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Abstract:
For some health professionals, communicating bad news is one of the most frequent tasks of their daily work. Conversations on new diagnosis of a dismal disease, discontinuation of therapy due to disease progression or end-of-life care goals are some examples of discussions that oncologists and other health professionals are responsible for everyday with patients and caregivers. However, despite the frequency of these conversations, few health professionals are properly trained in how to conduct difficult conversations in an effective and yet compassionate manner. Navigating through these difficult conversations with thoughtfulness are crucial moments on the patient-physician relationship. The way in how these conversations are delivered have a direct impact on how the patient will perceive and react to the situation and it might make the difference between failure and success of this relationship. Communicating bad news demonstrates personal courage and integrity and when conducted in the right way, increases patient’s confidence and trust on the oncologist and his ability to make the right decisions during the patient’s journey. In addition, empathic communication can influence patient’s satisfaction with care, quality of life and ultimately patient’s outcome. Some studies have reported that the most valued qualities in nurses and doctors communicating bad news –from the patient’s perspective, are: recognition (how the oncologist respond to the gravity of the news), guiding (what patient would like to get after news are delivered) and responsiveness (oncologist’s ability to sense patient’s need). Learning how to communicate bad news effectively with patients and family members is an essential requirement on becoming a successful and contemporary health professional. During this lecture we will review some communication strategies on how to efficiently lead these conversations with our patients. References: Baile WF, et al. Curr Opin Oncol 2005, Jul;17(4):331-5 Fujmori M, et al. J Clin Oncol 2014 jul 10;32(20):2166-72 Back AL, et al. Oncologist 2011;16(3):342-50 Baile WF, et al. Oncologist 2000; 5(4):302-11 Girgis A, at al. Aust N Z J Surg 1997 Nov;67(11):775-80

Abstract:
Background: Emotional reactions are natural and expected in individuals experiencing cancer and confronting the end of their lives, the differentiation between a normal and appropriate reaction to dying versus a psychiatric disorder such as major depression can be clinically difficult to differentiate. Depression is a common mental health problem in palliative cancer patients, unfortunately misunderstood, underdiagnosed, and undertreated. Depression is a major cause of suffering among patients with advanced disease or terminal illness like cancer. Depressive syndromes are correlated with a reduced quality of life, greater difficulty in managing the course of the patient's illness, decreased adherence to treatment, and earlier admission to inpatient or hospice care. It amplifies pain and other symptoms, and causes worry in family members and friends. Patients with advanced illness who suffer from depressive syndromes are also at high risk of suicide and suicidal ideation, and they have an increased desire for a hastened death. The recognition and diagnosis of patient depression, is often delayed in the course of the disease. Prevalence and risk factors: The reported prevalence of major depression in individuals with cancer varies from 3 to 38 percent. This wide variability is explained by the lack of agreement as to appropriate diagnostic criteria to be used in the setting of advanced illness, differences in patient populations, and variation in assessment methods. In general, rates are higher in populations with advanced cancer, greater levels of disability, and/or unrelieved pain. In several studies, younger cancer patients have higher rates of depressive disorders and self-reported distress. While depression is twice as common in women as compared to men in the general population, gender is not consistently reported to be a risk factor for depression in cancer patients. A prior history of depression is a risk factor for major depression in cancer patients. The presence of uncontrolled symptoms, particularly pain, is a major risk factor for depression and suicide among patients with cancer. The incidence of depression also depends upon the patient's particular illness. Among cancer patients, those with head and neck and pancreatic cancers are at a particularly high risk. Certain factors associated with the patient's illness or its treatment may be associated with depression. Central nervous tumors or metastasis to the central nervous system can cause depression. Other causes of depression in cancer patients include toxins created by the tumor, autoimmune reactions, and nutritional deficiencies. Depression can also represent an adverse effect from certain treatments, including glucocorticoids, chemotherapy drugs (vincristine, vinblastine, interferon and tamoxifen) as well as radiotherapy to the brain or head and neck. Patients who have high levels of spiritual well-being tend to be less depressed. The beneficial aspects of religion related primarily to spiritual well-being rather than to formal religious practice. Screening and diagnosis: Screening for depression should be carried out in all palliative care patients given the high prevalence of symptoms. Expert recommendations state that every patient with cancer should be screened for depression at initial diagnosis and thereafter as clinically indicated, especially with changes in cancer status or treatment. There are many tools to identify vulnerable patients by screening, Patient Health Questionnaire (PHQ-2) and PHQ-9 can identify deserving cases a deeper interview. Depressed mood, sadness, grief, and anticipatory feelings of loss are all appropriate responses to advanced disease and dying, however, feelings of hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are indicators of depressive syndromes in these patients. Although most used criteria for diagnosing major depression in non- oncology patients is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the most widely used for cancer patients is the substitutive approach of Endicott. This scale replaces four of the DSM-IV somatic criteria thought most likely attributable to medical illness or its treatment (ie, change of weight/appetite, sleep disturbance, loss of energy/fatigue, difficulty thinking or concentrating) with cognitive substitutes (depressed appearance, social withdrawal, brooding/self-pity/pessimism, and lack of reactivity in situations that would normally be pleasurable) Treatment: Unfortunately, some data suggest most cancer patients with depressive syndromes are undertreated. The first step in treating depression is to relieve uncontrolled symptoms, particularly pain and potentially reversible general medical cause of depressed mood. If depression persists once these are identified and controlled, specific therapy is warranted. Treatment should be tailored to the individual needs of the patient. In addition to drug therapy, effective psychosocial interventions include individual or group psychotherapy, cognitive-behavioral therapy, existential therapy, and self-help groups. There are no randomized trials that specifically address the benefit of psychotherapy for palliative care patients with depression. As a result, therapy for depression in these patients is generally based upon the larger evidence on effective treatments in patients of primary care populations with either no physical illness or less severe medical conditions. The agents used most commonly in palliative care patients are psychostimulants, selective serotonin reuptake inhibitors (SSRIs), and tricyclic antidepressants (TCAs), these drugs are an important option for treatment of depression at the end of life because they take effect quicker than other classical drugs. Other advantages as their more favorable side effect profile and the markedly lower danger with overdose, led to the recomendation of the American College of Physicians in the 2008 clinical practice guidelines for initial treatment of depression in primary care patients, to initiate an SSRI, serotonin and norepinephrine reuptake inhibitors SNRI, or atypical antidepressant in this group of patients. Meyer HA. et al. Palliat Med 2003; 17:604 Portenoy LK. et al. Qual Life Res 1994; 3:183 Wilson KG. et al. J Pain Symptom Manage 2007; 33:118 Akechi T. et al. J Clin Oncol 2004; 22:1957 DeFlorio ML. et al. Depression 1995; 3:66 Endicott J. Cancer 1984; 53:2243 Andersen B. et al. J Clin Oncol 2014; 32:1605 Qaseem et al. Ann Intern Med. 2008;149(10):725

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ln the UK, lung cancer has one of the lowest 5 year survival rates of all cancers (8.8% of men and 11.1% of women are alive 5 years after their diagnosis) whilst only 30% of people live for more than one year following their diagnosis (Macmillan, 2014). This poor outlook can have a profound impact on the quality of life of those affected by the disease (LCA, 2015). However, helping people and their families cope with the impact and consequences of the disease and its treatment can make a substantial difference to the quality of their lives. In this context coping might be regarded as a means of understanding and regulating the emotions in response to stress but it might also be viewed as solving problems and adapting lifestyles and behaviour through goal setting and seeking information and help. By adopting a structured and planned approach to care, the healthcare professional can enhance the coping capability of the person with cancer and their families and thereby directly contribute to their quality of life. This approach can be seen in the Recovery Package. Data from the London Cancer Alliance reveals that the top ten concerns for the person with lung cancer are a mix of physical and psychological issues including breathlessness, fatigue, anxiety, weight loss, sleeping, finances, walking, pain, eating and transport. People with lung cancer have the highest number of unmet needs out of all cancer patients, mainly due to higher psychological support and physical/daily living support needs (Li et al, 2006). Depression levels tend to be higher for people with lung cancer compared to cancer patients with other types of cancer (Fischer et al, 2010). Self reported sexual concerns are common in people with lung cancer and are related to shortness of breath and emotional distress (Reese et al, 2011) whilst people with lung cancer experience higher levels of pain compared with patients with other types of cancer (Fischer et al, 2010) Link et al (2005) discuss the work of Lazarus and Folkman, and their ‘Transactional model of distress and coping’ which suggests that people respond to stressful situations by a primary appraisal (where they evaluate the significance of the stressor) and a secondary appraisal (where they evaluate their ability to change the situation and manage their emotions). It is at these key junctures that effective interventions might be best employed. The Recovery Package allows the identification and selection of suitable interventions which can be tailored to meet the specific needs of people with cancer and their families. In the UK the report ‘Taking Action to Improve Outcomes (NCSI, 2013) envisaged that care should be designed with the following key aims: Providing information and support from the point of diagnosis Promoting recovery Sustaining recovery Managing the consequences of treatment Supporting people with active and advanced disease These key aims underpin The Recovery Package which is a series of key interventions which, when delivered together, can greatly improve outcomes for people living with and beyond cancer. The Recovery Package is made up of an assessment of holistic needs and the development of a care plan to address these issues; a treatment summary that explains to the General Practitioner and individual what treatment has taken place; a cancer care review by the General Practitioner within 6 months of diagnosis; attendance at a health and wellbeing educational event. The Recovery Package The success of the Recovery Package depends upon the creation of a partnership with the individual and the focus of care is on supporting self-management after a cancer diagnosis. This is underpinned by effective assessment. Holistic needs assessment acknowledges that coping strategies are mediated by social context and that the quality and quantity of the person’s support can be quite variable. The assessment works by gathering and discussing information in order to develop an understanding of what the person living with and beyond cancer knows, understands and needs. It is focused on the whole person and the entirety of his/her needs including the physical, emotional, spiritual, mental, social, and environmental needs of the individual. The process culminates when the assessment results are used to inform a care plan. Holistic assessment tools offer front-line health service staff a structured yet collaborative way to elicit people’s concerns and, with adequate training and informational resources, respond to these concerns effectively, efficiently and humanely. By integrating the assessment of very understandable emotional concerns within a holistic treatment review there is less likelihood that psychological difficulties become pathologised by professionals or seen as a source of shame for those living with and beyond cancer (Brennan et al, 2012). Lung cancer is often characterised by rapid deterioration and a complex interplay of symptoms, concerns and worries and health care professionals can play a critical role in choice of coping strategy (which can be used to help people to more actively participate in their care) (Link et al, 2005). This can be helped by a structured and planned approach to care such as The Recovery Package.

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Paraneoplastic Syndromes (PNS) are a group of clinical disorders that are associated with malignant diseases that are not directly related to the physical effects of the primary tumour (Spiro 2007). The mechanisms by which PNS occur is not fully understood (Dalmau 2014) but is related to the production of polypeptide hormones or cytokines by the cancer itself or an immune response to the cancer. PNS may occur in 10% of patients with lung cancer and with the type of cancer influencing the nature of syndrome (Kanaji 2014). A wide variety of PNS have been associated with lung cancer with the most common syndromes being endocrine and neurological syndromes. This paper will only address these two groups of syndromes. Paraneoplastic Endocrine Syndromes include: Inappropriate Antidiuretic Hormone Secretion: hyponatremia is seen in 30-70% of patients with lung cancer with only 1-5% having symptoms and mostly associated with small cell lung cancer (SCLC); symptoms include confusion, seizure, reduced consciousness and coma (Spiro 2007). Hypercalcaemia: the incidence ranges from 2-12% in lung cancer; symptoms include nausea, vomiting, abdominal pain, constipation, polyuria, thirst, dehydration, confusion and irritability (Spiro 2007). Cushing Syndrome: production of adrenocorticotropic hormone(ACTH) is the most common explanation with approximately 50% being neuroendocrine lung cancers with 36%-46% carcinoid tumours and 8%-20% SCLC of cases; symptoms include weakness, muscle wasting, drowsiness, confusion, psychosis, oedema, hypokalaemia alkalosis and hyperglycaemia. hypertrophic osteoarthropathy (HOA) and finger clubbing: 90% cases in lung cancer Prevalence of 5-15% in lung cancer most common with squamous cell and adenocarcinoma. occurs due to proliferation of connective tissue beneath the nail bed with HOA causing distal expansion of the long bones; The Paraneoplastic Neurological Syndromes most commonly displayed are peripheral neuropathies and include Lambert-Eaton Myasthenic Syndrome, necrotizing myelopathy, cerebral encephalopathy, visual loss and visceral neuropathy. Symptoms include muscle weakness, cognitive and personality changes, ataxia, cranial nerve deficits or numbness. Classical and Non-Classical Symptoms have been defined (Graus 2004 Table 1) to aid in diagnosis. These syndromes are often associated with the presence of anti-Hu antibodies which are produced together with antigen-specific T lymphocytes and attack parts of the nervous system (Pelosof 2010). This syndrome is detected in 80% of cases before cancer is diagnosed (Honnorat 2007) and upto 20 per cent of those with SCLC have detectable antibodies although this syndrome will not necessarily develop (Darnell 2003). There is a reported 4-5% incidence in SCLC. Diagnostic Pathway Patients with lung cancer usually present with multiple symptoms with a time delay between symptom recognition and the ultimate diagnosis of lung cancer. The presence of a PNS may not necessarily preclude treatment with a curative intent which may help in the improvement of symptoms. Pathways of care commence with clinical evaluation, CT scan, blood screen and rapid evaluation for the next diagnostic test. It is at this point where a PNS may become apparent and can aid in the diagnosis of lung cancer. Where there are concerning symptoms for Paraneoplastic Neurological Syndrome and there is difficulty in identifying the underlying cancer: antibody screening can be considered but require considered interpretation as patients without cancer can harbour paraneoplastic antibodies, variation in the consistency of the presence of antibodies can be associated with different syndromes and the absence of antibodies may not exclude a syndrome; PET may identify neurological syndrome activity; electrophysiology may confirm the syndrome but are not always associated with cancer; MRI can assist in the diagnosis of limbic encephalitis as atrophy can be detected. Treatment As symptoms often present prior to the confirmed diagnosis it is important to treat the signs and symptoms of: Hypercalcaemia with: an increase in fluid intake; Bisphosphonates. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) with: fluid restriction; chemotherapy (effective in 80% of SCLC cases); Demeclocycline; Vasopressin receptor antagonists (Conivaptan, Tolvaptan). direct inhibition of cortisol secretion to reduce circulating glucocorticoids (eg Ketoconazole); Octreotide (blocking the release of ACTH); bilateral adrenalectomy. Cushing syndrome by: Once the diagnosis of lung cancer has been established the optimal treatment for any PNS is to treat the disease. There is no randomised control trial data for treatment for PNS on which to base practice (Giometto 2012) but there is evidence that the anti-cancer treatments (surgery, radiotherapy, chemotherapy, biological therapies, immunotherapies, immunomodulation and immunosuppression including glucocorticoids) may be beneficial. One of the challenges is that irreversible neuronal damage may have already happened by the time the diagnosis has been established. Supportive Care The symptoms of PNS can have a major impact on the patient’s quality of life and on individual care requirements. It is recommended that a Health Needs Assessment (DoH 2011) is undertaken when symptoms first present, prior to starting any intervention and at the end of treatment. This assessment should take into account the patient’s physical, psychological, social, spiritual and practical needs and will enable interventions to be put in place to maximise the quality of daily life. When symptoms present the psychological and physical impact can be devastating as immobility, discomfort, cognitive dysfunction and loss of the ability to self-care can affect the patient and care providers. In the UK the role of the Lung Cancer Nurse Specialist (RCLCF 2014) is ideally placed to address these concerns not only when the diagnosis is first made but throughout treatment and beyond by providing psychological support and symptom management, home care coordination and referrals to other health professional such as Physiotherapists and Occupational Therapists. Once primary treatment has taken place the ongoing monitoring of response to treatment is required together with a comparison of presenting symptoms. Patients should know what to do if these reoccur and how they should access their clinical team. Conclusion The management of PNS is complex and in the absence of randomised trials there is available guidance to help with the management of Paraneoplastic Syndromes. The individual care of each patient should be tailored to the diagnosis, symptoms and holistic needs. References Dalmau J, Rosenfeld M (2014) Overview of paraneoplastic syndromes of the nervous system (Accessed 20[th] June 2015) http://www.uptodate.com/contents/overview-of-paraneoplastic-syndromes-of-the-nervous-system#subscribeMessage Darnell R, Posner J (2003) Paraneoplastic syndromes involving the nervous system. NEJM 349(16):1543-54. Department of Health (2011) Improving Outcomes: A strategy for Cancer. DoH Giometto B, Vitaliani R, Lindeck-Pozza E et al (2012) Treatment for Paraneoplastic Neuropathies. Cochrane Library (Assessed 30[th] June 2015) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007625.pub2/abstract Graus F, Delattre J, Antoine J et al (2004) Recommended diagnostic criteria for paraneoplastic neurological syndromes. Journal of Neurology, Neurosurgery and Psychiatry 75(8):1135-40 Honnorat J, Antoine, JC (2007) Paraneoplastic neurological syndromes Orphanet Journal of Rare Diseases 2.22 Kanaji N, Watanabe N, Kita N et al (2014) Paraneoplastic syndromes associated with lung cancer. World Journal of Clinical Oncology, 5(3), 197-223 Pelosof L, Gerber D (2010) Paraneoplastic syndromes: an approach to diagnosis and treatment. Mayo Clinic Proceedings 85:838–854. Roy Castle Lung Cancer Foundation (2013) Understanding the Value of Lung Cancer Nurse Specialists. RCLCF Spiro S, Gould M, Colice G (2007) Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition) Chest. 132:149S–160S. Figure 1

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Abstract:
There were 35,371 deaths from Lung cancer in the United Kingdom in 2012 and it remains the leading cause of United Kingdom cancer deaths (Cancer Research UK 2014). Many patients can carry a high burden of symptoms, so the nature and scale of the disease can present significant challenges for the patients, their carer’s and for those who care for them within the National Health Service. As health care professionals we have a responsibility to provide an excellent service including communication and support of the highest standard. Lung Cancer Nurse Specialists (LCNS) are involved across all stages of the patient journey and have a distinctive role in communicating information and enabling patients with lung cancer to take an inclusive role in decisions around their care. They are mostly known as the patient’s keyworker, although the identified keyworker may change throughout the pathway according to the patient’s needs. Effective face to face communication along with regular telephone contact between the LCNS and the patient and carers can aid the development and implementation of individualised care plans. The LCNS should be available at all stages to complement care and facilitate best practice, responsible for the provision of information to patients and their families in a timely manner, within a supportive environment (NICE 2011). With an average annual new caseload of 122 patients per LCNS (UKLCC, 2012) there can be an overstrain on the level of support provided by the LCNS which can lead to inequity of access and inconsistent support (Leary et al, 2008). Yet consistent specialist support and advice are essential as individuals care needs and treatment options can be complex. With this in mind we have restructured the lung cancer service at Aintree Hospitalwith the development of a support worker role. Implementation of the role is competency led and training needs structured around specific pathways (Brummell et al, 2014). With correct delegation, such as being an access point for patients and health care professionals, the support worker can release the LCNS to enable a more effective use of LCNS skills, improving patient experience. United Kingdom Lung Cancer Coalition (UKLCC, 2012) recommends that all lung cancer patients should be able to access LCNS support and advocacy when they need it throughout their whole journey to support their holistic needs. Holistic care is total patient care that considers the physical, psychological, social, economic and spiritual needs of the person with his or her response to illness. Holistic Needs Assessment (HNA) helps form a base on which to navigate care needs of the individual. It provides a framework to discuss individuals concerns and how they are feeling, to identify and understand individual needs, enable care that is personalised, sign post to appropriate agencies, and enables patients to access, identify, appraise and interpret information. HNA should be performed at or near diagnosis and at the end of treatment and whenever health and social needs change. Indeed, work undertaken by Tod et al (2013) ‘Opening Doors to treatment’ explored the impact of LCNS’s on access to anti-cancer treatment. The report demonstrated why and how the LCNS has an impact in accessing treatment, with the communication and coordination aspects of the LCNS role being essential in realising the impact in increasing treatment access. This paper sets out to demonstrate as to why the LCNS in the UK is pivotal to navigating the care of the lung cancer patient. Brummell S, Tod A, Guerin M, Beattie V et al (2014) An evaluation of the role of the support workers in lung cancer. Cancer Nursing Practice. 14, 1, 22-27. Cancer Research UK (2014) Lung Cancer Statistics. [Online ]http:// cancerresearchuk.org/health-professional/cancerstatistics-by-cancer-type/lung-cancer/mortality [Accessed June 30 2015] Leary A, Bell N, Darlison L et al (2008) An analysis of lung cancer clinical nurse specialist workload and value. Cancer Nursing Practice. 7, 10, 29-33. National Institute of Clinical Excellence (NICE) (2011) Diagnosis and treatment of Lung Cancer. Department of Health. London. UK Lung Cancer Coalition (2012) The Dream MDT for Lung Cancer: Delivering High Quality Lung Cancer Care and Outcomes

Abstract:
Occupational therapists are integral members of the lung cancer multidisciplinary team, working with lung cancer patients in the inpatient hospital setting, hospital outpatient clinics and in the community. The focus of the occupational therapist is on enabling an individual’s participation in chosen everyday activities (Morgan DD and White KM, 2012). For people living with metastatic lung cancer, this focus is on enabling continued participation in the face of functional decline and increasing symptom burden. This focus can also encompass rehabilitation for people who have undergone curative treatment for their lung cancer, with the aim of facilitating a return to previous chosen and meaningful roles. Occupational therapists can assist people living with lung cancer prioritise their goals while managing the side effects of treatment. They also have a vital role in assisting the person living with lung cancer as their function changes with progressive disease. People living with lung cancer experience high symptom burden, which can include refractory breathlessness, fatigue and pain (Yang P et al., 2012). There is a growing body of evidence for occupational therapy interventions for people living with cancer to assist with symptom management and many of these interventions are applicable for people living with lung cancer (Morgan DD and White KM, 2012). Interventions utilised by occupational therapists when working with people living with lung cancer include task analysis, task modification, equipment prescription, priority setting and relaxation therapy. The occupational therapist is in a unique position to facilitate mastery of non-pharmacological interventions to assist in the management of refractory breathlessness and fatigue. It is important to teach techniques early in the lung cancer trajectory, to ensure mastery prior to the escalation of symptoms. This assists with preventing decreasing function and supports the engagement of the individual in valued activities (White KM, 2013). Occupational therapy management of breathlessness has been extensively researched in chronic lung conditions. The work of Migliore Norweg et al (Migliore Norweg A et al., 2005)focuses on interventions targeting improvement in everyday function for people living with COPD through mastery of breathing techniques and task modification. These interventions focus on managing breathlessness during activities that provoke breathlessness. Participation in pulmonary rehabilitation programmes is an established form of care for people with chronic lung disease. There is now a growing interest in the role of pulmonary rehabilitation to optimise function pre and post surgery for lung cancer (Pasqua F et al., 2013), as well as the role of exercise generally for people living with lung cancer (Bade BC et al., 2015, Lin Y et al., 2014, Cheville AL et al., 2012). The use of rehabilitation programmes for people living with cancer are being reported more frequently in the literature, and the occupational therapist is identified as a key team member (Silver JK and Gilchrist LS, 2011). Energy conservation techniques are useful in managing both fatigue and breathlessness. The occupational therapist completes a detailed assessment, including task analysis of how the person completes their everyday activities. This then informs interventions which can include behaviour and task modification, relaxation techniques, biofeedback, prescription of adaptive techniques and environmental modifications (White, 2013). Those living with advanced lung cancer may not have the time, energy or function to achieve full mastery of fatigue and breathlessness management techniques. Using adaptive equipment can be an effective and immediate way of improving function and assisting with symptom management for people living with advanced lung cancer. Conclusion Occupational therapy interventions aim to improve and optimise a person’s participation in everyday activities (World Federation of Occupational Therapy, 2010). Internationally, there are few occupational therapists that specialise in the field of lung cancer. This has led to a paucity of evidence and research into occupational therapy interventions that may benefit people living with lung cancer. Many interventions utilised by occupational therapists have a research base in non-malignant conditions and nursing literature. It is critical that occupational therapists build on this evidence and continue to research the efficacy of interventions used to optimise function for people living with lung cancer. The focus of occupational therapy interventions for people living with lung cancer is on enabling continued participation in valued and chosen activities in the face of functional decline and increasing symptom burden. References BADE BC, THOMAS DD, SCOTT JB & SILVESTRI GA 2015. Increasing physical activity and exercise in lung cancer: reviewing safety, benefits, and application. Journal of Thoracic Oncology, 10, 861-871. CHEVILLE AL, DOSE AM, BASFORD JR & RHUDY LM 2012. Insights into the reluctance of the patients with late-stage cancer to adopt exercise as a means to reduce their symptoms and improve their function. Journal of Pain and Symptom Management, 44, 84-94. LIN Y, LIU MF, TZENG J & LIN C 2014. Effects of walking on quality of life among lung cancer patients. Cancer Nursing, Epub ahead of print. MIGLIORE NORWEG A, WHITESON J, MALGADY R, MOLA A & REY M 2005. The effectiveness of differenct combinations od pulmonary rehabilitation on program components: A randomized controlled trial. Chest, 128, 663-672. MORGAN DD & WHITE KM 2012. Occuptional therapy interventions for breathlessness at the end of life. Current Opinion in Supportive and Palliatve Care, 6, 138-142. PASQUA F, GERANEO K, NARDI I, LOCOCO F & CESARIO A 2013. Pulmonary rehabilitation in lung cancer. Monaldi Archives for Chest Diseases, 79, 73-80. SILVER JK & GILCHRIST LS 2011. Cancer rehabilitation with a focus on evidence-based outpatient physical and occupational therapy interventions. American Journal of Physical Medicine and Rehabilitation, 90, S5-S15. WHITE KM 2013. Occupational therapy interventions for people living with advanced lung cancer. Lung Cancer Management, 2, 121-127. WORLD FEDERATION OF OCCUPATIONAL THERAPY 2010. Definitions of occupational therapy from member organisations. World Federation of Occupational Therapy. YANG P, CHEVILLE A, WAMPFLER JA, GARCES YI, JATOI A, CLARK MM, CASSIVI SD, MIDTHUN DE, MARKS RS, AUBRY M, OKUNO SH, WILLIAMS BA, NICHOLS FC, TRASTEK VF, SUGIMURA H, SARNA L, ALLEN MS, DESCHAMPS C & SLOAN JA 2012. Quality of life and symptom burden among long-term lung cancer survivors. Journal of Thoracic Oncology, 7, 64-70.

Abstract:
Due to toxicity during chemoradiation, patients are at risk for discontinuation of treatment and might not benefit optimally from this treatment.Small intervention trials are a possible tool to reduce toxicity within limited time. Toxicity and discontinuation of treatment were scored in 188 NSCLC patients treated with concurrent chemoradiotherapy. Literature based small intervention studies were performed for the reduction of toxicity Severe toxicity was seen in 33% of the patients; discontinuation of treatment in 20%. Esophagitis, gastro-intestinal toxicity and renal impairment were the most prominent toxicities. Intervention studies led to a reduction of nausea, weight loss, nephro toxicity and dysphagia CCRT for NSCLC is the treatment of choice at the cost of severe toxicity. Small intervention studies have shown to be benificial in reducing severe toxicity, enabling patients to accomplish CCRT en thus benifit optimal from this treatment.

Abstract:
Lung cancer survivors may suffer difficulty breathing, coughing, fatigue, anxiety, depression, insomnia and pain. Lung cancer survivors often experience a reduced quality of life. The good news is that quality of life can be improved with exercise and it should be considered for every patient. Exercise reduces the risk of lung cancer and is associated with reduced mortality. Exercise also lessens adverse symptoms and may improve quality of life, by enhancing physical and social function and lessening fatigue. The following are three of the more recent studies that have examined the benefits of exercise for lung cancer patients: 1. A 2012 study from Denmark looked at 25 patients with stage III/IV non-small cell cancer, and four patients with extensive disease small cell lung cancer. They participated in a 6-week supervised structured exercise and relaxation-training program. The researchers found that of the 23 patients, who completed the program, the majority adhered to the program and there were significant improvements in VO2 peak and 6-minute walking distance, as well as in muscle strength. The patients also reported a significant improvement in emotional well being. 2. In 2014, a larger study in Germany, included 40 patients with predominantly advanced NSCLC, who were receiving simultaneous or sequential radio chemotherapy or chemotherapy alone. The authors concluded, “ In this pilot study, endurance and strength capacity improved over time, indicating the rehabilitative importance of the applied intervention.” 3. In 2015, Dr. Gerard Silvestri, Dr. Brett Bade, David Thomas, and JoAnn Scott at the Medical University of South Carolina researched the benefit of physical activity and exercise for lung cancer patients. Their results were published in the Journal of Thoracic Oncology, June 2015. They found that physical activity should be considered as a therapeutic option for patients with lung cancer. They also concluded that exercise is safe, reduces symptoms, improves quality of life, increases exercise tolerance, and decreases length of hospitalization and post-surgery complications for lung cancer. Additionally, health care professionals should recommend exercise and encourage physical activity in patients at any stage of lung cancer. We can conclude from these studies and from my experience of working with this population that lung cancer survivors benefit from cancer exercise programs. These programs teach survivors how to exercise properly, and provide an exercise schedule. They can also provide a social and educational forum. Lung cancer patients may see even the idea of exercising as overwhelming, particularly if they suffer from shortness of breath, coughing or fatigue.The Medical University of South Carolina study found that patients with lung cancer want advice about physical activity from a cancer center physician before, during and following cancer therapy. The researchers also found that, when patients received this type of advice, there was a greater likelihood that the patients would comply with an exercise program. Why exercise during and after treatment or surgery? Exercise is a safe and inexpensive cancer therapy that reduces symptoms and improves quality of life. It improves strength, endurance, pulmonary function and flexibility, decreases the side effects of treatment and post-operative complications. Inactivity in cancer patients is associated with poorer outcomes and can cause the heart and muscles to regress and become less efficient. Being physically active not only helps prevent lung cancer in the first place, but it appears to also improve survival and quality of life for those already diagnosed. How much and what type of exercise is needed? The goal is to be able to exercise every day with a total of 150 minutes a week, the same as a healthy person. Lung cancer survivors should progress slowly, set goals, and listen to their bodies. Exercises can be performed initially in small increments of 10 minutes at a time depending on the fatigue level. Aerobic exercise is a great way to improve fitness. It not only improves cardiac function, but also improves the oxygen capacity. Aerobic exercises include walking, dancing, or any activity that increase the heart rate. Participate in enjoyable low intensity activities. Low intensity exercise such as walking is a safe way to begin. Aerobic exercise can be performed at a time that is convenient and there is no need to belong to an expensive gym. You can start by walking around a room in the house and slowly increase the distance walked. This can be done several times a day. You can use a pedometer to measure your steps and to help you set and attain goals. When sedentary one loses strength and gets weaker. Try to add movement to your day. You can take the stairs, park far from your destination, dance or whatever you enjoy that involves movement. Lung cancer patients may also benefit from strength training because it can strengthen weakened muscles. Fatigue can lead to sedentary behavior. Muscle mass will decrease if you sit or lie in bed a lot. By getting stronger it may be possible to return to work and take care of activities of daily living. Strength training can help you to improve balance, posture and increase bone strength. Patients with shortness of breath due to their cancer should perform stretching exercises daily to increase lung capacity. These can help to keep chest muscles loose and encourage deep breathing. Stretching can also help improve posture. Sitting down all day at a desk or driving can cause rounded shoulders and kyphosis, which can decrease lung capacity. It is also good to exercise prior to surgery and treatments and for those who are not surgical candidates. Exercise before surgery has multiple benefits such as improved quality of life, pulmonary capacity, endurance and strength coupled with reduced fatigue and surgical complications. Fitness level before surgery may predict risks of surgical complications and pre-surgery fitness levels may also predict how long lung patients may live beyond traditional markers of longevity. Despite limited lung capacity, exercise can help patients with lung cancer improve their quality of life by reducing fatigue, adverse symptoms and depression, while improving muscle strength, flexibility and mood.

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Lung cancer is the leading cause of cancer death in Canada, and is associated with the highest levels of distress among all cancers (Canadian Cancer Statistics 2012, Zabora J et al 2001). Over two-thirds of newly diagnosed lung cancer patients are over 65 years of age and have advanced-stage disease. Many of these patients experience malnutrition comprising a combination of starvation (inadequate nutrient intake), sarcopenia (loss of muscle mass associated with loss of strength and or function), and cachexia (presence of systemic inflammation/altered metabolism). These factors are also major determinants of frailty in elderly lung cancer patients (ELCP), and are associated with reduced cancer treatment tolerance and response (Vigano and Morais, 2015). The addition of palliative care consultation initiated in parallel to treatment for lung cancer has been shown to improve both overall lung cancer mortality and patient symptom burden during cancer treatments (Greer et al, 2013). However, there is a paucity of information regarding the peri-diagnostic, pre-treatment phase. Most often, the pre-treatment phase of lung cancer care is defined as a prolonged period (mean = 6 weeks) of fragmented care that is associated with high levels of symptom burden and psychological distress (Dekhuijzen et al, 2014; Iyer et al 2013). The supportive care needs of patients during this period are often inadequately addressed. Thus, the potential for personalized interventions to reduce frailty in ELCP by targeting malnutrition and symptom burden have been largely unexplored during this critical phase. The Rapid Investigation Clinic (RIC) at the McGill University Health Centre (MUHC) currently investigates and stages patients with suspected lung cancer. The clinic operates on a bi-weekly basis and includes dedicated pulmonologists with a particular expertise in lung cancer, a dedicated nurse clinician, and a palliative care consultant. Once staged, patients’findings are discussed at tumor board meetings and are evaluated at the multidisciplinary lung cancer clinic. The mean time from referral to lung cancer treatment is approximately 6 weeks. When patients are identified at the RIC as requiring supportive care they are referred to one of seven interdisciplinary clinic/programs available at the Cancer Care Mission of the MUHC (see figure below). Figure 1 For instance, if a patient presents primarily with signs and symptoms of cachexia or deconditioning, he/she is referred to the Cancer Rehabilitation Program (CRP) and Cachexia Clinic (CC) at the MUHC, which are fully integrated with the MUHC Nutrition and Performance Laboratory (MNUPAL, www.mnupal.mcgill.ca) . MNUPAL is a state-of-the-art facility devoted to nutritional and functional assessment for patients with advanced cancer.. The primary goals of these assessments are: a) to identify presence and severity of cachexia and/or sarcopenia, b) to address reversible causes for these syndromes, such as inadequate symptom control, nutritional and hormonal deficits (i.e. hypogonadism, hypothyroidism etc), and c) to identify personalized interventions (pharmacological, nutritional, and functional) that will be appropriate for patients’ conditions and wishes. The current research at MNUPAL is driving some of the future directions of specific and personalized care, especially in terms of the Cachexia Clinic and the stages of cancer cachexia that will ultimately provide more specific and personalized care for those who are in the various stages of cancer cachexia (Vigano et al, 2012). The CRP and CC teams include a palliative care physician, a nurse clinician, a physiotherapist, an occupational therapist and a nutritionist. If patients present primarily with cancer related pain, they are referred to the Cancer Pain Clinic, whereas patients who have advanced disease and are no longer receiving treatment with a curative intent may be referred to the Palliative Care Clinic. Access to physiotherapy, occupational and nutritional services is available for all clinics which do not include these specialties in their teams.Patients assessed with psychosocial distress from all clinics are referred to the psychosocial oncology program and/or social services. CanSupport services (i.e. reimbursements for parking, transportation etc.) are also available upon request. Screening assessments for both malnutrition and symptom distress are available at the RIC. At the present time, there is ongoing research for using these screening to systematically identify frail elderly cancer patients prior to cancer treatment initiation. There is also a need to objectively determine if interventions targeted to decrease malnutrition and symptom burden will diminish frailty, may improve patient psychological and physiologic “readiness” for what are often aggressive treatments (chemotherapy, radiotherapy or surgery). There is a convincing body of research evidence including case reports (Carli et al., 2012, Carli et al., 2014), pilot studies (Li et al., 2013), and randomized clinical trials (Gillis et al., 2014) that supports geriatric patient engagement in multi-modal, cancer pre-habilitation programs designed to improve physical (physiological) and psychological (anxiety and depression) outcomes during a perioperative time period. We are therefore investigating ways to enhance access to supportive care services for elderly lung cancer patients, which include: Standardized screening for malnutrition and symptom burden. Standardized approaches to symptom control, psychological distress, as well as nutritional and functional problems Identification of specific therapeutic targets and interventions to reduce frailty Canadian Cancer Society’s Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012. Carli F, Brown R, Kennepohl S. Prehabilitation to enhance postoperative recovery for an octogenarian following robotic-assisted hysterectomy with endometrial cancer. Can J Anaesth. 2012 Aug;59(8):779-84. doi: 10.1007/s12630-012-9734-4. Epub 2012 May 26. Carli F, Awasthi R, Gillis C, Kassouf W Optimizing a frail elderly patient for radical cystectomy with a prehabilitation program. Can Urol Assoc J. 2014 Nov;8(11-12):E884-7. doi: 10.5489/cuaj.2025. Dahele, M., R. J. Skipworth, L. Wall, A. Voss, T. Preston and K. C. Fearon (2007). "Objective physical activity and self-reported quality of life in patients receiving palliative chemotherapy." J Pain Symptom Manage 33(6): 676-685. Dekhuijzen PN, Prins JB. Distress in suspected lung cancer patients following rapid and standard diagnostic programs: a prospective observational study. Psycho-oncology. 2014 Sep 9. doi: 10.1002/pon.3660. [Epub ahead of print] Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS, Carli F. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology. 2014 Nov;121(5):937-47. doi: 10.1097/ALN.0000000000000393. Greer JA, Jackson VA, Meier DE, Temel JS. Early integration of palliative care services with standard oncology care for patients with advanced cancer.CA Cancer J Clin. 2013 Sep;63(5):349-63. doi: 10.3322/caac.21192. Epub 2013 Jul 15. Iyer S, Roughley A, Rider A, Taylor-Stokes G. The symptom burden of non-small cell lung cancer in the USA: a real-world cross-sectional study Support Care Cancer. 2014 Jan;22(1):181-7. doi: 10.1007/s00520-013-1959-4. Epub 2013 Sep 12. Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS, Kaneva P, Augustin B, Wongyingsinn M, Gamsa A, Kim do J, Vassiliou MC, Feldman LS. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc. 2013 Apr;27(4):1072-82. doi: 10.1007/s00464-012-2560-5. Epub 2012 Oct 9. Vigano A, Morais JA. The elderly patient with cancer: a holistic view. Nutrition. Published on line January 8, 2015. http://dx.doi.org/10.1016/j.nut.2015.01.001 Vigano A, Del Fabbro E, Bruera E, Borod M. The cachexia clinic: from staging to managing nutritional and functional problems in advancer cancer patients. Critical Reviews in Oncogenesis 2012 17(3), 293–304 Zabora J, Brintzenhofeszoc K, Curbow B, Hooker C and Piantadosi S. The prevalence of psychological distress by cancer site. Psycho-oncology 10 : 19–28 (2001)

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Palliative care has been shown to improve outcomes for patients with life threatening illness and patients at the end of life, including decreasing symptom burden, improving quality of life, and working with patients and families to help ensure that the medical and nursing care provided is congruent with goals and preferences. Palliative care, focusing on assistance with advance care planning, decision-making, pain and symptom management, psycho-social support, and patient navigation, has the potential to improve care quality and reduce medical service utilization.[1] In a randomized controlled trial (RCT) of a palliative care intervention, Temel and colleagues demonstrated that patients with advanced lung cancer who received early palliative care had better quality of life, less depression, and lived longer.[2] The American Society of Clinical Oncology[3] and other organizations have published position statements supporting the need for oncologists, nurses, and other clinicians to participate in difficult conversations with patients regarding prognosis, preferences, and palliative care options earlier in the course of illness. Patients and their caregivers (family and/or significant others) need to be part of the discussion about care goals at the time of diagnosis, during treatment, and at the time of recurrence. Shared decision-making about end-of-life care must be based on patient/family caregiver beliefs, values, and preferences.[4] Developing rapport with patients and starting the conversation about care goals is often difficult and time-consuming. Often, patients do not understand the difference between palliative care and hospice and may not want to participate in a palliative care program because of their concern that health care providers are “giving up” on them. In a survey of health care professionals, barriers to goals of care discussions with seriously ill hospitalized patients and families include: patients’ and family members’ difficulty accepting a poor prognosis and understanding limitations/complications of life-sustaining treatments, family member disagreement about care goals, and patient incapacity to make care decisions.[5 ] Interventions to improve communication and shared decision making about plans and goals of care are key and must take into account cultural and spiritual preferences. Cultural and linguistic barriers increase disparities in providing palliative care for ethnic minorities. Patient and family cultural values have a major impact on care preferences at the end of life for some ethnic minorities and should be considered by the health care professional. Cultural, spiritual, and religious values often influence how palliative care and pain/symptom management are perceived and accepted. While nationwide averages of completed advance directives are low for all groups, patients of ethnic minority are less likely to have a living will, durable power of attorney, or a Do Not Resuscitate (DNR) order, are more likely to choose very aggressive care in the face of serious or incurable illness, and less likely to acknowledge their terminally ill status.[6] Palliative care and hospice services are rarely accessed by non-Caucasians. In addition, expanding evidence suggests that adequate pain and symptom assessment and management is not achieved for many persons with late stage disease; pain occurs in approximately 80% of patients with life-threatening illness.[7] Solano et al. found breathlessness and fatigue were present in >50% of patients with cancer and COPD.[8] All of these barriers suggest that improving palliative care access may have benefit for patients and their family caregivers. However, tertiary palliative care cannot grow fast enough to meet the demand. Models of care that promote primary palliative care are required in outpatient, community, homecare, and rural settings to maintain the capacity for the ever-growing needs of patients and their family caregivers. Primary care physicians and nurses play important roles in delivering palliative care, and may in fact not have the knowledge and skills to do so effectively. Significant barriers to integrating palliative care include lack of access to palliative care resources to implement change, personnel constraints, inadequate basic knowledge about palliative care strategies and communication, and little training, skills, or certification in palliative care.[11] It is imperative for health care professionals to improve their knowledge about palliative care, support the provision of early palliative care, and establish relationships with patients to understand values and preferences. Dr. Atul Gawande, in his recent book Being Mortal, suggests that patients be asked five key questions to open discussion about care goals.[12] These questions include the following: 1. What is the understanding of your current health and condition? 2. If your condition worsens, what are your goals? 3. What are your fears? 4. Are there any tradeoffs you are willing to make or not? 5. What would a good day be like? Additional suggestions and strategies to improve communication with patients and their family caregivers in the palliative care setting will be discussed in this presentation. 1. Ferris FD, Bruera E, Cherny N, et al. Palliative cancer care a decade later: accomplishments, the need, next steps -- from the American Society of Clinical Oncology. J Clin Oncol 2009;27:3052-8. 2. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42. 3. Peppercorn JM, Smith TJ, Helft PR, et al. American society of clinical oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol 2011;29:755-60. 4. Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134:835-43. 5. You JJ, Downar J, Fowler RA, et al. Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians. JAMA Intern Med February 2, 2015;epub E1-8. 6. Smith AK, McCarthy EP, Paulk E, et al. Racial and ethnic differences in advance care planning among patients with cancer: impact of terminal illness acknowledgment, religiousness, and treatment preferences. J Clin Oncol 2008;26:4131-7. 7. Kutner JS, Bryant LL, Beaty BL, Fairclough DL. Time course and characteristics of symptom distress and quality of life at the end of life. JPain Symptom Manage 2007;34:227-36. 8. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Sympt Manage 2006;31:58-69. 9. Fink RM, Oman KS, Youngwerth J, Bryant L. A palliative care needs assessment of rural hospitals. J Pall Med 2013;16(6):638-644. 10. Gawande A. Being Mortal: medicine and what matter in the end. New York: Metropolitan Books, Henry Holt and Company, 2014.

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Abstract:
Cancer has emerged as a major health problem in Africa.[1]Healthcare in Africa differ widely, countries in North Africa and the republic of South Africa have better health care services than those in sub Saharan Africa. In Africa particularly in sub-Saharan region, due to the limited access to cancer screening and early diagnosis, an estimated 80% of cancer patients are present with advanced stage. [2]Additionally, inadequate access to standard cancer therapies result in difficulty to achieve cure even for patients with early stage cancer. Despite the clear public health needs for multidisciplinary palliative care for millions of cancer patients, access to this option is limited in most African countries. Information regards palliative care in Africa is lacking.[3]It was estimated that only 5% of patients in need to palliative care receive it.[4]This is especially true in sub-Saharan Africa, where about 80% of cancer patients are likely to experience suffering in the course of their advanced illnesses.[2] Palliative care is a relatively new discipline in Africa, Initiatives in South Africa and Zimbabwe dated back to 1970s. There has been significant progress over the last ten years. From being significantly present in only five countries in 2004, palliative care services was established in nearly half of African countries in before the World Health Assembly in 2005.[4]These services usually confined to large cities, most of which are pain clinics driven by nongovernmental sector. The majority of health care professionals at palliative care clinics lack the appropriate training for pain assessment and management and they are relying on their own personal experience while practicing palliative care. Clark et al. [3]have conducted a multi-method survey to review services and experiences of palliative care development in 47 African countries. The 47 countries studied could be grouped into four categories of palliative care development: No identified hospice or palliative care activity (21 countries); Capacity-building activity underway to promote hospices and palliative care delivery (11countries); localized provision of hospices and palliative care in place, often supported by external donors (11countries); and Hospices and palliative care services achieving some measure of integration with mainstream service providers and gaining wider policy recognition (4 countries) The Limitations to the development of multidisciplinary palliative care programs in Africa are that: high burden of HIV and cancer, extreme shortage of trained health care professionals in palliative care, insufficient facilities, weak referral systems and lack of access to opioid or the restriction of their use in many African countries.[5, 6]Moreover, there is still a general lack of government policies that recognize palliative care as an essential component of health care along with great challenge to acquire funding for palliative care programs.[5] Despite these limitations, there has been some success so far. Uganda, Kenya, South Africa, and Zimbabwe developed successful models for the development of affordable, sustainable community- based hospices and palliative care services. [3]Kenya, South Africa, Uganda and Tanzania have integrated palliative care into healthcare policy. Uganda has mad oral morphine freely available to its patient’s population and it has passed law to allow prescription of morphine by nurses.[7]The Ministry of Health in Malawi acknowledged palliative care as part of a minimum standard of care for all tertiary institutions.[8] The importance of palliative care in the African setting have been recognized by the World Health Organization (WHO). There are several palliative care initiative in Africa that have provided good quality palliative care in limited recourse setting.[3]The majority of successful palliative care initiatives are supported by international organizations in collaboration with governments and non-governmental organization (NGOs) e.g. the WHO 5-country palliative care project. The Foundation for Hospices in Sub-Saharan Africa, has a grant support program operating in several African countries. The African Palliative Care Association (APCA) has a fast developing program of activities to promote development across the continent and supports governments and other local service providers to ensure the provision of opioids and other palliative care medications. The role of education and training has been essential in strengthening capacities to develop multidisciplinary palliative care programs. Efforts to develop in country training are underway in few African countries. The University of Cape Town offers Post Graduate Diploma/MPhil, in Palliative Medicine. Makerere University through its affiliated institution Hospice Africa Uganda in partnership with APCA offers a Bachelor’s Degree in Palliative Care. Nairobi Hospice in collaboration with Oxford Brookes University offers diploma in palliative care. The National Cancer Institute, Cairo offers Master degrees in pain management and palliative care has been incorporated in the curriculum of the oncology nursing program in the same institute. Palliative care in Africa is still at an early stage of development and faces many obstacles. A lot of progress has been made already, however much still remains to be done, particularly across sub-Saharan Africa. Many challenges cannot be corrected without governments and NGOs willing to effect changes and commit funds to research and training. References 1. Basu, A., B.N. Mittag-Leffler, and K. Miller, Palliative care in low- and medium-resource countries. Cancer J, 2013. 19(5): p. 410-3. 2. Spence, D., A. Merriman, and A. Binagwaho, Palliative care in Africa and the Caribbean. PLoS Med, 2004. 1(1): p. e5. 3. Clark, D., et al., Hospice and palliative care development in Africa: a multi-method review of services and experiences. J Pain Symptom Manage, 2007. 33(6): p. 698-710. 4. Grant, L., et al., Palliative care in Africa since 2005: good progress, but much further to go. BMJ Support Palliat Care, 2011. 1(2): p. 118-22. 5. Ddungu, H., Palliative care: what approaches are suitable in developing countries? Br J Haematol, 2011. 154(6): p. 728-35. 6. Harding, R. and I.J. Higginson, Palliative care in sub-Saharan Africa. Lancet, 2005. 365(9475): p. 1971-7. 7. Ramsay, S., Leading the way in African home-based palliative care. Free oral morphine has allowed expansion of model home-based palliative care in Uganda. Lancet, 2003. 362(9398): p. 1812-3. 8. Tapsfield, J.B. and M. Jane Bates, Hospital based palliative care in sub-Saharan Africa; a six month review from Malawi. BMC Palliat Care, 2011. 10: p. 12.

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Abstract:
The major societies of Supportive and Palliative Care in Europe are the Multinational Association of Supportive Care in Cancer (MASCC), the European Society for Medical Oncology (ESMO) and the European Association for Palliative Care (EAPC). Supportive Care is defined by MASCC as: “Supportive Care in Cancer is the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side effects across the continuum of the cancer experience from diagnosis through anticancer treatment to post-treatment care. Enhancing rehabilitation, secondary cancer prevention, survivorship and end of life care are integral to Supportive Care [1].” Palliative Care is defined by EAPC as: “Palliative Care is the active, total care of the patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of social, psychological and spiritual problems is paramount. Palliative Care is interdisciplinary in its approach and encompasses the patient, the family and the community in its scope. In a sense, palliative care is to offer the most basic concept of care – that of providing for the needs of the patient wherever he or she is cared for, either at home or in the hospital. Palliative care affirms life and regards dying as a normal process; it neither hastens nor postpones death. It sets out to preserve the best possible quality of life until death [2].” ESMO took a stand on Supportive and Palliative Care in 2003 as follows: “Supportive Care’ is defined as care that aims to optimize the comfort, function and social support of the patients and their family at all stages of the illness. This dimension of care emphasizes the oncologist’s role in optimizing quality of life for all patients, including those with potentially curative illness.” “Palliative Care’ is defined as care that aims to optimize the comfort, function and social support of the patients and their family when cure is not possible. This dimension of care emphasizes the special needs of patients whose illness is either unlikely to be cured or that is incurable. These needs include physical and psychological symptom control, education and optimization of community supports [3].” These definitions are summarized in the Figure. The definitions all respect the recent trend of early integration of Palliative Care in patients with advanced cancer. Two randomized studies showed a survival benefit [4] or an improvement in some quality of life parameters [5], whereas a recent randomized study was unable to demonstrate any benefit of early integration of Palliative Care [6]. Recently MASCC, ESMO and EAPC joint forces and completed two surveys to disclose the use of existing palliative care programs in Europe. The result of these surveys will be summarized [7, 8]. Figure 1 References 1. MASCC homepage accessed July 7, 2015 - http://www.mascc.org/about-mascc 2. EAPC homepage accessed July 7, 2015 - http://www.eapcnet.eu/Corporate/AbouttheEAPC/Definitionandaims.aspx 3. Cherny NI, Catane R, Kosmidis P et al. ESMO takes a stand on supportive and palliative care. Ann Oncol 2003;14:1335-1337. 4. Temel N, Greer JA, Muzikansky A et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42. 5. Zimmerman C, Swami N, Krzyzanowska M et al. Eraly palliative care for patients with advanced cancer: a cluster randomised controlled trial. Lancet 2014;383:1721-30. 6. Groenvold M, Petersen MA, Damkier A et al. The Danish palliative care trial (DanPaCT), a randomised trial of early palliative care in cancer: results of the primary analysis. EAPC 14th World Congress May 8-10, 2015: abstract PL7. 7. Davis MP, Strasser, F, Cherny N. How well is palliative care integrated into cancer care? A MASCC, ESMO and EAPC project. Support Care Cancer DOI 10.1007/s00520-015-2630-z 8. Davis MP, Strasser F, Cherny N, Levan N. MASCC/ESMO/EAPC survey of palliative care programs. Support Care Cancer 2015;23:1951-1968.

Abstract:
Dyspnea (or the subjective experience of breathlessness) has a prevalence of about 50% in people with any cancer (not just lung cancer), and moderate to severe dyspnea is present in 28% of terminally ill cancer patients. Up to 60% of patients with lung cancer can experience dyspnea. Typically dyspnea experience will be of moderate level intensity, distressing and interfere with activities of daily living. Managing dyspnea is often challenging and should include an assessment to identify first and treat reversible causes. The following table shows such causes and possible treatment (Cancer Care Ontario, 2010).

Treatable causes of dyspnea

Treatment Options

RESPIRATORY SYSTEM Chronic obstructive pulmonary disease (COPD) Large airway obstruction Pleural effusion Pneumonia Pulmonary emboli CARDIOVASCULAR SYSTEM Angina pectoris Atrial fibrillation Congestive Heart Failure Pericardial effusion Superior vena cava obstruction OTHER SYSTEMS Anemia Severe Ascites

Inhaled bronchodilators; inhaled or systemic corticosteroids Radiotherapy; systemic corticosteroids; stenting; heliox; nebulized epinephrine Drain; if recurrent - sclerosing agents; indwelling catheter Antibiotics Anti-coagulation; inferior vena cava filter Optimize conventional medications Medications for ventricular rate control Optimize conventional medications Drain; if recurrent - sclerosing agents; pericardial window; indwelling catheter Corticosteroids; radiotherapy; stenting Red blood cell transfusion Drain; if recurrent- indwelling catheter

Pharmacological options, beyond treating the underlying cause, include systemic opioids (but not nebulized opioids), and occasionally benzodiazepines for managing dyspnea-related anxiety. Systematic reviews and meta-analyses (ie. Ben-Aharon et al, 2012) have shown the following: Systemic opioids (Oral and parenteral routes) Effective Nebulised opioids Not effective (nebulized hydromorphone very effective in 1 small trial) Supplemental Oxygen (non-hypoxic patients) Not recommended Supplemental Oxygen (hypoxic patients) Recommended Nebulised furosemide Insufficient evidence but probably ineffective Nebulised lidocaine Not recommended Benzodiazepines Not recommended for managing dyspnea, but can be used to treat related anxiety Systemic corticosteroids No comparative data available Phenothiazines No comparative data available. To consider if other interventions have failed in severe dyspnea Morphine combined with midazolam More effective than either option alone. Contradictory evidence The session will provide more data supporting the above statements. Non-pharmacological interventions may include diaphragmatic breathing exercises, positioning, education or supportive counseling. The session will also focus on recent findings from a new intervention to manage the symptom cluster of respiratory distress (breathlessness-cough-fatigue) and the results of a new study testing the effects of resistance inspiratory muscle training (Yorke et al, in press; Molassiotis et al, 2015). In relation to the newly developed complex psycho-educational and self-management interventions in 101 patients with lung cancer, results suggest improvements in managing dyspnea over the 3 months of the follow-up. In the last study to be presented, using resistance inspiratory muscle training (IMT) through a breathing device in 46 patients with lung cancer, results suggest a clinically meaningful improvement for those patients using the device for 3 months. The session will look at the symptom clusters around breathlessness and also cough management as this is impacting dyspnea too. Finally, the research gaps in the field will be highlighted. References: Cancer Care Ontario (2010). Symptom Management Guide-to-Practice: Dyspnea. file:///C:/Users/hkpuadmin/Downloads/Dyspnea%20(Full)%20(2).pdf Ben-Aharon I, Gafter-Gvili A, Leibovici L, Stemmer SM. (2012). Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol.; 51(8):996-1008. Yorke J, Lloyd-Williams M, Smith J, Blackhall F, Harle A, Warden J, Ellis J, Pilling M, Haines J, Luker K, Molassiotis A. (in press). Management of the respiratory distress symptom cluster in lung cancer: a randomised controlled feasibility trial. Support Care Cancer. Molassiotis A, Charalambous A, Taylor P, Stamataki Z, Summers Y. (2015). The effect of resistance inspiratory muscle training in the management of breathlessness in patients with thoracic malignancies: a feasibility randomised trial. Support Care Cancer.; 23(6):1637-1645.

Abstract:
Outcomes for the majority of cancer prevention trials overall have been disappointing at best. Lung cancer remains the leading cause of cancer-related mortality worldwide, causing an estimated 156,000 deaths in the United States for 2013. Most lung cancers (>60%) are diagnosed at an advanced stage, with associated 5-year survival of less than 15%. Efforts in early diagnosis and cancer prevention remain crucial to reverse the impact of this deadly disease. For this session, I will be joined by Dr. Eva Szabo and Dr. Avi Spira to review perspectives on the past, present, and future of lung cancer chemoprevention trials. We will review a number of current concepts and important themes in lung cancer chemoprevention, including: 1. Genomic alterations in pre-malignant lesions for both lung adenocarcinoma and squamous cell carcinoma. 2. Patient stratification for applying chemoprevention. 3. Novel agents. 4. Strategies for individualized or precision chemoprevention. 5. Trial designs for rapid and efficient testing of chemoprevention hypotheses. 6. Priorities for further study. To reduce the mortality rate of lung cancer, and to prevent cancer initiation, progression and development, new techniques and approaches to cancer prevention must be developed. We will present both data and opinion regarding promising leads, routes to evaluation, and a vision for research priorities to advance the science of lung cancer chemoprevention.

Abstract:
It has been 10 years since we first understood about the importance of targeted therapies in lung cancer. This group of medications are now part of our everyday clinical care for patients with lung cancer who harbour an EGFR or ALK mutation. Mechanisms of action and the associated toxicities of targeted therapies, such as tyrosine kinase inhibitors (TKI), differ from chemotherapy. Whilst these medications tend to be better tolerated in patients, they still carry a number of associated side effects which require intervention and management. Amongst these are acneform rash, paronychia, diarrhoea, nausea, raised liver functions, interstitial lung disease, loss of appetite, neuropathy,vision problems,and fatigue. With many lung patients on multiple medications due to comorbidities at presentation there should also be consideration of drug interactions with the CYP450 pathway utilised to metabolise many medications. This session will explore traditional and more novel approaches to supporting patients on TKI medications, patient resources, and the role nurses play in ensuring compliance and improved outcomes for lung cancer patients.

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Abstract:
Background: Cetuximab, a chimeric monoclonal antibody targeting the epidermal growth factor receptor (EGFR), moderately increases survival in patients with advanced NSCLC. Our prior work suggested that EGFR gene copy number measured by fluorescent in-suit hybridization (FISH) could identify those patients most likely to benefit.Methods: Patients eligible for this NCTN multicenter open-label, phase III trial had histologically or cytological confirmed Stage IV NSCLC that was newly diagnosed or recurrent after previous surgery or radiation. Patients with controlled brain metastases were allowed entry. All patients were required to have tumor tissue available for EGFR FISH testing. Randomization was stratified by appropriateness for bevacizumab treatment, smoking status and M-substage. The co-primary objectives were progression-free survival (PFS) in EGFR-FISH positive (FISH+) patients and overall survival (OS) in the overall study population (OSP). Secondary objectives were OS in FISH-positive patients and clinical outcomes (PFS and OS) comparison among bevacizumab-appropriate (BA) and inappropriate (BI) patients.Results: The final accrual was 1,333 total and 1,313 eligible patients (control arm: 657 total, 275/382 BA/BI; cetuximab-containing arm: 656 total, 279/377 BA/BI). EGFR FISH status was determined on 976 patients, with 400 (41%) FISH+. Squamous carcinoma (SCCA) represented 24-25% of patients. PFS and OS were not significantly different in the OSP (HR (95%CI) =0.98 (0.87-1.09) and 0.94(0.84-1.06), respectively). There is some indication of benefit in PFS and OS (HR 0.91 (0.74-1.12) and 0.83 (0.67-1.04), respectively) in FISH+ patients, albeit not statistically significant. However, among FISH+ BI and SCCA patients, effect estimates for OS were 0.75 (0.57-1.00) and 0.56 (0.37-0.84), respectively. Cetuximab was generally well tolerated with a spectrum of adverse events consistent with prior reportsConclusion: The addition of cetuximab had minimal effect in unselected advanced NSCLC patients. In FISH+ patients there is a suggestion of benefit, predominantly in SCCA and BI. These data support using a new marker for determining who should receive an EGFR antibody inhibitor with chemotherapy.Support: NIH/NCI/NCTN grants SWOG: CA180888, CA180819; ECOG/ACRIN: CA180820; Alliance: CA180821; and in part by Bristol-Myers Squibb Co.

		N	PFS	OS
Analysis Group	OSP	FISH+	OSP	FISH+	OSP	FISH+
All Patients
	Cetuximab-Containing Arm, Median, 95% CI	656	199	4.6(4.2-5.2)	5.4(4.5-5.7)	10.9(9.6-12.0)	13.4(11.7-14.8)
	Control Arm, Median, 95% CI	657	201	4.5(4.2-4.9)	4.8(3.9-5.5)	9.4(8.7-10.3)	9.8(8.7-12.1)
	Hazard Ratio, 95% CI			0.98(0.87-1.09)	0.91(0.74-1.12)	0.94(0.84-1.06)	0.83(0.67-1.04)
	2-sided p-value			0.68	0.37	0.34	0.10
BA
	Cetuximab-Containing Arm, Median, 95% CI	279	86	5.6(5.3-6.1)	6.2(5.7-7.4)	12.7(10.9-13.4)	15.5(13.4-18.4)
	Control Arm, Median, 95% CI	275	80	5.9(5.5-6.6)	6.7(5.7-8.0)	11.6(10.5-13.8)	13.2(11.2-19.1)
	Hazard Ratio, 95% CI			1.05(0.88-1.25)	1.07(0.77-1.47)	1.04(0.86-1.25)	0.97(0.69-1.38)
	2-sided p-value			0.57	0.70	0.70	0.88
BI
	Cetuximab-Containing Arm, Median, 95% CI	377	113	4.1(3.6-4.4)	4.5(3.8-5.2)	9.2(8.2-10.9)	11.2(8.6-12.9)
	Control Arm, Median, 95% CI	382	121	3.8(3.1-4.2)	3.7(2.8-4.6)	8.2(7.3-8.7)	8.7(5.9-9.7)
	Hazard Ratio, 95% CI			0.93(0.80-1.07)	0.82(0.63-1.07)	0.88(0.76-1.03)	0.75(0.57-1.00)
	2-sided p-value			0.31	0.14	0.12	0.05
SCCA
	Cetuximab-Containing Arm, Median, 95% CI	160	55	4.2(3.7-4.6)	4.5(3.8-5.2)	9.6(8.2-11.5)	11.8(8.6-13.5)
	Control Arm, Median, 95% CI	161	56	3.7(2.8-4.3)	2.8(2.6-4.1)	8.0(7.1-8.9)	6.4(4.2-8.7)
	Hazard Ratio, 95% CI			0.88(0.70-1.11)	0.68(0.46-1.01)	0.85(0.67-1.08)	0.56(0.37-0.84)
	2-sided p-value			0.29	0.06	0.18	0.006

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