Readmissions Database was used to identify hospitalizations with high-risk PE from January 1, 2016, to December 31, 2019. The main outcome was the difference in all-cause in-hospital mortality. RESULTS: Among 28,547 weighted hospitalizations with high-risk PE, 4,825 (16.9%) had malignancy. Admissions with malignancy had a lower prevalence of other comorbid conditions except for anemia and coagulopathy. The use of systemic thrombolysis, catheter-directed interventions, and surgical embolectomy was less common among admissions with malignancy, whereas the use of inferior vena cava filter was more common among those with malignancy. All-cause in-hospital mortality was higher among admissions with malignancy even after adjustment (adjusted odds ratio, 1.91; 95% CI, 1.72 to 2.11; P<.001). Metastatic genitourinary, gastrointestinal (other than colorectal), and lung malignancies were associated with the highest incidence of in-hospital mortality. The incidence of intracranial hemorrhage (3.9% vs 3.1%; P=.056) and the composite of non-intracranial hemorrhage bleeding (21.9% vs 20.6%; P=.185) was not different between admissions with and without malignancy. However, admissions with malignancy had higher incidence of gastrointestinal bleeding. CONCLUSION: In this nationwide analysis of patients admitted with high-risk PE, malignancy was independently associated with an increased risk of in-hospital mortality. The risk was highest among patients with metastatic genitourinary, gastrointestinal, and lung malignancies. Advanced therapies were less frequently used among patients with malignancy.

Asunto(s)

Neoplasias Pulmonares , Embolia Pulmonar , Humanos , Resultado del Tratamiento , Embolia Pulmonar/epidemiología , Embolia Pulmonar/terapia , Embolia Pulmonar/complicaciones , Hospitalización , Hemorragia Gastrointestinal/etiología , Neoplasias Pulmonares/complicaciones , Neoplasias Pulmonares/epidemiología , Mortalidad Hospitalaria , Terapia Trombolítica/efectos adversos , Factores de Riesgo

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Patient-centered cancer care requires communication between patients and clinicians about patients' goals, values, and preferences. Serious illness communication improves patient and caregiver outcomes, the value and quality of cancer care, and the well-being of clinicians. Despite these benefits, there are competing factors including time, capacity, bandwidth, and resistance. Health systems and oncology practices have opportunities to invest in pathways that assist patients and clinicians to engage in serious illness conversations. We discuss how applying insights from behavioral economics and complexity science may help clinicians engage in serious illness conversation and improve patient-centered cancer care.

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Economía del Comportamiento , Neoplasias , Humanos , Comunicación , Neoplasias/terapia , Oncología Médica

RESUMEN

Coronary angiography has a limited ability to predict the functional significance of intermediate coronary lesions. Hence, physiological assessment of coronary lesions, via fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR), has been introduced to determine their functional significance. An accumulating body of evidence has consolidated the role of physiology-guided revascularization, particularly among patients with stable ischemic heart disease. The use of FFR or iFR to guide decision-making in patients with stable ischemic heart disease and intermediate coronary lesions received a class I recommendation from major societal guidelines. Nevertheless, the role of coronary physiology testing is less clear among certain patients' groups, including patients with serial coronary lesions, acute coronary syndromes, aortic stenosis, heart failure, as well as post-percutaneous coronary interventions. In this review, we aimed to discuss the utility and clinical evidence of coronary physiology (mainly FFR and iFR), with emphasis on those specific patient groups.

RESUMEN

This JAMA Internal Medicine Patient Page describes details of palliative care, including who it can benefit and when it should be considered.

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Cuidados Paliativos al Final de la Vida , Cuidados Paliativos , Humanos

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Fellowship training in Hospice and Palliative Medicine (HPM) and Hematology/Oncology (Hem/Onc) share common themes and roots in the holistic care of people living with cancer. As of 2021, approximately 630 physicians in the United States were board-certified in both HPM and Hem/Onc. There is increasing demand for an integrated fellowship pathway, and the inaugural integrated fellowship Match took place in 2022. We present the historical context of the overlap in HPM and Hem/Onc fellowship training, limitations of the standard training paradigm, and an overview of the recently developed integrated training pathway accredited by the Accreditation Council for Graduate Medical Education (ACGME). We explore applications of dual training in clinical care, program development, and research at the intersection of HPM and Hem/Onc. Finally, we consider challenges to the success and how best to assess the outcomes of this program. Integrated fellowship training in HPM and Hem/Onc is 1 avenue to develop a cohort of dual-trained physicians poised to effect broad cultural change in this important and evolving space. A subset of physicians with dual training has the potential to fill unmet needs by promoting enhanced patient-centered care, developing infrastructure for heightened collaboration between these distinct but closely related fields, and prioritizing research focused on advanced communication skills and symptom management for patients with cancer.

Asunto(s)

Cuidados Paliativos al Final de la Vida , Neoplasias , Medicina Paliativa , Humanos , Educación de Postgrado en Medicina , Neoplasias/terapia , Cuidados Paliativos , Medicina Paliativa/educación , Estados Unidos

RESUMEN

PURPOSE: Frequent visits to health care facilities can be time intensive and all-consuming for people with cancer. We measured health care contact days (days with healthcare contact outside the home) among decedents with advanced GI cancer and examined sources of contact days, their associations with demographic and clinical factors, and their temporal patterns over the course of illness. METHODS: We conducted a retrospective cohort study using a tumor registry and electronic medical record data for decedents with stage IV GI cancer between 2011 and 2019 in a large health care network in MN. We determined contact days from diagnosis to death using chart review. Using multivariable beta regression adjusted for sociodemographic and clinical characteristics offset by survival, we calculated adjusted estimates of contact days and determined patient-level factors associated with percentage of contact days. RESULTS: We identified 809 patients eligible for analysis (median [IQR] age at diagnosis, 65 [56-73] years). The median (IQR) overall survival was 175 (56-459) days. Patients spent a median (IQR) of 25.8% (17.4%-39.1%) of these as contact days. Of these days, 83.6% were spent on outpatient visits. In the multivariable analysis, older age, Black race, and never receiving systemic cancer-directed treatment were associated with a higher percentage of contact days. The percentage of contact days was highest in the first month after diagnosis (39.6%) and before death (32.2%), with a more moderate middle phase (U-shaped curve). CONCLUSION: Decedents with advanced GI cancer spend 1 in 4 days alive with health care contact, despite a median survival of under 6 months. This is even higher immediately postdiagnosis and near death. These findings highlight the need to understand sources of variation, benchmark appropriate care, and deliver more efficient care for this vulnerable population with limited time.

Asunto(s)

Neoplasias Gastrointestinales , Humanos , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Neoplasias Gastrointestinales/epidemiología , Neoplasias Gastrointestinales/terapia , Atención a la Salud

RESUMEN

Randomized controlled trials (RCTs) examining the outcomes of "polypill" therapy in cardiovascular disease prevention have yielded mixed results. We performed an electronic search through January 2023 for RCTs that examined the use of polypills for cardiovascular disease primary or secondary prevention. The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCEs). The final analysis included 11 RCTs with 25,389 patients; 12,791 patients were in the polypill arm, and 12,598 patients were in the control arm. The follow-up period ranged from 1 to 5.6 years. Polypill therapy was associated with a lower risk of MACCE (5.8% vs 7.7%; risk ratio [RR] 0.78, 95% confidence interval [CI] 0.67 to 0.91). The reduction of MACCE risk was consistent in both primary and secondary prevention. Polypill therapy was associated with a lower incidence of cardiovascular mortality (2.1% vs 3%; RR 0.69, 95% CI 0.55 to 0.87), myocardial infarction (2.3% vs 3.2%; RR 0.72, 95% CI 0.61 to 0.84) and stroke (0.9% vs 1.6%; RR 0.62, 95% CI 0.42 to 0.90). Polypill therapy was associated with a higher degree of adherence. There was no difference between both groups in the incidence of serious adverse events (16.1% vs 15.9%; RR 1.12, 95% CI 0.93 to 1.36). In conclusion, we found that a polypill strategy was associated with a lower incidence of cardiac events and higher adherence, without an increased incidence of adverse events. This benefit was consistent for both primary and secondary prevention.

Asunto(s)

Enfermedades Cardiovasculares , Infarto del Miocardio , Accidente Cerebrovascular , Humanos , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/prevención & control , Infarto del Miocardio/epidemiología , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Prevención Secundaria

RESUMEN

Substantial gaps in national healthcare spending and disparities in cancer mortality rates are noted across counties in the US. In this cross-sectional analysis, we investigated whether differences in local county-level social vulnerability impacts cancer-related mortality. We linked county-level age-adjusted mortality rates (AAMR) from the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research database, to county-level Social Vulnerability Index (SVI) from the CDC Agency for Toxic Substances and Disease Registry. SVI is a metric comprising 15 social factors including socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. AAMRs were compared between least and most vulnerable counties using robust linear regression models. There were 4 107 273 deaths with an overall AAMR of 173 per 100 000 individuals. Highest AAMRs were noted in older adults, men, non-Hispanic Black individuals, and rural and Southern counties. Highest mortality risk increases between least and most vulnerable counties were noted in Southern and rural counties, individuals aged 45-65, and lung and colorectal cancers, suggesting that these groups may face highest risk for health inequity. These findings inform ongoing deliberations in public health policy at the state and federal level and encourage increased investment into socially disadvantaged counties.

Asunto(s)

Neoplasias , Vulnerabilidad Social , Masculino , Humanos , Estados Unidos/epidemiología , Anciano , Estudios Transversales , Clase Social , Estudios Longitudinales

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COVID-19 , Embolia Pulmonar , Humanos , COVID-19/complicaciones , SARS-CoV-2 , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/etiología , Embolia Pulmonar/terapia , Estudios Retrospectivos

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Cuidados Paliativos , Medicina de Precisión , Humanos

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INTRODUCTION: Palliative care (PC) is a medical specialty focusing on providing relief from the symptoms and stress of serious illnesses such as cancer. Early outpatient specialty PC concurrent with cancer-directed treatment improves quality of life and symptom burden, decreases aggressive end-of-life care and is an evidence-based practice endorsed by national guidelines. However, nearly half of patients with advanced cancer do not receive specialty PC prior to dying. The objective of this study is to test the impact of an oncologist-directed default PC referral orders on rates of PC utilisation and patient quality of life. METHODS AND ANALYSIS: This single-centre two-arm pragmatic randomised trial randomises four clinician-led pods, caring for approximately 250 patients who meet guideline-based criteria for PC referral, in a 1:1 fashion into a control or intervention arm. Intervention oncologists receive a nudge consisting of an electronic health record message indicating a patient has a default pended order for PC. Intervention oncologists are given an opportunity to opt out of referral to PC. Oncologists in pods randomised to the control arm will receive no intervention beyond usual practice. The primary outcome is completed PC visits within 12 weeks. Secondary outcomes are change in quality of life and absolute quality of life scores between the two arms. ETHICS AND DISSEMINATION: This study has been approved by the Institutional Review Board at the University of Pennsylvania. Study results will be disseminated in peer-reviewed journals and scientific conferences using methods that describe the results in ways that key stakeholders can best understand and implement. TRIAL REGISTRATION NUMBER: NCT05365997.

Asunto(s)

Neoplasias , Cuidado Terminal , Humanos , Cuidados Paliativos/métodos , Calidad de Vida , Economía del Comportamiento , Cuidado Terminal/métodos , Neoplasias/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto