scholarly journals Intellectual Equipoise and Challenges: Accruing Patients With Advanced Cancer to a Trial Randomizing to Surgical or Nonsurgical Management (SWOG S1316)

2019 ◽  
Vol 37 (1) ◽  
pp. 12-18
Author(s):  
Gary B. Deutsch ◽  
Jeremiah L. Deneve ◽  
Mazin F. Al-kasspooles ◽  
Valentine N. Nfonsam ◽  
Camille C. Gunderson ◽  
...  
Keyword(s):  
Palliative Care ◽  
Bowel Obstruction ◽  
Treatment Options ◽  
Team Approach ◽  
Malignant Bowel Obstruction ◽  
Related Factors ◽  
Treatment Approaches ◽  
Clinician Bias ◽  
Nonsurgical Management ◽  
Care Problems

Background: Prospective, randomized trials are needed to determine optimal treatment approaches for palliative care problems such as malignant bowel obstruction (MBO). Randomization poses unique issues for such studies, especially with divergent treatment approaches and varying levels of equipoise. We report our experience accruing randomized patients to the Prospective Comparative Effectiveness Trial for Malignant Bowel Obstruction (SWOG S1316) study, comparing surgical and nonsurgical management of MBO. Methods: Patients with MBO who were surgical candidates and had treatment equipoise were accrued and offered randomization to surgical or nonsurgical management. Patients choosing nonrandomization were offered prospective observation. Trial details are listed on www.clinicaltrials.gov (NCT #02270450). An accrual algorithm was developed to enhance enrollment. Results: Accrual is ongoing with 176 patients enrolled. Most (89%) patients chose nonrandomization, opting for nonsurgical management. Of 25 sites that have accrued to this study, 6 enrolled patients on the randomization arm. Approximately 59% (20/34) of the randomization accrual goal has been achieved. Patient-related factors and clinician bias have been the most prevalent reasons for lack of randomization. An algorithm was developed from clinician experience to aid randomization. Using principles in this tool, repeated physician conversations discussing treatment options and goals of care, and a supportive team–approach has helped increase accrual. Conclusions: Experience gained from the S1316 study can aid future palliative care trials. Although difficult, it is possible to randomize patients to palliative studies by giving clinicians clear recommendations utilizing an algorithm of conversation, allotment of necessary time to discuss the trial, and encouragement to overcome internal bias.

Gastrointestinal Symptom Management

2019 ◽  
pp. 33-45
Author(s):  
Gary Hsin
Keyword(s):  
Palliative Care ◽  
Bowel Obstruction ◽  
Symptom Management ◽  
Gastrointestinal Symptom ◽  
Treatment Options ◽  
Gastrointestinal Symptoms ◽  
Malignant Bowel Obstruction ◽  
Nonpharmacological Treatment

This chapter looks at the most commonly encountered gastrointestinal symptoms in palliative care, including diarrhea, constipation, nausea, vomiting, anorexia, cachexia, and malignant bowel obstruction (MBO). The chapter gives an overview of these symptoms along with recommendations for both pharmacological and nonpharmacological treatment options. It also provides helpful tips and general principles to help guide the clinician practicing in the field.

scholarly journals Approach to Palliative Care Consultation for Patients With Malignant Bowel Obstruction in Gynecologic Oncology: A Qualitative Analysis of Physician Perspectives

2020 ◽  
Vol 16 (8) ◽  
pp. 483-489
Author(s):  
Claire Hoppenot ◽  
Fay J. Hlubocky ◽  
Julie Chor ◽  
S. Diane Yamada ◽  
Nita K. Lee
Keyword(s):  
Palliative Care ◽  
Qualitative Analysis ◽  
Bowel Obstruction ◽  
Gynecologic Oncology ◽  
Gynecologic Cancer ◽  
Malignant Bowel Obstruction ◽  
Specific Patient ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Nonsurgical Patients

PURPOSE: Malignant bowel obstruction (MBO) from gynecologic cancer is associated with increased symptoms and short survival. A gynecologic oncologist’s approach to palliative care consultation in the setting of MBO has not been well studied—it could be an opportune time for collaboration with palliative care. MATERIALS AND METHODS: This qualitative analysis of interviews with gynecologic oncologists focuses on their perspectives on palliative care consultation at the time of MBO. Interviews were analyzed using a framework analysis, and key themes and quotations were extracted. RESULTS: We interviewed 15 gynecologic oncologists from 8 institutions in Chicago. They described a variety of expectations from palliative care consultation. Most frequently, they consulted palliative care for specific questions but managed the remainder of the care. Most participants frequently consulted palliative care, but they also worried about fragmentation of care, the timing of when to introduce a new team during MBO, and the selection of appropriate patients for a limited resource. Many participants preferred earlier palliative care consultation, and many described an emotional toll of caring for patients with MBO. Palliative care consultation was most readily discussed for nonsurgical patients. CONCLUSION: Participants’ expectations of palliative care consultations during MBO varied and were not always met. We recommend strengthening communication and protocols for palliative care involvement that meet the needs of specific patient populations and physician teams for surgical and nonsurgical patients. More research is needed to better understand how to integrate palliative care into oncologic and surgical care with gynecologic oncologists.

scholarly journals Illness Understanding, Prognostic Awareness, and End-of-Life Care in Patients With GI Cancer and Malignant Bowel Obstruction With Drainage Percutaneous Endoscopic Gastrostomy

2020 ◽  
pp. OP.20.00035
Author(s):  
Jessica I. Goldberg ◽  
Debra A. Goldman ◽  
Sarah McCaskey ◽  
Douglas J. Koo ◽  
Andrew S. Epstein
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Bowel Obstruction ◽  
Percutaneous Endoscopic Gastrostomy ◽  
Malignant Bowel Obstruction ◽  
Do Not Resuscitate ◽  
Future Expectations ◽  
Endoscopic Gastrostomy ◽  
Gi Cancer ◽  
Additional Chemotherapy

PURPOSE: Malignant bowel obstruction (MBO) is common in advanced GI cancer, and MBO management, including drainage percutaneous endoscopic gastrostomy (dPEG), is palliative. How patients understand the goals of dPEG and its impact on disease is inadequately understood in the literature. Therefore, we analyzed these issues in patients with GI cancer. METHODS: Demographics, clinical variables, and patient outcomes were abstracted from the medical record. Illness understanding and future expectations were retrieved from palliative care notes. We described additional treatment and outcomes after dPEG and estimated overall survival (OS). RESULTS: From January 2015 to June 2017, 125 admitted patients with metastatic GI cancer underwent dPEG for MBO. Cancers were most commonly colorectal (34%) and pancreatic/ampullary (25%). During the dPEG admission, 32% (40 of 125) of patients had a palliative care consultation, and 22% (28 of 125) were asked about illness understanding and future expectations. All (28 of 28) reported good understanding of the advanced nature of their disease, but few were accurate about prognosis given their stage IV disease (10 of 28). Of the 117 (94%) discharged, 13% (15 of 117) received additional chemotherapy, which rarely prevented progression; half (63 of 117) had a do-not-resuscitate order; and most (101 of 117) were enrolled in hospice at death. Median time to death was 37 days (95% CI, 29 to 45 days); 6-month OS was 3.7% (95% CI, 1.2% to 8.4%). CONCLUSION: dPEGs are placed close to end of life in patients with advanced GI cancer. A minority of patients receive additional chemotherapy post-dPEG. Many have adequate disease understanding, but chemotherapy benefit is low, and future expectations vary. This may be an opportunity for improved communication regarding palliative procedures in advanced cancer.

scholarly journals Management of Malignant Bowel Obstruction Associated With GI Cancers

2017 ◽  
Vol 13 (7) ◽  
pp. 426-434 ◽  
Author(s):  
Aaron J. Franke ◽  
Atif Iqbal ◽  
Jason S. Starr ◽  
Rajesh M. Nair ◽  
Thomas J. George
Keyword(s):  
Palliative Care ◽  
Peritoneal Carcinomatosis ◽  
Bowel Obstruction ◽  
Abdominal Cavity ◽  
Symptom Control ◽  
Disease Process ◽  
Terminal Phase ◽  
Malignant Bowel Obstruction ◽  
Gi Cancers

For many patients with GI malignancies, the seeding of the abdominal cavity with tumor cells, called peritoneal carcinomatosis, is a common mode of metastases and disease progression. Prognosis for patients with this aspect of their disease remains poor, with high disease-related morbidity and complications. Uniform and proven practices that provide optimal palliative care and quality of life for these patients are needed. The objective of this review is to critically assess the current literature regarding palliative strategies in the management of peritoneal carcinomatosis and associated symptoms in patients with advanced GI cancers. Despite encouraging results in the select population where cytoreductive surgery and intraperitoneal chemotherapy are indicated, the majority of patients who develop peritoneal carcinomatosis in the setting of GI cancers have poor prognosis, with malignant bowel obstruction representing a common terminal phase of their disease process. For all patients with peritoneal carcinomatosis, aggressive symptom control and early multimodality palliative care as further outlined should be sought.

scholarly journals Constipation and malignant bowel obstruction in palliative care

Medicine ◽  
2020 ◽  
Vol 48 (1) ◽  
pp. 18-22
Author(s):  
Jason W. Boland ◽  
Elaine G. Boland
Keyword(s):  
Palliative Care ◽  
Bowel Obstruction ◽  
Malignant Bowel Obstruction

QIM19-127: Novel Admission Checklist for Malignant Bowel Obstruction

2019 ◽  
Vol 17 (3.5) ◽  
pp. QIM19-127
Author(s):  
Gabrielle Gauvin ◽  
Leigh Selesner ◽  
Marcin Chwistek ◽  
Molly Collins ◽  
Crystal Denlinger ◽  
...  
Keyword(s):  
Palliative Care ◽  
Bowel Obstruction ◽  
Multidisciplinary Team ◽  
Care Center ◽  
Tertiary Care ◽  
Management Plan ◽  
Care Plan ◽  
Malignant Bowel Obstruction ◽  
Goals Of Care ◽  
Nccn Guidelines

Background: Malignant bowel obstruction (MBO) is a frequent presentation of advanced abdominal malignancy. Despite the frequency of MBO and the availability of NCCN Guidelines for its management, clinicians struggle to create a personalized care plan accounting for a patient’s current condition, prognosis, and goals of care. The aim of this project is to develop a discussion tool to implement on admission to ensure realistic prognostication and appropriate involvement of the patient, caregivers, and multidisciplinary team in treatment decisions. Methods: At our tertiary care center, a multidisciplinary team composed of surgical oncologists, medical oncologists, palliative care specialists, hospitalists, social workers, and nutritionists developed an algorithm to implement when a patient is admitted with MBO. The algorithm was influenced by the NCCN Guidelines for palliative care but was designed as a single-page checklist that could be easily executed by all team members. Results: The MBO admission checklist is divided into 4 sections. The general assessment section includes information about the etiology, severity, and reversibility of the current and past MBO. Also, the patient’s resuscitation and functional status are reviewed. The cancer care coordination/communication section covers the patient’s oncological history and estimated lifespan, as well as the need for further coordination of care and a goals of care discussion. The subsequent portion covers the management plan, with specific decisions resulting from a goals of care discussion as well as the need for specialized consults. The medical, procedural, and operative interventions the team and patient discussed as options are also documented. A key portion is the risks and benefits discussion for each treatment modality. Lastly, the discussion about future considerations section explores the patient’s wishes for the next episode of MBO. Conclusions: The goal of this checklist is to ensure that a comprehensive discussion is held between the different services involved in a patient’s care at every admission for MBO in order to provide a personalized management plan and improve communication. The next step in our study is to assess the effectiveness of implementation of the checklist as well as its impact on patient satisfaction, quality of life, early hospice referral, and outcomes.

Real-world evidence highlights sizeable gap in adopting early palliative care referral in patients with advanced cancers.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e24147-e24147
Author(s):  
Suzanne Cole ◽  
Sarah Storie ◽  
Sonya Owens ◽  
LaShanta Gipson ◽  
Michael Hardy ◽  
...  
Keyword(s):  
Palliative Care ◽  
Real World ◽  
Qualitative Methodology ◽  
Treatment Options ◽  
Community Setting ◽  
Symptom Burden ◽  
Community Practice ◽  
Related Factors ◽  
Early Integration ◽  
Early Palliative Care

e24147 Background: Early referral to palliative care (PC) for patients w/ adv cancer is supported by compelling evidence from large RCTs demonstrating a lower symptom burden, higher QOL, and increased OS. However, these studies reflect pts who have self-selected to accept a PC referral and attend a PC visit. WHO/NCCN/ASCO guidelines support early integration of PC. We sought to characterize the referral patterns in our heme/onc practice to identify and mitigate the barriers to early PC adoption in the community setting. We began a concerted effort to discuss early PC referral w/ pts recently diagnosed w/ adv cancer at the time systemic therapy was initiated. Methods: To ensure real-world applicability of this study, we identified a large satellite clinic of a major academic center w/ access to PC on the main campus (located 20 miles from the satellite clinic). We retrospectively reviewed new pts age 18y+ w/ adv cancer, characterized PC referrals and outcomes. Using qualitative methodology, we identified pt-reported barriers to accepting PC care. Results: 407 new pts were seen; 168 w/ benign heme, 145 w/ early cancers, 94 w/ adv cancers. Of the 94 pts w/ adv cancers, 25 pts had one-time 2ndopinion visits, and 16 pts were not candidates for, or did not desire cancer treatment and directly enrolled on hospice. Our analysis cohort consisted of 53 pts w/ adv cancer pursuing life prolonging therapy. At initiation of treatment, 57 % (n=30) were not offered a PC referral, 22% (n=12) received a PC referral and attended the appt, however 21% (n=11) received a PC referral but did not attend the appt. A qualitative analysis of the 11 patients referred to early PC who did not attend the appt revealed; 5 patients scheduled an appt but did not attend (3-unknown reason, 2-hospitalized during appt, 1-lack of transportation), 2 pts were unreachable, and 4 pts were contacted but declined to schedule stating: “I feel pressured” “I want to hear what other treatment options I have” “I want to be treated first and then see if I need it” "I am overwhelmed with too many new doctors and visits". Conclusions: Despite the benefit of early PC referral in pts w/ adv cancer, we identified a considerable gap in its adoption in our community practice despite access to proximate PC clinic. Further studies are under design to address institutional and pt-related factors to improve real-world adoption of this critical service.

scholarly journals EP.FRI.468 A review of the management of malignant bowel obstruction at an NHS teaching hospital

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Jessica Banks ◽  
Sony Aiynattu ◽  
Rafik Ishak
Keyword(s):  
Palliative Care ◽  
Length Of Stay ◽  
Bowel Obstruction ◽  
Peritoneal Metastasis ◽  
Palliative Surgery ◽  
Malignant Bowel Obstruction ◽  
Readmission Rates ◽  
Mortality And Morbidity ◽  
Clinical Dilemma ◽  
Complications And Mortality

Abstract Patients presenting with malignant bowel obstruction (MBO) due to peritoneal metastasis present a clinical dilemma for surgeons: although palliative surgery is beneficial, post-operative complications and mortality are as high as 30%.  A personalised and multi-disciplinary approach is paramount when treating these patients. Aims This study aimed to review the management (surgical versus conservative) of patients presenting with MBO; ascertain if a multi-disciplinary approach was adopted; and compare clinical outcomes including length-of-stay, readmission rates and mortality.  Methods All patients admitted with MBO secondary to peritoneal metastasis between January 2019 – January 2021 were identified. Results 29 patients; 14 females, were identified with a median age 72. The median length of stay was 16 days. All patients had a CT scan and 76% were performed within 24 hours of admission. 25/29 patients were referred to palliative care. Conclusions Overall mortality and morbidity in our cohort, regardless of surgical or conservative management, is consistent with existing literature. Palliative care input was sought for the majority of patients. Management decisions should be individualised and focus on ensuring the best quality of life for the patient. All decisions should be made with multi-disciplinary input. 

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