L’intégration des familles aux soins en cancérologie: perspectives et limites

The fight against cancer concerns us all, and significant others who are badly affected by the illness of their loved ones, have a role to play in implementing the cancer care plan. Confronted with new expectations from both patient and significant others in terms of consideration and participation, the current trend is to consider significant others as active players in the care process with a new role to play. But before we can discuss the role of participants in the care process, we must first define what we mean by significant other. A new area of research, known as proximology, invites us to take a new look at the real impact of chronic conditions and their management on a daily basis. Patients and family alike are demanding this integrated approach to care management. What, then, is the role of the significant other? It is also important to emphasise the ethical dimension of this discussion, being careful not to assign the significant other a fixed — and therefore decisive — role, or even to actively encourage the sick person to turn to his or her significant others for support. We must respect the freedom of each individual. These general reflections lead us to look more specifically at the patient/significant other/caregiver relationship, within the context of a cancer diagnosis. To illustrate our remarks, we will draw on research into the place of family participation in care currently being undertaken at Clermont Ferrand University Hospital in partnership with the Centre Anti Cancéreux Jean Perrin (Jean Perrin Anti-Cancer Centre) in Clermont Ferrand. This research, which is of a multidisciplinary nature, raises a number of questions Can family participation in care be beneficial? What are the benefits and risks for patients and their significant others?     

Role of surgery for locally advanced and metastatic renal cell carcinoma

Both locally advanced and metastatic renal cell carcinoma (RCC) present a challenge in terms of their optimal management. This article reviews the literature and evaluates the role of surgery in the treatment of advanced RCC. Surgery is the optimal treatment for locally advanced RCC and minimal, resectable, metastatic disease. Patients with metastatic disease, and some forms of locally advanced disease, may also benefit from multimodal management with local surgical therapy and systemic treatment using either immunotherapy or targeted therapy. Regardless of the disease stage, patients with locally advanced or metastatic RCC represent heterogenous patient populations with different disease characteristics and risk factors. Individualization of care in the setting of a sound oncologic framework may optimize the risk/benefit ratio within individual patient cohorts.     

Terminology: the historical perspective,evolution and current usage – room for confusion?

Modern palliative care started with St Christopher's Hospice in 1967 and was initially regarded as 'terminal care'. This served as a template for a developing model of multidisciplinary clinical care, teaching and research. A decade later, several hospital Palliative Care Teams were established and different terms were used to describe them. An evidence base developed slowly and a medical subspeciality was established, known as Palliative Medicine. Over the last two decades we have seen an expansion in non-hospice palliative care. The terms used to describe this care have been variable and inconsistent. Our challenges in progress involve establishing clear terminology and an evolving improved evidence base, along with a realisation that there are large gaps in patient care.     

Patientenorientierung in der Onkologie

Patient orientation in medicine is a new concept which encompasses the orientation of patient care to the needs, interests and preferences of patients in terms of the structures as well as the processes of care systems. Due to an increasing process of a new orientation within the whole field of the medical care system, the concept of patient orientation has been extensively discussed also in oncology. Therefore, the National Cancer Plan initiated in 2008 in Germany by the Federal Ministry of Health, the German Cancer Society, German Cancer Aid and the German Association of Tumor Centers, was established within a broad field of various tasks to improve patient care and included a working group for promotion of patient orientation. This working group is focusing on various goals including patient information, communication skills, patient competence and shared decision making. This article gives an overview of the current state of the discussion and the recommendations to improve patient orientation in the care system of cancer patients.     

Radiologist participation in multi‐disciplinary teams in breast cancer improves reflective practice,decision making and isolation

This study aims to explore Australian radiologists' experiences of participating in breast cancer multi‐disciplinary team (MDT) meetings to identify enablers and barriers to participation as well their perception of confidence and patient care. Qualitative methods incorporating observation and interviews were used. Twenty‐one breast cancer MDT meetings were observed across Sydney to study the dynamics of the meetings, the level of participation by radiologists and their most important interactions. Qualitative semi‐structured interviews were conducted with 10 radiologists participating in these meetings regarding participation, educational opportunities and improvements to work practices. Radiologists' participation in breast cancer MDT meetings is influenced by the type of meeting they attend with higher levels of participation and a more dominant ‘valued’ role being evident in pre‐interventional meetings. The key themes to emerge from the data include the importance of ‘sharing experiences’, the ‘radiologist–pathologist relationship’ and the value of ‘continuing participation’. Radiologists believed their confidence in their clinical decision making increased when there was immediate feedback from pathologists. This study highlights the benefits of radiologists regularly participating in breast cancer MDT meetings in terms of continuing professional education resulting from collegial experiential learning. Radiologists' perceived patient care and workplace isolation were improved by sharing experiences with other cancer care colleagues.     

Techniques of hepatic resection

Liver resections are high risk procedures performed by experienced surgeons. The role of liver resection in malignant disease has changed over the last 100 years with great improvement in morbidity, mortality and long term survival. New understanding in liver anatomy, improved perioperative care, anesthesia techniques, and technological advances has improved this aspect of patient care. With improved techniques, patients previously considered unresectable have an opportunity to undergo curative surgery. This review article describes the various approaches and techniques for liver resection. The relevant anatomy and terminology of hepatic resections is discussed, as well as the role of anatomic vs. nonanatomic resection. Methods of vascular control are examined and the multiple strategies of parenchymal transection are compared, as well as minimally-invasive techniques. Finally, a brief review of the authors’ practice in terms of surgical technique is offered.Key Words: Colorectal cancer, liver resection, techniques     

Surgical management of pancreatic cancer

The overall prognosis after resection for adenocarcinoma of the pancreas remains poor; however, considerable progress has been made in terms of preoperative patient selection and radiographic staging, refinements in the technical aspects of surgical care, and investigations into the role of multimodality care for patients with potentially curable, resected cancers. Improvements in endoscopic decompression of malignant biliary obstruction have decreased the need for palliative bypass operations and have focused current surgical issues on ways to improve clinical outcomes after potentially curative resections. Controversies such as whether or not to perform extended lymph node dissections and standard versus pylorus-preserving resections have been addressed by randomized, prospective clinical trials. Major venous resections secondary to local tumor extension are now performed without an increase in morbidity or mortality and with survival rates comparable to standard resections. The impact of surgical specialization and regionalization of referrals to tertiary care centers is evident in markedly improved perioperative mortality rates. Neoadjuvant therapy is an area of current clinical investigation. This article describes the current preoperative, intraoperative, and postoperative issues in the surgical management of pancreatic cancer.     

An investigation of inpatient referrals to a clinical psychologist in a hospice

A clinical psychologist, in a new post in a hospice, developed an assessment, therapeutic and consultation role. A retrospective, diary-based audit was made of the inpatients referred during the first 2 years, allowing an examination of referral practices and changes over time as the psychologist's role developed. During the 2 years 11% of the hospice inpatients were referred, consistent with previous published work in this area. Referrals increased from 10% in year 1 to 12% in year 2. Referrals were not skewed in terms of patient gender or diagnosis but younger patients were referred more. Comparison with other studies suggests the psychologist's gender may influence referral rates of woman patients. Referrals for depression and anxiety increased in year 2 but decreased for pain. The number of patients seen with marital/family stresses also increased with time. Such patients required the most psychological input. Patients with problems of alcohol misuse or dementia were particularly challenging for the hospice team and specific training was developed. The psychologist's role is discussed in the light of these findings, particularly in enhancing the multidisciplinary team's holistic approach to the patient and their family, by emphasizing the patient's experience and the collaborative basis of care.     

Computers in oncology nursing: present use and future potential

Computers assist oncology nurses in their roles as "care integrators" and caregivers. Computers assist nurses in their care integrator role by supporting communication with ancillary departments and by aiding in the collection, organization, and storage of data. Computers helps nurses in their role as caregivers through automated care planning, discharge planning, and patient monitoring and by tracking patients' educational, therapeutic, comfort, or other needs. Using computers, nurses can document their assessments and interventions and patient outcomes while receiving cues and reminders about policies, procedures, and standards of care. In the future, oncology nurses can expect to see computer technology in more hospitals and a host of new developments, such as more intelligent systems, nursing and medical knowledge on-line, documentation at the bedside, and use of patient data bases in education and research.     

Nurses as patient navigators in cancer diagnosis: review, consultation and model design

The diagnostic phase of cancer care is an anxious time for patients. Patient navigation is a way of assisting and supporting individuals during this time. The aim of this review is to explore patient navigation and its role in the diagnostic phase of cancer care. We reviewed the literature for definitions and models of navigation, preparation for the role and impact on patient outcomes, specifically addressing the role of the nurse in patient navigation. Interviews and focus groups with healthcare providers and managers provided further insight from these stakeholder groups. Common to most definitions of navigation is the navigator's multifaceted role in facilitating processes of care, assisting patients to overcome barriers and providing information and support. Navigation may be provided by laypersons, clerical staff and/or healthcare professionals. In the diagnostic phase it has the potential to affect efficiency of diagnostic testing, patients' experience during this time and preparation for decision-making around treatment options. Patient care during the diagnostic phase requires various levels of navigation, according to individual informational, physical and psychosocial needs. Identifying those individuals who require more support--whether physical or psychosocial--during the diagnostic phase is of critical importance.     

Quality of care assessment for breast cancer: how to measure benefits of prevention and therapy in oncology

Over the last few years evaluation of quality of diagnostic and therapeutic care has become one of the most controversial and fastest growing fields of research in many areas of medicine. In this situation, oncology represents a model case as the conditions in which new therapeutic strategies are tested and implemented largely differ from routine practice, both in terms of availability of sophisticated technology and comparability of patient populations. The promising role of health care research for the understanding of factors through which research advances can be generalized to routine clinical practice has only recently being appreciated. From this point of view, the paper discusses the rationale and key findings of a multi-annual++ evaluation program on breast cancer care, underway in Italy since 1980. Special attention is given to how results (such as data on diagnostic delay or non-adherence to recommended treatment guidelines) can be used for the implementation of educational programs, controlled studies and ad hoc demonstration projects.     

Ovarian cancer care: a case study in determined living

BACKGROUND: The balance between quality of life and aggressive treatment fuels strong debate in cancer care. Recently, more attention is focused on blending advanced care, palliative care and hospice treatments in a patient-specific, tailored manner. This case study explores quality of life, the role of psychosocial factors in treatment selection, and the role of medical bias in end-of-life decision-making. CASE REPORT: The patient was a 55-year-old woman with advanced recurrent epithelial ovarian cancer. The disease course was essentially unremitting with only 5 months of non-progression after initial treatment. Multiple courses of chemotherapy were provided, in addition to a wide range of advanced and aggressive therapies to treat the cancer, as well as prolong life. Hospice care was an active part of treatment over 2 separate time periods, with a 1-year hiatus between admissions into hospice care. CONCLUSION: This case study provides an example of blending aggressive treatment, palliative care and hospice care to allow a patient to achieve specific life milestones, while attempting to preserve quality of life.     

Experiences of family caregivers for patients suffering from dysphagia--the attempt of subjective caregiving

The purpose of this study was to investigate the experiences of family caregivers for patients suffering from dysphagia following a stroke. This study, in particular, examines an approach for subjective caregiving. Eight primary caregivers for dysphagic patients, who receive homecare from visiting nurses, were interviewed in this research. A qualitative content analysis of semi structured interviews was used to analyze transcribed interview data. The overall experience of care is explained in seven phases. Phase 1: An initiation of caring for a dysphagic patient at home with a belief that it is possible to manage the care for patient, Phase 2: The sway of mind and acceptance of the reality of coming to terms with having to take care of a dysphagic patient, and then, to take a wise decision of doing so, Phase 3: A caregiver's inner struggle to provide foods even if patients cannot enjoy foods as before, and then, to take a wise decision of doing so, Phase 4: Coexistent feelings of "whether I can continue to give the care for the patient or I can't manage the care in the future", Phase 5: The feeling of caregiver, imaging that "if I were the caregiver, I would be able to take care of the patient," is obtained, Phase 6: An approach that aims at restructuring the life of the patient and Phase 7: Adjusting and balancing dysphagic patient's care and caregiver's personal life. An implication of this research includes the importance of assessing each caregiver's experiences. These findings may provide a direction for homecare nurses and other health professionals in targeting interventions that will meet the demand for caregivers.     

Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy.

PURPOSE: Professionally administered psychosocial interventions have been shown to improve the quality of life of cancer patients undergoing chemotherapy. The present study sought to improve access to psychosocial interventions during chemotherapy treatment by evaluating the efficacy and costs of a patient self-administered form of stress management training that requires limited professional time or experience to deliver. PATIENTS AND METHODS: Four hundred eleven patients about to start chemotherapy were randomly assigned to receive usual psychosocial care only, a professionally administered form of stress management training, or a patient self-administered form of stress management training. Quality-of-life assessments were conducted before randomization and before the second, third, and fourth treatment cycles. Intervention costs were estimated from both payer and societal perspectives. RESULTS: Compared with patients who received usual care only, patients receiving the self-administered intervention reported significantly (P < or = .05) better physical functioning, greater vitality, fewer role limitations because of emotional problems, and better mental health. In contrast, patients who received the professionally administered intervention fared no better in terms of quality of life than patients receiving usual care only. Costs of the self-administered intervention were estimated to be 66% (from a payer perspective) to 68% (from a societal perspective) less than the average costs of professionally administered psychosocial interventions for patients starting chemotherapy. CONCLUSION: Evidence regarding the efficacy and favorable costs of self-administered stress management training suggests that this intervention has the potential to greatly improve patient access to psychosocial intervention during chemotherapy treatment.     

Patient generated health data and electronic health record integration in oncologic surgery: A call for artificial intelligence and machine learning

In this review, we aim to assess the current state of science in relation to the integration of patient‐generated health data (PGHD) and patient‐reported outcomes (PROs) into routine clinical care with a focus on surgical oncology populations. We will also describe the critical role of artificial intelligence and machine‐learning methodology in the efficient translation of PGHD, PROs, and traditional outcome measures into meaningful patient care models.     

Follow-up care of patients treated for breast cancer: a structured review

Breast cancer follow-up services vary, with little evidence to support which practice is best. A systematic review methodology was employed to identify and integrate primary research on the effectiveness of follow-up services. From 4418 articles identified by searches, 38 were eligible for review inclusion. Data were not sufficiently homogenous to integrate statistically, however the following patterns of findings were observed: patient survival and quality of life were not affected by intensity of follow-up or location of care; patients held positive attitudes towards follow-up but psychological distress was consistently high regardless of location of services; few studies assessed patient involvement in treatment choices; studies' research quality was poor with inadequate measures of effectiveness or research designs. There is insufficient primary empirical evidence to draw broad conclusions regarding best practice for breast cancer follow-up care in terms of (a) patient involvement in care, (b) reductions in morbidity, and (c) cost effectiveness of service provision.     

Ways to make cooperation between hospital nurse and home visiting nurse in treating a final stage cancer patient at home

Due to a payment system based on Comprehensive Medical Evaluation has been adopted, both a shorter hospitalization and the use of home nursing care have been increasing. A good cooperation between hospital and home visiting nurses is desired in order to transfer continued nursing. Regarding a home nursing care service for the most terminal cancer patients, we conducted a survey of 459 home visiting nurses with twelve questions in five categories: (1) Before transferring to home care, (2) Right after the transfer to home care, (3) Patient in a stable period, (4) Time of near death and (5) Other (Requests to hospital nurses). The following issues became clearer in terms of how hospital and home visiting nurses should be cooperating with the handling of last stage terminal cancer patients: (1) A home visiting nurse should have a coordinating role with a hospital nurse when the patient is discharged from the hospital. (2) A participation of home visiting nurses on the coordination guidance at the time of a patient discharge is influenced by a manpower of the nursing station. (3) Even though home visiting nurses found a discrepancy between the hospital information and what patients and their families were getting from the hospital, home visiting nurses have learned through the job to clarify what patient and family needs were, and they responded accordingly. (4) A coordination between hospital and home visiting nurses was needed quite often when the patient's time has come to die at home.     

Family and caregiver needs over the course of the cancer trajectory

When a patient is diagnosed with cancer, family members often assume responsibility for providing care. They are typically involved not only with the diagnostic and treatment phases of care but also across the care trajectory and into survivorship. These caregivers are a primary source of support to individuals with cancer. The purpose of this article is to present an overview of the challenges, needs, and roles of family caregivers over the course of the cancer treatment trajectory and to discuss what support the professionals can provide. Caregivers require support, coordination, and communication with health care providers if they are to be successful in carrying out tasks of care. Concern for caregivers as partners in patient care and caregiver outcomes deserves attention from health care professionals. Considering the caregivers' value to the health care team, this role should not be underestimated.