Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology

Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.

Changes in Inflammatory Biomarkers Related to C-reactive Protein and Albumin in Patients With Terminal Cancer Receiving Palliative Care: a Longitudinal Study

Background: Evidence about how inflammatory biomarkers vary during the end-stage cancer trajectory is lacking. This study investigates the longitudinal changes in albumin and C-reactive protein (CRP) levels, and CRP/albumin ratio (CAR) in patients with terminal cancer receiving palliative care in the last three months of life.Methods: This is a retrospective analysis of variables extracted from a prospective cohort study that included admitted patients to the exclusive Palliative Care Unit of the National Cancer Institute in Brazil. Routine blood examination results of albumin and CRP were recorded at 0-15 (T1), 16-30 (T2), 31-45 (T3), 46-60 (T4), 61-75 (T5), and 76-90 (T6) days before death and only patients with at least two measurements were included. Crude and adjusted linear mixed-effects regression models were performed to verify the relationships between the longitudinal trajectories of biomarkers and death. Results: A total of 1,635 patients were included. Median albumin was 3.00g/dL across the whole time-period analyzed (interquartile range, IQR: 2.50-3.60) and decreased with the approach of death, while median CRP was 9.31mg/L (IQR: 4.42-17.30) and CAR was 3.20 (IQR: 1.40-6.60), and both increased. The albumin (slope: 0.01 to 0.02; p <0.001), CRP (slope: -0.10 to -0.12; p <0.001), and CAR (slope: -0.06; p <0.001) showed a linear dose-response relationship with death in crude and adjusted models tested. Conclusions: The longitudinal change levels of inflammatory biomarkers worsen with the approach of death and could be used to predict end-stage in patients with terminal cancer.

“When I Heard the Word Palliative”: Obscuring and Clarifying Factors Affecting the Stigma Around Palliative Care Referral in Oncology

PURPOSE Palliative care (PC) can help patients with cancer manage symptoms and achieve a greater quality of life. However, there are many barriers to patients with cancer receiving referrals to PC, including the stigmatizing association of PC with end of life. This study explores factors that obscure or clarify the stigma around PC referrals and its associations with end of life in cancer care. METHODS A qualitative descriptive design using grounded theory components was designed to investigate barriers to PC referrals for patients receiving treatment at an outpatient cancer center. Interviews with patients, caregivers, and oncology professionals were audio-recorded, transcribed, and independently coded by three investigators to ensure rigor. Participants were asked about their perceptions of PC and PC referral experiences. RESULTS Interviews with 44 participants revealed both obscuring and clarifying factors surrounding the association of PC as end of life. Prognostic uncertainty, confusion about PC's role, and social network influence all perpetuated an inaccurate and stigmatizing association of PC with end of life. Contrarily, familiarity with PC, prognostic confidence, and clear referral communication helped delineate PC as distinct from end of life. CONCLUSION To reduce the stigmatizing association of PC with end of life, referring clinicians should clearly communicate prognosis, PC's role, and the reason for referral within the context of each patient and his or her unique cancer trajectory. The oncology team plays a vital role in framing the messaging surrounding referrals to PC.

Providing Telephone-Based Support for Patients With Haematological Malignancies: A Qualitative Investigation of Expert Nurses

Background Telephone-based interventions are frequently used to address cancer patient’s needs, often delivered by nurses; however, little is known about nurses’ opinions of such interventions. Purpose The objective of this study was to investigate expert nurses’ perceptions of hemato-oncology patient’s needs, use of telephone interventions providing support and symptom management and intervention acceptability from a service provider perspective. A qualitative study was undertaken with focus group and individual interview. Inductive and deductive data analysis was performed using Framework Analysis and the Theoretical Framework of Acceptability. Results Two themes emerged: (1) perceived needs of haemato-oncology patients across the cancer trajectory – multifactorial influences, dynamic information needs, and continuity of care, (2) acceptability for nurses delivering interventions was determined by identification of need, agreed expectations and organisational support for the intervention. Conclusions Greater understanding of contextual factors for recipients and individuals delivering healthcare interventions may contribute to identification of potential barriers and facilitators to adoption in clinical practice.

Quality of life support in advanced cancer—web and technological interventions: systematic review and narrative synthesis

BackgroundAs treatments continue to progress, patients with advanced cancer are living longer. However, ongoing physical side-effects and psychosocial concerns can compromise quality of life (QoL). Patients and physicians increasingly look to the internet and other technologies to address diverse supportive needs encountered across this evolving cancer trajectory.Objectives1. To examine the features and delivery of web and technological interventions supporting patients with advanced cancer. 2. To explore their efficacy relating to QoL and psychosocial well-being.MethodsRelevant studies were identified through electronic database searches (MEDLINE, PsychINFO, Embase, CINAHL, CENTRAL, Web of Science and ProQuest) and handsearching. Findings were collated and explored through narrative synthesis.ResultsOf 5274 identified records, 37 articles were included. Interventions were evaluated within studies targeting advanced cancer (13) or encompassing all stages (24). Five subtypes emerged: Interactive Health Communication Applications (n=12), virtual programmes of support (n=11), symptom monitoring tools (n=8), communication conduits (n=3) and information websites (n=3). Modes of delivery ranged from self-management to clinically integrated. Support largely targeted psychosocial well-being, alongside symptom management and healthy living. Most studies (78%) evidenced varying degrees of efficacy through QoL and psychosocial measures. Intervention complexity made it challenging to distinguish the most effective components. Incomplete reporting limited risk of bias assessment.ConclusionWhile complex and varied in their content, features and delivery, most interventions led to improvements in QoL or psychosocial well-being across the cancer trajectory. Ongoing development and evaluation of such innovations should specifically target patients requiring longer-term support for later-stage cancer.PROSPERO registration numberCRD42018089153.

Challenges in breast cancer control in Malaysia

: High proportion of late presentation and poor survival of women with breast cancer in Malaysia does not reflect the country’s status as the third richest country in South East Asia. Herein, we examined, and collated research articles related to breast cancer trajectory i.e., primary, secondary, and tertiary prevention in Malaysia to understand, appreciate and recognize the achievements but also gaps which undermines Malaysia’s response in handling the disease. In summary, the integral task for Malaysia is to strategically align research to improve local data (research) on the extent of the country’s breast cancer problem thus from there, effective, comprehensive, evidence-based cancer control programme founded on resource level can be generated.

Telehealth Strategies to Support Patients and Families Across the Cancer Trajectory

Effective delivery of cancer care via telehealth requires a planned care system that accounts for myriad patient, provider, and practice/cancer center resources before, during, and after the care episode. Telehealth is broadly defined as a method to have virtual, bidirectional communication between patients and providers. Telehealth can include methods such as audio-only, video-consultation, and tele-monitoring, which can occur in a synchronous, asynchronous, or blended format. The purpose of this review is to present common foundational principles for providing clinical cancer care via telehealth, followed by an overview of three distinct examples of comprehensive telehealth programs that have been developed to meet the needs of patients and families across the cancer trajectory, including survivorship, rehabilitation, and palliative care phases. The programs described are exemplars that were developed and implemented prior to the coronavirus pandemic, so they reflect many years of planning and evidence. Lessons learned include the need for ongoing patient support, clinician training, and cancer health system/practice programmatic considerations such as billing, scheduling, reimbursement, software, and hardware/platform security. Although the COVID-19 pandemic produced an explosive shift in regulations and implementation, sustainability of these changes may not be long-term. Nevertheless, a permanent shift in cancer care to include telehealth is likely here to stay.